Longitudinal associations between self-reported sleep duration and cardiometabolic disease risk in corporate executives.

OBJECTIVE: This study aimed to determine the longitudinal associations between self-reported sleep duration and cardiometabolic disease (CMD) risk in corporate executives. METHODS: Self-reported sleep duration and lifestyle, occupational, psychological, and anthropometrical, blood pressure and blood marker variables were obtained from 1512 employees at annual health risk assessments in South Africa between 2016 and 2019. Gender-stratified linear mixed models, adjusting for age, lifestyle, occupational and psychological covariates were used to explore these longitudinal associations. RESULTS: Among women, shorter sleep duration was associated with higher body mass index (BMI) covarying for age only (ß with 95% confidence intervals: -0.19 [-0.36, -0.03]), age and occupational factors (-0.20 [-0.36, -0.03]) and age and psychological factors (-0.20 [-0.37, -0.03]). Among men, shorter sleep was associated with both BMI and waist circumference (WC) covarying for age only (BMI: -0.15 [-0.22; -0.08]; WC: -0.62 [-0.88; -0.37]); age and lifestyle factors (BMI: -0.12 [-0.21; -0.04]); WC: -0.016 [-0.92; -0.29], age and occupational factors (BMI: -0.20 [-0.22; 0.08]; WC: -0.62 [-0.88; -0.36]), and age and psychological factors (BMI: -0.15 [-0.22; -0.07]; WC: -0.59 [-0.86; -0.33]). Among men, shorter sleep was also longitudinally associated with higher CMD risk scores in models adjusted for age and lifestyle factors (CMD: -0.12 [-0.20; -0.04]) and age and psychological factors (CMD: -0.08 [-0.15; -0.01]). CONCLUSION: Corporate executives who report shorter sleep durations may present with poorer CMD risk profiles, independent of age, lifestyle, occupational and psychological factors. Addressing sleep health in workplace health programmes may help mitigate the development of CMD in such employees.

Delayed circadian rhythms in older Africans living with human immunodeficiency virus (HIV).

The increasing number of people living with human immunodeficiency virus, HIV, (PLWH) have an elevated incidence of risk for noncommunicable comorbidities, the aetiology of which remains incompletely understood. While sleep disturbances are often reported in PLWH, it is unknown to what extent they relate to changes in the circadian and/or sleep homeostatic processes. We studied the relationship between sleep characteristics, circadian phase, and HIV status in older adults from the HAALSI (Health and Ageing in Africa: a Longitudinal Study of an INDEPTH Community in South Africa) subsample of the Agincourt Health and Demographic Surveillance System in South Africa (n = 187, 36 human immunodeficiency virus positive [HIV+], age: 66.7 ± 11.5 years, range 45-93 years), where HIV prevalence is high and (in contrast to the global north) does not associate significantly with potentially confounding behavioural differences. In participants with valid actigraphy data (n = 172), regression analyses adjusted for age and sex indicated that HIV+ participants had slightly later sleep onset (ß = .16, p = .039), earlier sleep offset times (ß = -.16, p = .049) and shorter total sleep times (ß = -.20, p = .009) compared to the HIV negative (HIV-) participants. In a subset of participants (n = 51, 11 HIV+), we observed a later dim light melatonin onset (DLMO) in HIV+ (21:16 ± 01:47) than in HIV- (20:06 ± 00:58) participants (p = .006). This substantial difference remained when adjusted for age and sex (ß = 1.21; p = .006). In 36 participants (6 HIV+) with DLMO and actigraphy data, median phase angle of entrainment was -6 min in the HIV+ group and +1 h 25 min in the HIV- group. DLMO time correlated with sleep offset (ρ = 0.47, p = .005) but not sleep onset (ρ = -0.086, p = .623). Collectively, our data suggest that the sleep phase occurred earlier than what would be biologically optimal among the HIV+ participants. This is the first report of a mistimed circadian phase in PLWH, which has important potential implications for their health and well-being, especially given the well-established relationships between circadian asynchrony and sleep deprivation with poorer health outcomes.

Prevalence of obesity, hypertension and diabetes among people living with HIV in South Africa: a systematic review and meta-analysis.

BACKGROUND: HIV has become a manageable chronic condition due to the success and scale-up of antiretroviral therapy (ART). Globally, South Africa has the highest number of people living with HIV (PLHIV) and research evidence indicates that countries with the highest burden of PLHIV have a substantial burden of obesity, hypertension (HPT) and type 2 diabetes (T2D). We sought to summarize the burden of these three common NCDs among PLHIV in South Africa. METHODS: In this systematic review, multiple databases were searched for articles reporting on the prevalence of obesity, HPT, and T2D among PLHIV in South Africa published since journal inception until March 2022. A meta-analysis was conducted using random-effects models to obtain pooled prevalence estimates of the three NCDs. Heterogeneity was assessed using X2 test on Cochran's Q statistic. RESULTS: We included 32 studies, with 19, 22 and 18 studies reporting the prevalence of obesity, HPT, and T2D among PLHIV, respectively. The overall prevalence of obesity, HPT, and T2D was 23.2% [95% CI 17.6; 29.9], 25.5% [95% CI 15.6; 38.7], and 6.1% [95% CI 3.8; 9.7] respectively. The prevalence of obesity was significantly higher among women (P = 0.034) compared to men, however the prevalence of HPT and T2D did not differ by sex. The prevalence of each of the three NCDs did not differ significantly between rural, urban, and peri-urban areas. The prevalence of obesity and T2D was higher in studies conducted between 2013 and 2022 compared to studies conducted between 2000 and 2012, while the prevalence of HPT was higher between 2000 and 2012 compared to between 2013 and 2022. CONCLUSIONS: These findings suggest that South Africa is experiencing a syndemic of NCDs among people PLHIV highlighting the need to increase cost-effective interventions and management strategies that involve integrated HIV and NCD care in the South African setting.

Cross-sectional associations between mental health indicators and social vulnerability, with physical activity, sedentary behaviour and sleep in urban African young women.

BACKGROUND: Relationships between mental health and multiple health behaviours have not been explored in young South African women experiencing social constraints. The aim of this study was to identify associations between mental health indicators and risk factors with physical activity, sedentary behaviour, and sleep, amongst young women living in Soweto, a predominantly low-income, urban South African setting. METHODS: For this cross-sectional study, baseline measurements for participants (n = 1719, 18.0-25.9 years old) recruited for the Healthy Life Trajectories Initiative were used including: physical activity, sedentary behaviour (sitting, screen and television time), sleep (duration and quality), depression and anxiety indicators, emotional health, adverse childhood experiences, alcohol-use risk; social vulnerability, self-efficacy, and social support. RESULTS: Multiple regression analyses showed that depression (ß = 0.161, p < 0.001), anxiety (ß = 0.126, p = 0.001), adverse childhood experiences (ß = 0.076, p = 0.014), and alcohol-use risk (ß = 0.089, p = 0.002) were associated with poor quality sleep. Alcohol-use risk was associated with more screen time (ß = 0.105, p < 0.001) and television time (ß = 0.075, p < 0.016). Social vulnerability was associated with lower sitting time (ß = - 0.187, p < 0001) and screen time (ß = - 0.014, p < 0.001). Higher self-efficacy was associated with more moderate- to vigorous-intensity physical activity (ß = 0.07, p = 0.036), better-quality sleep (ß = - 0.069, p = 0.020) and less television time (ß = - 0.079, p = 0.012). Having no family support was associated with more sitting time (ß = 0.075, p = 0.022). Binomial logistic regression analyses supported these findings regarding sleep quality, with anxiety and depression risk doubling the risk of poor-quality sleep (OR = 2.425, p < 0.001, OR = 2.036, p = 0.003 respectively). CONCLUSIONS: These findings contribute to our understanding of how mental health indicators and risk factors can be barriers to health behaviours of young women in Soweto, and that self-efficacy and social support can be protective for certain of these behaviours for these women. Our results highlight the uniqueness of this setting regarding associations between mental health and behaviours associated with non-communicable diseases risk.

Sleep and BMI in South African urban and rural, high and low-income preschool children.

BACKGROUND: The extent to which income setting or rural and urban environments modify the association between sleep and obesity in young children is unclear. The aims of this cross-sectional observational study were to (i) describe and compare sleep in South African preschool children from rural low-income (RL), urban low-income (UL) and urban high-income (UH) settings; and (ii) test for associations between sleep parameters and body mass index (BMI). METHODS: Participants were preschoolers (5.2 ± 0.7y, 49.5% boys) from RL (n = 111), UL (n = 65) and UH (n = 22) settings. Height and weight were measured. Sleep, sedentary behaviour and physical activity were assessed using accelerometery. RESULTS: UL children had higher BMI z-scores (median: 0.39; interquartile range: - 0.27, 0.99) than the UH (- 0.38; - 0.88, 0.11) and RL (- 0.08; - 0.83, 0.53) children (p = 0.001). The UL children had later bedtimes (p < 0.001) and wake-up times (p < 0.001) and shorter 24 h (p < 0.001) and nocturnal (p < 0.001) sleep durations than the RL and UH children. After adjusting for age, sex, setting, SB and PA, for every hour less sleep obtained (24 h and nocturnal), children were 2.28 (95% CI: 1.28-4.35) and 2.22 (95% CI: 1.27-3.85) more likely, respectively, to belong to a higher BMI z-score quartile. CONCLUSIONS: Shorter sleep is associated with a higher BMI z-score in South African preschoolers, despite high levels of PA, with UL children appearing to be particularly vulnerable.

Association between self-reported sleep duration and cardiometabolic risk in corporate executives.

PURPOSE: This cross-sectional study aimed to compare the association between self-reported sleep duration and cardiometabolic risk among men and women corporate executives and investigate potential lifestyle, work- and stress-related mediators thereof. METHODS: Self-reported sleep duration and lifestyle, occupational, psychological and measured anthropometrical, blood pressure (BP) and blood marker variables were obtained from health risk assessment data of 3583 corporate executives. Sex-stratified regression analyses investigated the relationships between occupational and psychological variables with self-reported sleep duration, and sleep duration with individual cardiometabolic risk factors. Mediation analyses investigated the effects of work, psychological and lifestyle factors on the relationships between self-reported sleep duration and cardiometabolic risk factors, as well as a continuous cardiometabolic risk score calculated from the sum of sex-stratified z-standardized scores of negative fasting serum HDL, and positive plasma Glu, serum TG, body mass index (BMI), waist circumference, systolic and diastolic BP. RESULTS: Longer work hours and work commute time, depression, anxiety and stress were associated with shorter sleep duration in both men and women (all p < 0.05). Shorter sleep duration was associated with higher BMI, larger waist circumference and greater cardiometabolic risk scores in both men and women (all p < 0.05), higher diastolic BP in men (p < 0.05) and lower HDL cholesterol in women (p < 0.05). Physical activity, working hours and stress significantly mediated the relationships between self-reported sleep duration and BMI, waist circumference, diastolic BP and cardiometabolic risk score in men only. CONCLUSION: In these corporate executives, shorter self-reported sleep duration is associated with poorer psychological, occupational and cardiometabolic risk outcomes in both men and women. Given that physical activity, working hours and stress mediate this association among the men, the case for sleep health interventions in workplace health programmes is warranted.

The effects of sleep extension on cardiometabolic risk factors: A systematic review.

Studies have shown bidirectional relationships between short- or long-sleep duration and risk for obesity, non-communicable diseases, all-cause mortality and cardiovascular disease mortality. Increasing sleep duration may be an appropriate strategy to reduce cardiometabolic risk in short-sleeping individuals. The aim is to review the effects of sleep extension interventions on cardiometabolic risk in adults. The PubMed and Scopus databases were searched for relevant, English, peer-reviewed scientific publications (until August 2018). Seven studies that aimed to increase sleep duration in adults by any sleep extension intervention and described at least one cardiometabolic risk factor were included. These studies had a combined sample size of 138 participants who were either healthy (n = 14), healthy short-sleeping (n = 92), overweight short-sleeping (n = 10), or pre- or hypertensive short-sleeping (n = 22) individuals. The durations of the sleep extension interventions ranged from 3 days to 6 weeks, and all successfully increased total sleep time by between 21 and 177 min. Sleep extension was associated with improved direct and indirect measures of insulin sensitivity, decreased leptin and peptide tyrosine-tyrosine, and reductions in overall appetite, desire for sweet and salty foods, intake of daily free sugar, and percentage of daily caloric intake from protein. This review provides preliminary evidence for a role for sleep extension to improve cardiometabolic outcomes and directive towards future studies in the field of cardiometabolic health and sleep.

The metabolic effects of a commercially available chicken peri-peri (African bird's eye chilli) meal in overweight individuals.

A growing body of evidence suggests that capsaicin ingestion may lead to desirable metabolic outcomes; however, the results in humans are equivocal. Whether or not benefits may be gained from ingestion of capsaicin via a commercially available meal has not been determined. The objectives of this randomised, cross-over intervention study were to compare the 2 h postprandial effects of a standard commercially prepared meal containing chilli (HOT, 5·82 mg total capsaicinoids) with a similar meal with no chilli (CON, 25 kg/m2 and a waist circumference >94 cm (men) or 80 cm (women), were studied. Participants had normal glucose tolerance and were accustomed, but were not regular chilli eaters. A paired t test indicated that insulin AUC was smaller following the HOT meal (P=0·002). Similarly, there was a tendency for glucose AUC to be reduced following the HOT meal (P=0·056). No discernable effects of the HOT meal were observed on metabolic rate, core temperature, hs-CRP concentrations and endothelial-dependent microvascular reactivity. The results from this study indicate that a standard restaurant meal containing a relatively small dose of capsaicin delivered via African bird's eye chilli, which is currently available to the public, results in lower postprandial insulin concentrations in overweight individuals, compared with the same meal without chilli.

One night of partial sleep deprivation impairs recovery from a single exercise training session.

PURPOSE: The effects of sleep deprivation on physical performance are well documented, but data on the consequence of sleep deprivation on recovery from exercise are limited. The aim was to compare cyclists' recovery from a single bout of high-intensity interval training (HIIT) after which they were given either a normal night of sleep (CON, 7.56 ± 0.63 h) or half of their usual time in bed (DEP, 3.83 ± 0.33 h). METHODS: In this randomized cross-over intervention study, 16 trained male cyclists (age 32 ± 7 years), relative peak power output (PPO 4.6 ± 0.7 W kg-1) performed a HIIT session at ±18:00 followed by either the CON or DEP sleep condition. Recovery from the HIIT session was assessed the following day by comparing pre-HIIT variables to those measured 12 and 24 h after the session. Following a 2-week washout, cyclists repeated the trial, but under the alternate sleep condition. RESULTS: PPO was reduced more 24 h after the HIIT session in the DEP (ΔPPO -0.22 ± 0.22 W kg-1; range -0.75 to 0.1 W kg-1) compared to the CON condition (ΔPPO -0.05 ± 0.09 W kg-1, range -0.19 to 0.17 W kg-1, p = 0.008, d = -2.16). Cyclists were sleepier (12 h: p = 0.002, d = 1.90; 24 h: p = 0.001, d = 1.41) and felt less motivated to train (12 h, p = 0.012, d = -0.89) during the 24 h recovery phase when the HIIT session was followed by the DEP condition. The exercise-induced 24 h reduction in systolic blood pressure observed in the CON condition was absent in the DEP condition (p = 0.039, d = 0.75). CONCLUSIONS: One night of partial sleep deprivation impairs recovery from a single HIIT session in cyclists. Further research is needed to understand the mechanisms behind this observation.

Factors to consider when assessing diurnal variation in sports performance: the influence of chronotype and habitual training time-of-day.

PURPOSE: The aim of this study was to compare morning and evening time-trial performance, RPE and mood state of trained swimmers, taking into account chronotype, habitual training time-of-day and PERIOD3 (PER3) variable number tandem repeat genotype. METHODS: Twenty-six swimmers (18 males, age: 32.6 ± 5.7 years) swam 200 m time trials (TT) at 06h30 and 18h30 in a randomised order. RESULTS: There was no difference between morning and evening performance when the swimmers were considered as a single group (06h30: 158.8 ± 22.7 s, 18h30: 158.5 ± 22.0 s, p = 0.611). However, grouping swimmers by chronotype and habitual training time-of-day allowed us to detect significant diurnal variation in performance, such that morning-type swimmers and those who habitually train in the morning were faster in the 06h30 TT (p = 0.036 and p = 0.011, respectively). This was accompanied by lower ratings of perceived exertion (RPE) scores post-warm-up, higher vigour and lower fatigues scores prior to the 06h30 TT in morning-type swimmers or those who trained in the morning. Similarly, neither types and those who trained in the evenings had lower fatigue and higher vigour prior to the 18h30 TT. CONCLUSIONS: It appears that both chronotype and habitual training time-of-day need to be considered when assessing diurnal variation in performance. From a practical point of view, athletes and coaches should be aware of the potentially powerful effect of training time on shifting time-of-day variation in performance.

Perception of effort in morning-type cyclists is lower when exercising in the morning.

A recent study found that South African endurance athletes are likely to be morning-types and carry the PER3(5) allele, which has been associated with a preference for mornings. The aim of this study was to measure the response of morning-type cyclists to a standardised bout of exercise performed at different times of the day. Participants ncluded 20 trained male cyclists (age: 39.8 ± 7.7 years, VO2max: 51.0 ± 7.0 ml · kg(-1) · min(-1), training: 166 ± 98 km · wk(-1)), categorised as morning-types (mean Horne-Östberg score: 68.3 ± 5.5) and carrying the PER3(5) allele. They completed a 17-min sub-maximal cycling test at 60%, 80% and 90% of maximum heart rate (HRmax) at 06h00, 10h00, 14h00, 18h00 and 22h00. These morning-type cyclists reported higher ratings of perceived exertion when cycling at 60% (P = 0.044), 80% (P < 0.001) and 90% (P < 0.001) of HRmax during the evening (18h00 and 22h00) compared to the other sessions (0600, 10h00 and 14h00). This was despite absolute power output, speed and cadence displaying no time-of-day differences. Thus, morning-type cyclists perceive the same relative intensity workload to be harder in the evening compared to the morning. This may have implications for both training and competition scheduling, and highlights the importance of considering individual chronotype in sports in which diurnal variation may be relevant to training and competition.

Barriers and Facilitators to Participation and Key Components of Sleep Health Programs: Perspectives for the Corporate Work Environment.

OBJECTIVE: The aim of the study is to explore the barriers and facilitators of participation and key components for sleep health programs designed for corporate work environments. METHODS: Semistructured interviews with corporate executives and occupational medicine specialists in the decision making and management of workplace health promotion programs (WHPP) within their companies were held before and during COVID-19. Interviews were transcribed verbatim and analyzed using thematic content analysis to identify themes. RESULTS: Barrier and facilitator themes emerging from the data include sleep health awareness, work culture, work-family balance, and confidentiality. Key components for sleep health programs included the following: identifying the need for a program, incorporating sleep health risk screening to WHPP, and promoting sleep health by raising awareness thereof. CONCLUSIONS: The identified barriers and facilitators to employee participation and key components of an ideal sleep health program provide guidance for further WHPP.

Associations between fears related to safety during sleep and self-reported sleep in men and women living in a low-socioeconomic status setting.

South Africans living in low socioeconomic areas have self-reported unusually long sleep durations (approximately 9-10 h). One hypothesis is that these long durations may be a compensatory response to poor sleep quality as a result of stressful environments. This study aimed to investigate whether fear of not being safe during sleep is associated with markers of sleep quality or duration in men and women. South Africans (n = 411, 25-50 y, 57% women) of African-origin living in an urban township, characterised by high crime and poverty rates, participated in this study. Participants are part of a larger longitudinal cohort study: Modelling the Epidemiologic Transition Study (METS)-Microbiome. Customised questions were used to assess the presence or absence of fears related to feeling safe during sleep, and the Epworth Sleepiness Scale, Pittsburgh Sleep Quality Index (PSQI) and Insomnia Severity Index were used to assess daytime sleepiness, sleep quality and insomnia symptom severity respectively. Adjusted logistic regression models indicated that participants who reported fears related to safety during sleep were more likely to report poor sleep quality (PSQI > 5) compared to participants not reporting such fears and that this relationship was stronger among men than women. This is one of the first studies outside American or European populations to suggest that poor quality sleep is associated with fear of personal safety in low-SES South African adults.

Silhouette showcards confirm altered obesity-associated body image perception in international cohort study of African-origin populations.

OBJECTIVES: Given the increasing prevalence of obesity and need for effective interventions, there is a growing interest in understanding how an individual's body image can inform obesity prevention and management. This study's objective was to examine the use of silhouette showcards to measure body size perception compared with measured body mass index, and assess body size dissatisfaction, in three different African-origin populations spanning the epidemiological transition. An ancillary objective was to investigate associations between body size perception and dissatisfaction with diabetes and hypertension. SETTING: Research visits were completed in local research clinics in respective countries. PARTICIPANTS: Seven hundred and fifty-one African-origin participants from the USA and the Republic of Seychelles (both high-income countries), and Ghana (low/middle-income country). PRIMARY AND SECONDARY OUTCOME MEASURES: Silhouette showcards were used to measure perceived body size and body size dissatisfaction. Objectively measured body size was measured using a scale and stadiometer. Diabetes was defined as fasting blood glucose ≥126 mg/dL and hypertension was defined as ≥130 mm Hg/80 mm Hg. RESULTS: Most women and men from the USA and Seychelles had 'Perceived minus Actual weight status Discrepancy' scores less than 0, meaning they underestimated their actual body size. Similarly, most overweight or obese men and women also underestimated their body size, while normal weight men and women were accurately able to estimate their body size. Finally, participants with diabetes were able to accurately estimate their body size and similarly desired a smaller body size. CONCLUSIONS: This study highlights that overweight and obese women and men from countries spanning the epidemiological transition were unable to accurately perceive their actual body size. Understanding people's perception of their body size is critical to implementing successful obesity prevention programmes across the epidemiological transition.

Associations between sleep-related heart rate variability and both sleep and symptoms of depression and anxiety: A systematic review.

There is a bidirectional relationship between poor sleep and both mood- and anxiety-related disorders, which are among leading global health concerns. Additionally, both disordered sleep and these psychiatric disorders appear to be independently associated with altered autonomic nervous system (ANS) function. We hypothesise that ANS dysregulation during sleep may explain part of the relationship between poor sleep and mood- and anxiety-related disorders. Heart rate variability (HRV) is a frequently used marker of ANS function and gives an indication of ANS input to the heart - in particular, of the relative contributions of sympathetic and parasympathetic activity. A systematic review of PubMed, Scopus and Web of Science yielded 41 studies dealing with sleep, mood- and anxiety-related disorders and sleep-related HRV. Hyperarousal during sleep, reflecting a predominance of sympathetic activation and indicative of ANS dysregulation, may be an important factor in the association between poor sleep and mood-related disorders. Longitudinal studies and mediation analyses are necessary to further understand the potential mediating role of ANS dysregulation on the relationship between poor sleep and mood- and anxiety-related disorders.

Dim light melatonin onset following simulated eastward travel is earlier in young males genotyped as PER35/5 than PER34/4.

Inter-individual variability exists in recovery from jetlag following travel across time zones. Part of this variation may be due to genetic differences at the variable number tandem repeat (VNTR) polymorphism of the PERIOD3 (PER3) gene as this polymorphism has been associated with chronotype and sleep, as well as sensitivity to blue light on melatonin suppression. To test this hypothesis we conducted a laboratory-based study to compare re-entrainment in males genotyped as PER34/4 (n = 8) and PER35/5 (n = 8) following simulated eastward travel across six time zones. The recovery strategy included morning blue-enriched light exposure and appropriately-timed meals during the first 24 h after simulated travel. Dim light melatonin onset (DLMO), sleep characteristics, perceived sleepiness levels (Stanford Sleepiness Scale), and resting metabolic parameters were measured during constant routine periods before and after simulated travel. While DLMO time was similar between the two groups prior to simulated eastward travel (p = .223), it was earlier in the PER35/5 group (17h23 (17h15; 17h37)) than the PER34/4 group (18h05 (17h53; 18h12)) afterwards (p = .046). During resynchronisation, perceived sleepiness and metabolic parameters were similar to pre-travel in both groups but sleep was more disturbed in the PER35/5 group (total sleep time: p = .008, sleep efficiency: p = .008, wake after sleep onset: p = .023). The PER3 VNTR genotype may influence the efficacy of re-entrainment following trans-meridian travel when blue-enriched light exposure is incorporated into the recovery strategy on the first day following travel.

Sleep disturbances in HIV infection and their biological basis.

Antiretroviral therapy has significantly reduced morbidity and mortality in people living with HIV (PLWH). However, a direct consequence of higher survival is the development of ageing-related co-morbidities that have considerable potential to affect quality of life. Sleep disturbances in PLWH are a significant source of morbidity. A meta-analysis has estimated the prevalence of self-reported sleep disturbances in PLWH to be 58%, with commonly identified disturbances including insomnia, obstructive sleep apnoea and poor sleep quality. Not only do sleep disturbances impair daytime functioning, but chronic sleep disruption also associates with metabolic dysregulation and cardiometabolic disease. Therefore, an understanding of the pathogenesis of sleep disturbances in PLWH is important for reducing morbidity and improving quality of life. Several pathophysiological processes in HIV infection may cause sleep-wake dysregulation. In early infection stages, immunological changes such as expression of sleep-promoting cytokines could mediate sleep disturbances. Long term, chronic immune activation, in addition to side effects of antiretroviral therapy, may impact sleep homeostasis more severely, for example through increasing the risk of obstructive sleep apnoea. These sleep disturbances may further contribute to an inflammatory state, due to the bi-directional relationship between sleep and immunity. In summary, further elucidating the link between HIV, immune activation, and sleep is an underexplored avenue for minimising population morbidity and mortality.

Ramadan Observance Exacerbated the Negative Effects of COVID-19 Lockdown on Sleep and Training Behaviors: A International Survey on 1,681 Muslim Athletes.

Objective: Disrupted sleep and training behaviors in athletes have been reported during the COVID-19 pandemic. We aimed at investigating the combined effects of Ramadan observance and COVID-19 related lockdown in Muslim athletes. Methods: From an international sample of athletes (n = 3,911), 1,681 Muslim athletes (from 44 countries; 25.1 ± 8.7 years, 38% females, 41% elite, 51% team sport athletes) answered a retrospective, cross-sectional questionnaire relating to their behavioral habits pre- and during- COVID-19 lockdown, including: (i) Pittsburgh sleep quality index (PSQI); (ii) insomnia severity index (ISI); (iii) bespoke questions about training, napping, and eating behaviors, and (iv) questions related to training and sleep behaviors during-lockdown and Ramadan compared to lockdown outside of Ramadan. The survey was disseminated predominately through social media, opening 8 July and closing 30 September 2020. Results: The lockdown reduced sleep quality and increased insomnia severity (both p < 0.001). Compared to non-Muslim (n = 2,230), Muslim athletes reported higher PSQI and ISI scores during-lockdown (both p < 0.001), but not pre-lockdown (p > 0.05). Muslim athletes reported longer (p < 0.001; d = 0.29) and later (p < 0.001; d = 0.14) daytime naps, and an increase in late-night meals (p < 0.001; d = 0.49) during- compared to pre-lockdown, associated with lower sleep quality (all p < 0.001). Both sleep quality (χ2 = 222.6; p < 0.001) and training volume (χ2 = 342.4; p < 0.001) were lower during-lockdown and Ramadan compared to lockdown outside of Ramadan in the Muslims athletes. Conclusion: Muslim athletes reported lower sleep quality and higher insomnia severity during- compared to pre-lockdown, and this was exacerbated by Ramadan observance. Therefore, further attention to Muslim athletes is warranted when a circadian disrupter (e.g., lockdown) occurs during Ramadan.

COVID-19 Lockdowns: A Worldwide Survey of Circadian Rhythms and Sleep Quality in 3911 Athletes from 49 Countries, with Data-Driven Recommendations.

OBJECTIVE: In a convenience sample of athletes, we conducted a survey of COVID-19-mediated lockdown (termed 'lockdown' from this point forward) effects on: (i) circadian rhythms; (ii) sleep; (iii) eating; and (iv) training behaviors. METHODS: In total, 3911 athletes [mean age: 25.1 (range 18-61) years, 1764 female (45%), 2427 team-sport (63%) and 1442 elite (37%) athletes] from 49 countries completed a multilingual cross-sectional survey including the Pittsburgh Sleep Quality Index and Insomnia Severity Index questionnaires, alongside bespoke questions about napping, training, and nutrition behaviors. RESULTS: Pittsburgh Sleep Quality Index (4.3 ± 2.4 to 5.8 ± 3.1) and Insomnia Severity Index (4.8 ± 4.7 to 7.2 ± 6.4) scores increased from pre- to during lockdown (p < 0.001). Pittsburgh Sleep Quality Index was predominantly influenced by sleep-onset latency (p < 0.001; + 29.8%), sleep efficiency (p < 0.001; - 21.1%), and total sleep time (p < 0.001; - 20.1%), whilst Insomnia Severity Index was affected by sleep-onset latency (p < 0.001; + 21.4%), bedtime (p < 0.001; + 9.4%), and eating after midnight (p < 0.001; + 9.1%). During lockdown, athletes reported fewer training sessions per week (- 29.1%; d = 0.99). Athletes went to bed (+ 75 min; 5.4%; d = 1.14) and woke up (+ 150 min; 34.5%; d = 1.71) later during lockdown with an increased total sleep time (+ 48 min; 10.6%; d = 0.83). Lockdown-mediated circadian disruption had more deleterious effects on the sleep quality of individual-sport athletes compared with team-sport athletes (p < 0.001; d = 0.41), elite compared with non-elite athletes (p = 0.028; d = 0.44) and older compared with younger (p = 0.008; d = 0.46) athletes. CONCLUSIONS: These lockdown-induced behavioral changes reduced sleep quality and increased insomnia in athletes. Data-driven and evidence-based recommendations to counter these include, but are not limited to: (i) early outdoor training; (ii) regular meal scheduling (whilst avoiding meals prior to bedtime and caffeine in the evening) with appropriate composition; (iii) regular bedtimes and wake-up times; and (iv) avoidance of long and/or late naps.

Lockdown Duration and Training Intensity Affect Sleep Behavior in an International Sample of 1,454 Elite Athletes.

Objective: To investigate the effect of 1) lockdown duration and 2) training intensity on sleep quality and insomnia symptoms in elite athletes. Methods: 1,454 elite athletes (24.1 ± 6.7 years; 42% female; 41% individual sports) from 40 countries answered a retrospective, cross-sectional, web-based questionnaire relating to their behavioral habits pre- and during- COVID-19 lockdown, including: 1) Pittsburgh sleep quality index (PSQI); 2) Insomnia severity index (ISI); bespoke questions about 3) napping; and 4) training behaviors. The association between dependent (PSQI and ISI) and independent variables (sleep, napping and training behaviors) was determined with multiple regression and is reported as semi-partial correlation coefficient squared (in percentage). Results: 15% of the sample spent < 1 month, 27% spent 1-2 months and 58% spent > 2 months in lockdown. 29% self-reported maintaining the same training intensity during-lockdown whilst 71% reduced training intensity. PSQI (4.1 ± 2.4 to 5.8 ± 3.1; mean difference (MD): 1.7; 95% confidence interval of the difference (95% CI): 1.6-1.9) and ISI (5.1 ± 4.7 to 7.7 ± 6.4; MD: 2.6; 95% CI: 2.3-2.9) scores were higher during-compared to pre-lockdown, associated (all p < 0.001) with longer sleep onset latency (PSQI: 28%; ISI: 23%), later bedtime (PSQI: 13%; ISI: 14%) and later preferred time of day to train (PSQI: 9%; ISI: 5%) during-lockdown. Those who reduced training intensity during-lockdown showed higher PSQI (p < 0.001; MD: 1.25; 95% CI: 0.87-1.63) and ISI (p < 0.001; MD: 2.5; 95% CI: 1.72-3.27) scores compared to those who maintained training intensity. Although PSQI score was not affected by the lockdown duration, ISI score was higher in athletes who spent > 2 months confined compared to those who spent < 1 month (p < 0.001; MD: 1.28; 95% CI: 0.26-2.3). Conclusion: Reducing training intensity during the COVID-19-induced lockdown was associated with lower sleep quality and higher insomnia severity in elite athletes. Lockdown duration had further disrupting effects on elite athletes' sleep behavior. These findings could be of relevance in future lockdown or lockdown-like situations (e.g., prolonged illness, injury, and quarantine after international travel).