Efficacy of an m-Health Physical Activity and Sleep Intervention to Improve Sleep Quality in Middle-Aged Adults: The Refresh Study Randomized Controlled Trial

Effectiveness of mobile applications in improving insomnia symptoms among adults from multi-community: A systematic review and meta-analysis

OBJECTIVE/BACKGROUND

To clarify whether mobile sleep applications alleviate insomnia symptoms among adults from multi-community.

PATIENTS/METHODS

A literature search was conducted using the PubMed, Cochrane, PsycINFO, and Web of Science databases for articles related to mobile technology and sleep interventions published between database inceptions and March 27, 2023. We pooled relevant data using a random-effects model, and a meta-analysis was performed using a web version of the Cochrane Review Manager. The effect size was estimated and reported as the combined overall effect (weighted average). Forest plots were created, and the Cochrane risk-of-bias tool and Newcastle-Ottawa Scale were used to evaluate studies.

RESULTS

After an initial screening and full-text reviews, seven studies were identified with a total of 10,139 participants (females n = 8844, 87.2 %) recruited from multi-community and not diagnosed with sleep disorders or taking medications. These studies included one cross-sectional study investigating mindfulness meditation apps and six randomized-controlled trials (RCTs), including one with sleep-feedback messaging, one comparing sleep applications with or without a wearable device, and four with multicomponent interventions based on cognitive theory and subsequent behavioral change techniques. In a meta-analysis of three cognitive behavior therapy (CBT)-based RCTs, the intervention group showed statistically significant improvements in insomnia symptoms according to the Pittsburgh Sleep Quality Index but with high heterogeneity, while two CBT-based RCTs showed no significant improvements in the Insomnia Severity Index with low heterogeneity.

CONCLUSIONS

A small body of evidence supports the use of CBT-based sleep applications to improve insomnia symptoms among adults from multi-community.

The effects of nonpharmacological sleep hygiene on sleep quality in nonelderly individuals: A systematic review and network meta-analysis of randomized controlled trials

The prevalence of locomotive syndrome naturally increases with age, but approximately half of nonelderly individuals also meet the criteria for locomotive syndrome, suggesting that even younger people need to pay attention to their own health status. Sleep is important for physical, cognitive, and psychological health. Some individuals with poor sleep quality may be at risk of developing negative health status. Although the effects of sleep hygiene strategies for elderly individuals have been well investigated, optimal nonpharmacological sleep hygiene strategies for improving sleep quality in nonelderly individuals has not been identified. We conducted a systematic review and network meta-analysis (NMA) of randomized controlled trials aimed to elucidate the effects of various nonpharmacological interventions on sleep quality in nonelderly individuals and to identify the optimal intervention. Cochrane Central Register of Controlled Trials, Medline, Cumulative Index to Nursing and Allied Health Literature, Physiotherapy Evidence Database, and Scopus were comprehensively searched. We identified 27 studies focusing on the effects of various nonpharmacological sleep hygiene strategies in nonelderly individuals, and 24 studies were applied into NMA. The present results showed that resistance training was the most effective intervention for improving sleep quality in nonelderly individuals. In addition, this study revealed the effects of nonpharmacological interventions, such as physical activity, nutritional intervention, as well as exercise interventions. This is the first report that utilized NMA to compare the effects of various nonpharmacological interventions on sleep quality in nonelderly individuals.

Effect of physical activity on sleep problems in sedentary adults: a scoping systematic review

This systematic review was steered forward with the aim of analyzing how different forms of exercise could influence the objective and subjective sleep outcome among sedentary adults with sleep problems. A pre-detailed study protocol (PROSPERO ID: CRD42021229649) was used to search for RCTs through five databases. The methodological quality of the included RCTs was assessed by PEDro and studies were included if they scored > 5. Effect size of all outcome measures were calculated using Cohen's d. Of the 4154 studies, 19 studies met the inclusion criteria and underwent quality assessment using 11-point PEDRO scale. 9 studies with PEDro score > 5 were finally included in this systematic review out of which, participants of 4 studies had insomnia (nrange = 37-48, agerange = 44-60 years), 3 studies had poor sleep quality (nrange = 80-275, agerange = 52-70 years) and 2 studies had obstructive sleep apnea syndrome (nrange = 26-68, agerange = 51 years). Majority of studies revealed that physical activity seems to have greater improvement with a large effect size on subjective sleep outcomes among sedentary adults with sleep problems like insomnia, poor sleep quality and OSAS, whereas limited studies and non-significant results were observed on objective sleep outcomes. Physical activity improves sleep outcomes especially among sedentary middle-aged and older adults. More research is needed to examine the effect of physical activity programs on objective sleep outcomes especially in younger sedentary adults with different sleep problems.

Supplementary Information

The online version contains supplementary material available at 10.1007/s41105-023-00494-w.

Effect of cognitive behavioral therapy for insomnia in workers: A systematic review and meta-analysis of randomized controlled trials

Although cognitive behavioral therapy for insomnia (CBT-I) is recommended as a first-line treatment, its efficacy for workers with insomnia remains unclear. This systematic review and meta-analysis aimed to determine the effectiveness of CBT-I in the management of insomnia symptoms in workers. We searched the literature in three electronic databases, namely PubMed, PsycINFO, and Embase, and included 21 studies in the meta-analysis. Compared with the control group, CBT-I overall resulted in significant improvements in terms of severity of insomnia (g = -0.91), sleep onset latency (g = -0.62), wakefulness after sleep onset (g = -0.60), early morning awakening (g = -0.58), and sleep efficiency (g = 0.71). However, there was no improvement in the total sleep time relative to that in the control group. Furthermore, CBT-I significantly alleviated depressive (g = -0.37) and anxiety (g = -0.35) symptoms and fatigue (g = -0.47) compared with the control group. Our study findings suggest that both web-based and face-to-face CBT-I are effective interventions for managing insomnia symptoms in daytime workers, although it is important to note that only face-to-face CBT-I achieved clinically meaningful changes. The effectiveness of CBT-I for shift workers could not be determined.

The effect of physical activity on sleep disturbance in various populations: a scoping review of randomized clinical trials

BACKGROUND

Promoting physical activity (PA) in different populations experiencing sleep disturbance may increase population PA levels and improve sleep. This scoping review aimed to examine the effect of various PA intervention strategies on sleep across different populations, identify key sleep outcomes, and analyze knowledge gaps by mapping the relevant literature.

METHODS

For this study, we systematically searched articles published till March 2022 from PubMed, Web of Science, Cochrane Library, and Embase databases for randomized clinical trials (RCTs) regarding the effect of physical activity on sleep. Two authors extracted key data and descriptively analyzed the data. Thematic analysis was used to categorize the results into themes by all authors. Arksey and O'Malley's scoping review framework was used to present the findings.

RESULTS

Twenty-one randomized controlled trials out of 3052 studies were finally included with 3677 participants (2852 females (78%)). Five trials were conducted in healthy working-age adults with sleep disturbance but without the diagnosis of insomnia, five in healthy older adults, two in perinatal women, four in patients with cancer, three in mental illness related subjects, and another two in other disease-related areas. PA interventions were diverse, including walking, resistance training, aerobic exercise, housework, water exercise, basketball, smartphone/tablet "apps", web, online videos or wearable actigraphy, and self-determined exercise. Three major themes were identified: (1) Sleep environment may be important to address prior to instituting PA interventions, (2) All types of PA were effective for improving sleep in all populations studied, (3) Self-tolerated PA is safe for improving sleep in the elderly and in co-morbid or perinatal populations.

CONCLUSIONS

PA is effective and safe for improving sleep in both healthy and co-morbid populations with sleep disturbance by increasing daily activity levels using a variety of strategies, even low intensity, such as housekeeping, sit-to-stand repetitions, along with encouraging PA through web pages, videos, and self-goal setting apps. In addition, this scoping review identifies the need for further therapeutic research and future exploration in populations with sleep initiation or sleep maintenance disturbance.

eHealth-Based Psychosocial Interventions for Adults With Insomnia: Systematic Review and Meta-analysis of Randomized Controlled Trials

BACKGROUND

Worldwide, insomnia remains a highly prevalent public health problem. eHealth presents a novel opportunity to deliver effective, accessible, and affordable insomnia treatments on a population-wide scale. However, there is no quantitative integration of evidence regarding the effectiveness of eHealth-based psychosocial interventions on insomnia.

OBJECTIVE

We aimed to evaluate the effectiveness of eHealth-based psychosocial interventions for insomnia and investigate the influence of specific study characteristics and intervention features on these effects.

METHODS

We searched PubMed, Embase, Web of Science, PsycINFO, and the Cochrane Central Register of Controlled Trials from database inception to February 16, 2021, for publications investigating eHealth-based psychosocial interventions targeting insomnia and updated the search of PubMed to December 6, 2021. We also screened gray literature for unpublished data. Eligible studies were randomized controlled trials of eHealth-based psychosocial interventions targeting adults with insomnia. Random-effects meta-analysis models were used to assess primary and secondary outcomes. Primary outcomes were insomnia severity and sleep quality. Meta-analyses were performed by pooling the effects of eHealth-based psychosocial interventions on insomnia compared with inactive and in-person conditions. We performed subgroup analyses and metaregressions to explore specific factors that affected the effectiveness. Secondary outcomes included sleep diary parameters and mental health-related outcomes.

RESULTS

Of the 19,980 identified records, 37 randomized controlled trials (13,227 participants) were included. eHealth-based psychosocial interventions significantly reduced insomnia severity (Hedges g=-1.01, 95% CI -1.12 to -0.89; P<.001) and improved sleep quality (Hedges g=-0.58, 95% CI -0.75 to -0.41; P<.001) compared with inactive control conditions, with no evidence of publication bias. We found no significant difference compared with in-person treatment in alleviating insomnia severity (Hedges g=0.41, 95% CI -0.02 to 0.85; P=.06) and a significant advantage for in-person treatment in enhancing sleep quality (Hedges g=0.56, 95% CI 0.24-0.88; P<.001). eHealth-based psychosocial interventions had significantly larger effects (P=.01) on alleviating insomnia severity in clinical samples than in subclinical samples. eHealth-based psychosocial interventions that incorporated guidance from trained therapists had a significantly greater effect on insomnia severity (P=.05) and sleep quality (P=.02) than those with guidance from animated therapists or no guidance. Higher baseline insomnia severity and longer intervention duration were associated with a larger reduction in insomnia severity (P=.004). eHealth-based psychosocial interventions significantly improved each secondary outcome.

CONCLUSIONS

eHealth interventions for insomnia are effective in improving sleep and mental health and can be considered a promising treatment for insomnia. Our findings support the wider dissemination of eHealth interventions and their further promotion in a stepped-care model. Offering blended care could improve treatment effectiveness. Future research needs to elucidate which specific intervention components are most important to achieve intervention effectiveness. Blended eHealth interventions may be tailored to benefit people with low socioeconomic status, limited access to health care, or lack of eHealth literacy.

Efficacy of lifestyle medicine on sleep quality: A meta-analysis of randomized controlled trials

OBJECTIVES

Randomized controlled trials (RCTs) on the efficacy of multicomponent lifestyle medicine (LM) interventions for improving sleep quality have yielded inconsistent findings. This study marks the first meta-analysis to evaluate the efficacy of multicomponent LM interventions in improving sleep quality.

METHODS

We searched six online databases for RCTs that compared multicomponent LM interventions to an active or inactive control group in an adult population and assessed subjective sleep quality as a primary or secondary outcome using validated sleep measures at any post-intervention time-point.

RESULTS

A total of 23 RCTs with 26 comparisons involving 2534 participants were included in the meta-analysis. After excluding outliers, the analysis revealed that multicomponent LM interventions significantly improved sleep quality at immediate post-intervention (d = 0.45) and at short-term follow-up (i.e., <three months) (d = 0.50) relative to an inactive control group. Regarding the comparison with active control, no significant between-group difference was found at any time-point. No meta-analysis was conducted at the medium- and long-term follow-up due to insufficient data. Subgroup analyses supported that multicomponent LM interventions had a more clinically relevant effect on improving sleep quality in participants with clinical levels of sleep disturbance (d = 1.02) relative to an inactive control at immediate post-intervention assessment. There was no evidence of publication bias.

CONCLUSION

Our findings provided preliminary evidence that multicomponent LM interventions were efficacious in improving sleep quality relative to an inactive control at immediate post-intervention and at short-term follow-up. Additional high-quality RCTs targeting individuals with clinically significant sleep disturbance and long-term follow-up are warranted.

Effectiveness of Telemedicine for Reducing Cardiovascular Risk: A Systematic Review and Meta-Analysis

BACKGROUND

Cardiovascular diseases are the leading cause of death globally. There are six cardiovascular risk factors: diabetes, hypertension, hypercholesterolemia, overweight, sedentary lifestyle and smoking. Due to the low attendance of healthy people in the health system, the use of telemedicine can influence the acquisition of a heart-healthy lifestyle.

OBJECTIVE

this systematic review and meta-analysis aimed to determine the effectiveness of telemedicine and e-health in reducing cardiovascular risk.

METHODS

A systematic review and meta-analysis were carried out using the PubMed, Scopus, Cinhal and WOS databases. Randomized controlled studies between 2017 and 2022 in which telemedicine was used to reduce any of the risk factors were included. The methodological quality was assessed using the "PEDro" scale.

RESULTS

In total, 763 studies were obtained; after the review, 28 target articles were selected and finally grouped as follows: 13 studies on diabetes, six on hypertension, seven on obesity and two on physical activity. For all of the risk factors, a small effect of the intervention was seen.

CONCLUSIONS

although the current evidence is heterogeneous regarding the statistically significant effects of telemedicine on various cardiovascular risk factors, its clinical relevance is undeniable; therefore, its use is recommended as long as the necessary infrastructure exists.

The association between sedentary behavior, exercise, and sleep disturbance: A mediation analysis of inflammatory biomarkers

Background

Two related lifestyle behaviors associated with sleep disturbance are sedentary behavior and physical exercise participation. We aimed to use a population-based study to disentangle the relationships between sedentary behavior, exercise, and sleep disturbance based on blood-cell-based inflammatory biomarkers.

Methods

A total of 22,599 participants from the National Health and Nutrition Examination Survey (NHANES) were included in the analyses. Sleep disturbance was assessed according to the NHANES questionnaire. Exercise participation ansd sedentary behavior were evaluated by the global physical activity questionnaire. The inflammatory biomarkers in the examination were white blood cell (WBC) count, neutrophil count (NEU), neutrophil-to-lymphocyte ratio (NLR), and systemic immune inflammation index (SII). A complex multistage sampling design and weighted multivariable logistic regression were applied for further analysis. Mediation models were constructed to figure out the mediating role of inflammatory biomarkers.

Results

The weighted prevalence of sleep disturbance was 24.17%. Sedentary behavior and exercise were associated with sleep disturbance after full adjustment [for sedentary behavior, OR (95% CI): 1.261 (1.154, 1.377); for exercise, OR (95% CI): 0.849 (0.757, 0.953)]. In severe sedentary behavior groups, the mitigation effect of exercise on sleep disturbance was observed [OR (95% CI): 0.687 (0.551, 0.857)]. For the mechanism, strong associations were detected between inflammatory biomarkers and sleep disturbance. Mediation analysis showed that WBC, NEU, NLR, and SII mediated the statistical association between sedentary behavior and sleep disturbance with proportions (%) of 2.09, 2.27, 1.76, and 0.82, respectively.

Conclusions

Our data suggested that sedentary behavior was a risk factor for sleep disturbance. Blood-cell-based inflammatory biomarkers were an easily accessible and cost-effective strategy for identifying sleep disturbance and also significantly mediated the association between sedentary behavior and sleep disturbance. Exercise was proved to be effective in severe sedentary behavior groups to improve sleep disturbance symptoms, while the internal mechanism needed further exploration.

Associations between aerobic and muscle-strengthening physical activity, sleep duration, and risk of all-cause mortality: A prospective cohort study of 282,473 U.S. adults

PURPOSE

To examine the joint associations between meeting guidelines for physical activity (PA) and sleep duration and all-cause mortality risk among adults.

METHODS

Participants were adults (n = 282,473) aged 18-84 years who participated in the 2004-2014 U.S. National Health Interview Survey. Mortality status was ascertained using the National Death Index through December 2015. Self-reported PA (Active: meeting both aerobic (AER) and muscle-strengthening (MSA) guidelines, AER only (AER), MSA only (MSA), or not meeting either AER or MSA (Inactive)) and sleep duration (Short, recommended (Rec), or Long) were classified according to guidelines, and 12 PA-sleep categories were derived. Adjusted hazard ratios and 95% confidence intervals (95%CIs) for all-cause mortality risk were estimated using Cox proportional hazards regression models.

RESULTS

A total of 282,473 participants (55% females) were included; 18,793 deaths (6.7%) occurred over an average follow-up of 5.4 years. Relative to the Active-Rec group, all other PA-sleep groups were associated with increased mortality risk except for the Active-Short group (hazard ratio = 1.08; 95%CI: 0.92-1.26). The combination of long sleep with either MSA or Inactive appeared to be synergistic. For a given sleep duration, mortality risk progressively increased among participants classified as AER, MSA, and Inactive. Within each activity level, the mortality risk was greatest among adults with long sleep.

CONCLUSION

Relative to adults meeting guidelines for both PA and sleep duration, adults who failed to meet guidelines for both AER and muscle strengthening PA and who also failed to meet sleep duration guidelines had elevated all-cause mortality risks. These results support interventions targeting both PA and sleep duration to reduce mortality risk.

Cardiovascular risks and sociodemographic correlates of multidimensional sleep phenotypes in two samples of US adults

Study Objectives

Sleep is a modifiable risk factor for cardiovascular conditions. Holistic examination of within-person, multidimensional sleep patterns may offer more detailed information about the sleep-cardiovascular condition link, including who is more vulnerable to both. This study aimed to identify common sleep phenotypes in adulthood, establish the validity of the phenotypes in relation to cardiovascular conditions, and explore sociodemographic and background characteristics of the phenotypes.

Methods

Across two independent samples of adults (N ₁ = 4600; N ₂ = 2598) from the Midlife in the United States Study, latent class analysis (LCA) extracted sleep phenotypes using five key self-reported sleep dimensions. Log-binomial regression was used to determine whether sleep phenotypes differentially predicted cardiovascular conditions, adjusting for known risk factors. LCA with covariates was used to compare sociodemographic characteristics of the identified sleep phenotypes.

Results

Four sleep phenotypes were identified consistently across the two samples: good sleepers, nappers, dissatisfied/inefficient sleepers, and irregular sleepers. Compared to good sleepers (reference), dissatisfied/inefficient sleepers exhibited a higher risk of cardiovascular conditions in both samples (RR _Sample1: 29%, RR _Sample2: 53%) and consisted of relatively more racial/ethnic minorities. Nappers exhibited a higher risk of cardiovascular conditions in one sample (RR _Sample1: 38%) and consisted of more women and older adults. Irregular sleepers exhibited no significantly different cardiovascular risk and were relatively younger.

Conclusions

Common sleep phenotypes in adulthood exhibit differential risks for cardiovascular conditions. Cooccurring sleep dissatisfaction and inefficiency, in particular, may relate to increased risk of cardiovascular conditions. Certain sociodemographic groups (racial minorities, women, older adults) disproportionately fit within high-risk sleep phenotypes.

Effectiveness of physical activity monitors in adults: systematic review and meta-analysis

OBJECTIVE

To estimate the effectiveness of physical activity monitor (PAM) based interventions among adults and explore reasons for the heterogeneity.

DESIGN

Systematic review and meta-analysis.

STUDY SELECTION

The electronic databases MEDLINE, Embase, SPORTDiscus, CINAHL, and the Cochrane Central Register of Controlled Trials (CENTRAL) were searched on 4 June 2021. Eligible randomised controlled trials compared interventions in which adults received feedback from PAMs with control interventions in which no feedback was provided. No restrictions on type of outcome measurement, publication date, or language were applied.

DATA EXTRACTION AND SYNTHESIS

Two reviewers independently extracted data and assessed risk of bias. Random effects meta-analyses were used to synthesise the results. The certainty of evidence was rated by the Grading of Recommendations Assessment and Evaluation (GRADE) approach.

MAIN OUTCOME MEASURES

The three primary outcomes of interest were physical activity, moderate to vigorous physical activity, and sedentary time.

RESULTS

121 randomised controlled trials with 141 study comparisons, including 16 743 participants, were included. The PAM based interventions showed a moderate effect (standardised mean difference 0.42, 95% confidence interval 0.28 to 0.55) on physical activity, equivalent to 1235 daily steps; a small effect (0.23, 0.16 to 0.30) on moderate to vigorous physical activity, equivalent to 48.5 weekly minutes; and a small insignificant effect (-0.12, -0.25 to 0.01) on sedentary time, equal to 9.9 daily minutes. All outcomes favoured the PAM interventions.

CONCLUSIONS

The certainty of evidence was low for the effect of PAM based interventions on physical activity and moderate for moderate to vigorous physical activity and sedentary time. PAM based interventions are safe and effectively increase physical activity and moderate to vigorous physical activity. The effect on physical activity and moderate to vigorous physical activity is well established but might be overestimated owing to publication bias.

STUDY REGISTRATION

PROSPERO CRD42018102719.

Quality improvement and usability testing of the PortfolioDiet.app, a web-based health application to translate nutrition therapy for cardiovascular risk reduction in primary care (Preprint)

Background

The Portfolio Diet, or Dietary Portfolio, is a therapeutic dietary pattern that combines cholesterol-lowering foods to manage dyslipidemia for the prevention of cardiovascular disease. To translate the Portfolio Diet for primary care, we developed the PortfolioDiet.app as a patient and physician educational and engagement tool for PCs and smartphones. The PortfolioDiet.app is currently being used as an add-on therapy to the standard of care (usual care) for the prevention of cardiovascular disease in primary care. To enhance the adoption of this tool, it is important to ensure that the PortfolioDiet.app meets the needs of its target end users.

Objective

The main objective of this project is to undertake user testing to inform modifications to the PortfolioDiet.app as part of ongoing engagement in quality improvement (QI).

Methods

We undertook a 2-phase QI project from February 2021 to September 2021. We recruited users by convenience sampling. Users included patients, family physicians, and dietitians, as well as nutrition and medical students. For both phases, users were asked to use the PortfolioDiet.app daily for 7 days. In phase 1, a mixed-form questionnaire was administered to evaluate the users’ perceived acceptability, knowledge acquisition, and engagement with the PortfolioDiet.app. The questionnaire collected both quantitative and qualitative data, including 2 open-ended questions. The responses were used to inform modifications to the PortfolioDiet.app. In phase 2, the System Usability Scale was used to assess the usability of the updated PortfolioDiet.app, with a score higher than 70 being considered acceptable.

Results

A total of 30 and 19 users were recruited for phase 1 and phase 2, respectively. In phase 1, the PortfolioDiet.app increased users’ perceived knowledge of the Portfolio Diet and influenced their perceived food choices. Limitations identified by users included challenges navigating to resources and profile settings, limited information on plant sterols, inaccuracies in points, timed-logout frustration, request for step-by-step pop-up windows, and request for a mobile app version; when looking at positive feedback, the recipe section was the most commonly praised feature. Between the project phases, 6 modifications were made to the PortfolioDiet.app to incorporate and address user feedback. At phase 2, the average System Usability Scale score was 85.39 (SD 11.47), with 100 being the best possible.

Conclusions

By undertaking user testing of the PortfolioDiet.app, its limitations and strengths were able to be identified, informing modifications to the application, which resulted in a clinical tool that better meets users’ needs. The PortfolioDiet.app educates users on the Portfolio Diet and is considered acceptable by users. Although further refinements to the PortfolioDiet.app will continue to be made before its evaluation in a clinical trial, the result of this QI project is an improved clinical tool.

Efficacy of a Multi-Component m-Health Diet, Physical Activity, and Sleep Intervention on Dietary Intake in Adults with Overweight and Obesity: A Randomised Controlled Trial

This three-arm randomised controlled trial evaluated whether (1) a multi-component weight loss intervention targeting diet, physical activity (PA), and sleep was effective at improving dietary intake over six months and 12 months, compared with a control, and (2) the enhanced diet, PA, and sleep intervention was more effective at improving dietary intake than the traditional diet and PA intervention. A total of 116 adults (70% female, 44.5 years, BMI 31.7 kg/m²) were randomised to either traditional diet and PA intervention; enhanced diet, PA, and sleep intervention; or wait-list control. To examine between-group differences, intervention groups were pooled and compared with the control. Then, the two intervention groups were compared. At six months, the pooled intervention group consumed 1011 fewer kilojoules/day (95% CI −1922, −101), less sodium (−313.2 mg/day; 95% CI −591.3, −35.0), and higher %EI from fruit (+2.1%EI; 95% CI 0.1, 4.1) than the controls. There were no differences in intake between the enhanced and traditional groups at six months. At 12 months, the pooled intervention and control groups reported no significant differences. However, compared to the traditional group, the enhanced reported higher %EI from nutrient-dense foods (+7.4%EI; 95% CI 1.3, 13.5) and protein (+2.4%EI; 95% CI 0.1, 4.6), and reduced %EI from fried/takeaway foods (−3.6%EI; 95% CI −6.5, −0.7), baked sweet products (−2.0%EI; 95% CI −3.6, −0.4), and packaged snacks (−1.1%EI; 95% CI −2.2, −0.3). This weight loss intervention reduced total energy and sodium intakes as well as increased fruit intake in adults at six months. The enhanced intervention group reported improved dietary intake relative to the traditional group at 12 months.

The Association Between Logging Steps Using a Website, App, or Fitbit and Engaging With the 10,000 Steps Physical Activity Program: Observational Study

Background

Engagement is positively associated with the effectiveness of digital health interventions. It is unclear whether tracking devices that automatically synchronize data (eg, Fitbit) produce different engagement levels compared with manually entering data.

Objective

This study examines how different step logging methods in the freely available 10,000 Steps physical activity program differ according to age and gender and are associated with program engagement.

Methods

A subsample of users (n=22,142) of the free 10,000 Steps physical activity program were classified into one of the following user groups based on the step-logging method: Website Only (14,617/22,142, 66.01%), App Only (2100/22,142, 9.48%), Fitbit Only (1705/22,142, 7.7%), Web and App (2057/22,142, 9.29%), and Fitbit Combination (combination of web, app, and Fitbit; 1663/22,142, 7.51%). Generalized linear regression and binary logistic regression were used to examine differences between user groups’ engagement and participation parameters. The time to nonusage attrition was assessed using Cox proportional hazards regression.

Results

App Only users were significantly younger and Fitbit user groups had higher proportions of women compared with other groups. The following outcomes were significant and relative to the Website Only group. The App Only group had fewer website sessions (odds ratio [OR] −6.9, 95% CI −7.6 to −6.2), whereas the Fitbit Only (OR 10.6, 95% CI 8.8-12.3), Web and App (OR 1.5, 95% CI 0.4-2.6), and Fitbit Combination (OR 8.0; 95% CI 6.2-9.7) groups had more sessions. The App Only (OR −0.7, 95% CI −0.9 to −0.4) and Fitbit Only (OR −0.5, 95% CI −0.7 to −0.2) groups spent fewer minutes on the website per session, whereas the Fitbit Combination group (OR 0.2, 95% CI 0.0-0.5) spent more minutes. All groups, except the Fitbit Combination group, viewed fewer website pages per session. The mean daily step count was lower for the App Only (OR −201.9, 95% CI −387.7 to −116.0) and Fitbit Only (OR −492.9, 95% CI −679.9 to −305.8) groups but higher for the Web and App group (OR 258.0, 95% CI 76.9-439.2). The Fitbit Only (OR 5.0, 95% CI 3.4-6.6), Web and App (OR 7.2, 95% CI 5.9-8.6), and Fitbit Combination (OR 15.6, 95% CI 13.7-17.5) groups logged a greater number of step entries. The App Only group was less likely (OR 0.65, 95% CI 0.46-0.94) and other groups were more likely to participate in Challenges. The mean time to nonusage attrition was 35 (SD 26) days and was lower than average in the Website Only and App Only groups and higher than average in the Web and App and Fitbit Combination groups.

Conclusions

Using a Fitbit in combination with the 10,000 Steps app or website enhanced engagement with a real-world physical activity program. Integrating tracking devices that synchronize data automatically into real-world physical activity interventions is one strategy for improving engagement.

Joint association of physical activity and sleep difficulties with the incidence of hypertension in mid-age Australian women

INTRODUCTION

Little is known about the joint effects of physical activity and sleep difficulties on hypertension. The aim of this study was to examine the joint associations of physical activity and sleep difficulties with the incidence of hypertension in mid-aged women.

STUDY DESIGN

Prospective cohort study.

MAIN OUTCOME MEASURES

Mid-aged participants (n = 5,300) in the Australian Longitudinal Study on Women's Health completed four triennial surveys starting in 2004, when they had a mean age of 55 years. The presence of hypertension, physical activity and the number of sleep difficulties (range 0-4) were reported at each survey. Total MET.min/week of physical activity was assessed, and dichotomised as inactive (<500 MET.min/wk) or active (≥500 MET.min/wk). Joint categories of physical activity and sleep difficulties were created using six mutually exclusive groups. Associations of joint physical activity and sleep difficulty groups with incident hypertension were examined via discrete-time survival analysis using logit-hazard models.

RESULTS

There were 1,175 cases of incident hypertension (22.2%). Compared with the Active and No Difficulties group, women in the Inactive and 1 Difficulty (Odds Ratio (95% confidence interval) (1.31 (1.06, 1.62)) and Inactive and 2-4 Difficulties (1.44 (1.16, 1.78)) groups were more likely to develop hypertension. Sleep difficulties were not associated with hypertension among active women.

CONCLUSIONS

Mid-aged inactive women with sleep difficulties were more likely to develop hypertension. Physical activity appeared to protect against the increased risk of hypertension in women with sleeping difficulties.

Effect of a physical activity and sleep m-health intervention on a composite activity-sleep behaviour score and mental health: a mediation analysis of two randomised controlled trials

BACKGROUND

To examine if a composite activity-sleep behaviour index (ASI) mediates the effects of a combined physical activity and sleep intervention on symptoms of depression, anxiety, or stress, quality of life (QOL), energy and fatigue in adults.

METHODS

This analysis used data pooled from two studies: Synergy and Refresh. Synergy: Physically inactive adults (18-65 years) who reported poor sleep quality were recruited for a two-arm Randomised Controlled Trial (RCT) (Physical Activity and Sleep Health (PAS; n = 80), or Wait-list Control (CON; n = 80) groups). Refresh: Physically inactive adults (40-65 years) who reported poor sleep quality were recruited for a three-arm RCT (PAS (n = 110), Sleep Health-Only (SO; n = 110) or CON (n = 55) groups). The SO group was omitted from this study. The PAS groups received a pedometer, and accessed a smartphone/tablet "app" using behaviour change strategies (e.g., self-monitoring, goal setting, action planning), with additional email/SMS support. The ASI score comprised self-reported moderate-to-vigorous-intensity physical activity, resistance training, sitting time, sleep duration, efficiency, quality and timing. Outcomes were assessed using DASS-21 (depression, anxiety, stress), SF-12 (QOL-physical, QOL-mental) and SF-36 (Energy & Fatigue). Assessments were conducted at baseline, 3 months (primary time-point), and 6 months. Mediation effects were examined using Structural Equation Modelling and the product of coefficients approach (AB), with significance set at 0.05.

RESULTS

At 3 months there were no direct intervention effects on mental health, QOL or energy and fatigue (all p > 0.05), and the intervention significantly improved the ASI (all p < 0.05). A more favourable ASI score was associated with improved symptoms of depression, anxiety, stress, QOL-mental and of energy and fatigue (all p < 0.05). The intervention effects on symptoms of depression ([AB; 95%CI] -0.31; - 0.60,-0.11), anxiety (- 0.11; - 0.27,-0.01), stress (- 0.37; - 0.65,-0.174), QOL-mental (0.53; 0.22, 1.01) and ratings of energy and fatigue (0.85; 0.33, 1.63) were mediated by ASI. At 6 months the magnitude of association was larger although the overall pattern of results remained similar.

CONCLUSIONS

Improvements in the overall physical activity and sleep behaviours of adults partially mediated the intervention effects on mental health and quality of life outcomes. This highlights the potential benefit of improving the overall pattern of physical activity and sleep on these outcomes.

TRIAL REGISTRATION

Australian New Zealand Clinical Trial Registry: ACTRN12617000680369 ; ACTRN12617000376347 . Universal Trial number: U1111-1194-2680; U1111-1186-6588. Human Research Ethics Committee Approval: H-2016-0267; H-2016-0181.

The influence of sleep health on dietary intake: a systematic review and meta-analysis of intervention studies

BACKGROUND

Poor dietary intake increases disease risk, and poor sleep influences diet. This systematic review and meta-analysis of intervention studies aimed to evaluate the effect of sleep health on dietary intake in adults.

METHODS

Five online databases were used to identify studies published between 1970 and 2019. Included studies were interventions that modified sleep and reported dietary outcomes.

RESULTS

Fifty four full texts were assessed and 24 publications were included. Following risk of bias appraisal, data were narratively summarised and a sub-group of studies (n = 15) was meta-analysed to determine the effect of sleep on dietary intake. One intervention modified sleep timing and 23 modified duration. Sleep duration was partially restricted (≤5.5 h night^-1 ) (n = 16), totally restricted (n = 4), partially and totally restricted (n = 1), and extended (n = 2). Dietary outcomes were energy intake (n = 24), carbohydrate, fat, protein intake (n = 20), single nutrient intake (n = 5), diet quality (n = 1) and food types (n = 1). Meta-analysis indicated partial sleep restriction results in higher energy intake in intervention compared with control [standardised mean difference (SMD) = 0.37; 95% confidence interval (CI) = 0.21-0.52; P < 0.001], with a mean difference of 204 kcal (95% CI = 112-295; P < 0.001) in daily energy intake, and a higher percentage of energy from fat, protein, carbohydrate (fat: SMD = 0.33; 95% CI = 0.16-0.51; P < 0.001; protein: SMD = 0.30, 95% CI = 0.12-0.47, P = 0.001; carbohydrate: SMD = 0.22, 95% CI = 0.04-0.39, P = 0.014).

CONCLUSIONS

Partial sleep restriction with duration of ≤5.5 h day^-1 increases daily energy intake, as well as fat, protein and carbohydrate intake. Further research is needed to determine the relationship between other dimensions of sleep health and dietary intake.

Efficacy of a Multi-component m-Health Weight-loss Intervention in Overweight and Obese Adults: A Randomised Controlled Trial

BACKGROUND

This study compared the efficacy of two multi-component m-health interventions with a wait-list control group on body weight (primary outcome), and secondary outcomes of cardiovascular risk factors, lifestyle behaviours, and mental health.

METHODS

Three-arm randomised controlled trial (Enhanced: physical activity, diet, sleep, Traditional: physical activity, diet, Control) with assessments conducted at baseline, 6 and 12 months. Participants (n = 116) were overweight or obese adults aged 19-65 (M = 44.5 [SD = 10.5]). The 6-month intervention was delivered via a smartphone app providing educational materials, goal-setting, self-monitoring and feedback, and also included one face-to-face dietary consultation, a Fitbit and scales. The trial was prospectively registered and conducted between May 2017 and September 2018. Group differences on primary and secondary outcomes were examined between the Pooled Intervention groups (Pooled Intervention = Enhanced and Traditional) and Control groups, and then between Enhanced and Traditional groups.

RESULTS

Nineteen participants (16.4%) formally withdrew from the trial. Compared with the Control group, average body weight of the Pooled Intervention group did not differ at 6 (between-group difference = -0.92, (95% CI -3.33, 1.48)) or 12 months (0.00, (95% CI -2.62, 2.62)). Compared with the Control group, the Pooled Intervention group significantly increased resistance training (OR = 7.83, (95% CI 1.08, 56.63)) and reduced energy intake at 6 months (-1037.03, (-2028.84, -45.22)), and improved insomnia symptoms at 12 months (-2.59, (-4.79, -0.39)). Compared with the Traditional group, the Enhanced group had increased waist circumferences (2.69, (0.20, 5.18)) and sedentary time at 6 months (105.66, (30.83, 180.48)), and improved bed time variability at 12 months (-1.08, (-1.86, -0.29)). No other significant differences were observed between groups.

CONCLUSIONS

Relative to Controls, the Pooled Intervention groups did not differ on body weight but improved resistance training, and reduced energy intake and insomnia symptom severity. No additional weight loss was apparent when targeting improvements in physical activity, diet and sleep in combination compared with physical activity and diet.