Application of the Plan-Do-Study-Act method to optimize the ordering and administration of dexmedetomidine for sleep hygiene in the intensive care unit.

PURPOSE: To describe the Plan-Do-Study-Act (PDSA) methodology utilized by a multidisciplinary team to address the discordance between ordering and administration of dexmedetomidine for sleep hygiene in the intensive care unit (ICU). SUMMARY: The addition of sleep hygiene as an indication for the use of dexmedetomidine at University of Virginia (UVA) Health led to discordance between the medication orders in the electronic medical record and the subsequent administration of dexmedetomidine. A multidisciplinary team implemented interventions that included modifying the order panel, streamlining the institutional formulary, developing institutional practice guidelines, and providing education to healthcare team members. After completion of the first PDSA cycle, the mean number of discordant order elements decreased to 1.96 out of 5 possible order elements from an initial 2.5 out of 5 elements before the interventions, meeting the aim to reduce the mean to less than 2. There was a significant decrease in the discordance in the duration of infusion (discordant for 14 of 30 orders before the interventions vs 1 of 28 orders after the interventions, P = 0.0002) but a significant increase in the discordance in the titration dose (discordant for 13 of 30 orders before the interventions vs 24 of 28 orders after the interventions, P < 0.0001). Other discordant order elements including the starting dose, maximum rate, and titration interval time decreased in frequency after the interventions, although the differences were not statistically significant. The interventions made during the first PDSA cycle are anticipated to lead to an estimated cost savings of up to $180,000 per year within the UVA Health system. CONCLUSION: The multidisciplinary team utilizing a PDSA method to modify the order panel, streamline the institutional formulary, develop institutional practice guidelines, and provide education to healthcare team members was effective at reducing overall discordance between order intent and administration of dexmedetomidine for sleep hygiene in the ICU.

Disparities in sleep duration among American children: effects of race and ethnicity, income, age, and sex.

Children in the United States sleep less than the recommended amount and sleep deficiencies may be worse among disadvantaged children. Prior studies that compared sleep time in children of different race/ethnic groups mostly relied on questionnaires or were limited to small sample sizes. Our study takes advantage of the Adolescent Brain Cognitive Development study to compare total sleep time using a week of actigraphy data among American children (n = 4,207, 9 to 13 y old) of different racial/ethnic and income groups. We also assessed the effects of neighborhood deprivation, experience of discrimination, parent's age at child's birth, body mass index (BMI), and time the child fell asleep on sleep times. Daily total sleep time for the sample was 7.45 h and race/ethnicity, income, sex, age, BMI, were all significant predictors of total sleep time. Black children slept less than White children (∼34 min; Cohen's d = 0.95), children from lower income families slept less than those from higher incomes (∼16 min; Cohen's d = 0.44), boys slept less than girls (∼7 min; Cohen's d = 0.18), and older children slept less than younger ones (∼32 min; Cohen's d = 0.91); mostly due to later sleep times. Children with higher BMI also had shorter sleep times. Neither area deprivation index, experience of discrimination, or parent's age at child's birth significantly contributed to sleep time. Our findings indicate that children in the United States sleep significantly less than the recommended amount for healthy development and identifies significant racial and income disparities. Interventions to improve sleep hygiene in children will help improve health and ameliorate racial disparities in health outcomes.

Validation of the Japanese version of the Sleep Hygiene Practice Scale.

OBJECTIVE: This study sought to validate the Japanese version of the Sleep Hygiene Practices Scale (SHPS-J). PATIENTS/METHODS: A cross-sectional questionnaire-based study was conducted via the internet. In total, 854 participants (435 men, 419 women; mean age, 42.91 ± 11.54 years) were asked to complete all scales, and 283 of them were asked to complete the same scales two weeks later. The survey consisted of the SHPS-J, the Japanese version of the Insomnia Severity Index (ISI-J), and the Japanese version of the Pittsburgh Sleep Quality Index (PSQI-J). The SHPS-J was developed according to the International Society for Pharmacoeconomics and Outcomes Research Task Force for Translation and Cultural Adaption. For the analysis, participants were divided into three groups: insomnia syndrome, insomnia symptoms, and good sleep groups. RESULTS: The SHPS-J had good test-retest reliability (ICC: 0.55-0.76) and adequate internal consistency (α = 0.54-0.74), except with regard to eating/drinking behaviors. The factorial validity of the four-factor structure was confirmed through a confirmatory factor analysis; however, one item related to eating/drinking behaviors had no significant factor loading. The construct validity was confirmed through a correlation analysis between each domain of the SHPS-J and ISI-J (r = 0.19-0.60, p < 0.01). The results of clinical validation confirmed that all domains of the SHPS-J were significantly higher for individuals with insomnia than for good sleepers. CONCLUSIONS: This study confirmed both the reliability and validity of the SHPS-J.

Disparities in Sleep Health and Potential Intervention Models: A Focused Review.

Disparities in sleep health are important but underrecognized contributors to health disparities. Understanding the factors contributing to sleep heath disparities and developing effective interventions are critical to improving all aspects of heath. Sleep heath disparities are impacted by socioeconomic status, racism, discrimination, neighborhood segregation, geography, social patterns, and access to health care as well as by cultural beliefs, necessitating a cultural appropriateness component in any intervention devised for reducing sleep health disparities. Pediatric sleep disparities require innovative and urgent intervention to establish a foundation of lifelong healthy sleep. Tapping the vast potential of technology in improving sleep health access may be an underutilized tool to reduce sleep heath disparities. Identifying, implementing, replicating, and disseminating successful interventions to address sleep disparities have the potential to reduce overall disparities in health and quality of life.

Which sleep hygiene factors are important? comprehensive assessment of lifestyle habits and job environment on sleep among office workers.

BACKGROUND: Although several lifestyle habits are associated with sleep, it is unclear which factors are important. Among office workers, the effect of job environment should also be considered. The multivariate analyses on the effects of lifestyle habits and job environment on sleep among office workers was conducted. METHODS: A cross-sectional survey of 6,342 employees from 29 companies was conducted in 2017-2019. Complete responses and informed consent were provided by 5,640 participants. The survey examined demographic variables, sleep schedules, Pittsburgh Sleep Quality Index (PSQI), Brief Job Stress Questionnaire (BJSQ), and lifestyle habits. RESULTS: Mean values were as follows: age, 36.9 years (±10.2); PSQI, 6.52 (±2.83); and total sleep time, 6h06m (±1h40m) on work days and 7h39m (±1h58m) on free days. After adjusting for job environment and demographic variables, irregular meal time (1.45-2.86), not eating vegetables every day (1.35), nightcap (2.74-3.55), weight gain (1.20-1.42), lack of sunlight in the morning in the bedroom (1.48-1.60), waking up before dawn (2.18), electronic display use in bed (1.50), and daily caffeine intake (1.27) were significantly associated with sleep disturbance. Irregular meal time (1.51-2.37), lack of morning breakfast (1.74-2.95), having dinner within 2 hours before bed time (0.49-0.64), not eating vegetables every day (1.52), lack of sunlight exposure in the morning (1.43-2.01), and caffeine use every day (1.42) were also associated with eveningness (p<.01). CONCLUSION: Each sleep hygiene factor had a different effect size. Sleep hygiene interventions to promote worker sleep health should prioritize factors in accordance with effect size.

Racial and ethnic disparities in sleep outcomes among urban children with and without asthma.

BACKGROUND: Suboptimal sleep has been documented in at-risk groups such as urban minority children, particularly those with asthma. It is therefore critical to examine differences in sleep outcomes across specific racial and ethnic groups and to identify factors that contribute to such variations in sleep outcomes to inform tailored interventions to improve sleep health. OBJECTIVES: The objectives were to examine racial/ethnic differences in sleep outcomes among urban children with and without asthma and to evaluate the extent to which asthma status and aspects of sleep hygiene and the sleep environment contribute to racial/ethnic differences in sleep outcomes in this sample. METHODS: Two hundred and sixteen African American, Latino, or non-Latino white (NLW) urban children, ages 7-9 years, with (n = 216) and without asthma (n = 130) and their primary caregivers were included. Objective sleep duration and efficiency were assessed via actigraphy. Asthma status was assessed by a study clinician. Caregiver-reported sleep hygiene and exposure to noise were assessed using a questionnaire. RESULTS: Minority children in the sample had, on average, shorter sleep duration compared to NLW children during the monitoring period (mean difference Latino vs NLW = -22.10, SE = 5.02; mean difference AA vs NLW = -18.69, SE = 5.28) Additionally, several racial/ethnic group differences in sleep outcomes emerged and were dependent on whether or not children had asthma. Specifically, Latinos had lower mean number of awakenings compared to NLWs but only among control participants with no asthma. Furthermore, specific aspects of sleep hygiene and exposure to nighttime noise in the home and neighborhood contributed to racial/ethnic differences in sleep outcomes. CONCLUSION: Considering urban stressors and asthma status when treating pediatric populations is important, as factors related to urban stress and asthma management may influence sleep hygiene practices and sleep outcomes.

Prospective repeated assessment of self-reported sleep quality and sleep disruptive factors in the intensive care unit: acceptability of daily assessment of sleep quality.

INTRODUCTION: Despite the importance of sleep, the assessment of sleep quality does not form part of standard clinical care in intensive care unit (ICU). Continuous assessment of self-reported quality of ICU patients' sleep has been strongly recommended. Prior to implementing such an assessment in the ICU, it is important to assess the acceptability of this method of assessment to the ICU's patients. The aims of this study were to assess the acceptability to ICU patients of completing daily self-reports on sleep quality during their ICU stay and to assess ICU patients' self-reported sleep quality and sleep disruptive factors during their time in ICU. METHODS: An observational prospective-repeated assessment was conducted on n=120 patients in an ICU in Saudi Arabia. The participants were both intubated and non-intubated. OUTCOMES MEASURES: Over a 3-month period, sleep quality was assessed using the Arabic version of the Richards-Campbell Sleep Questionnaire (RCSQ-A), and self-reported sleep disruptive factors were identified. Clinical factors, such as ICU interventions, and previously administered sedatives were also examined. The patients' acceptance of completing daily RCSQ-A reports was assessed using various indicators of acceptability. RESULTS: A total of 381 self-reports (RCSQ-A) were collected for this analysis. The patients reported 34.4±5.60, indicating that sleep quality was poor on average. The group of intubated patients reported much poorer sleep quality during intubation than after extubation. In the multivariate analysis, factors which most significantly affected sleep (exp(b), p value) were midazolam (-6.424, p<0.0005), propofol (-3.600, p<0.05), noise (-1.033, p<0.05), gender (1.836, p<0.05), daytime sleepiness (0.856, p<0.05) and the presence of mechanical ventilation (-1.218, p<0.05). CONCLUSION: The acceptability and feasibility of using daily RCSQ-A for sleep quality assessment was demonstrated. Sleep quality was reported as poor by all participants and the factors affecting sleep were varied. This study provided various recommendations for healthcare providers and researchers in terms of evaluating and improving sleep quality in ICU patients.

Assessment and comparison of sleep patterns among medical and non-medical undergraduates of Karachi: A cross-sectional study - SPECIAL REPORT.

To assess and compare patterns, habits and quality of sleep in undergraduate medical and non-medical students. The cross-sectional study was conducted from February to March, 2018, at Dow Medical College, Karachi, and Pakistan Air Force-Karachi Institute of Economics and Technology. Data was collected by self-reported questionnaires. Sleep quality of individuals was assessed using Pittsburg Sleep Quality Index. Data was analysed using SPSS 21. Of the 245 subjects, 137(55%) were medical students and 108(45%) were non-medical. Overall, 101(41.2%) subjects aid 8 hours of sleep was sufficient for them; 153(62.4%) reported daytime sleeping; and 168(68.5%) did not take naps. The duration of nap was >30 minutes in 118(48%) students. Factors affecting sleep were cited as electronic media 132(53.9%), caffeine 42(17.1%) and stress 126(51.4%). Of the total, 161(65.7%) subjects had poor sleep quality. There was no significant difference between medical and non-medical students (p>0.05). Majority of medical and non-medical undergraduate students were poor sleepers.

Individualized sleep education improves subjective and objective sleep indices in elite cricket athletes: A pilot study.

The aim of the current study was to evaluate the effect of personalized sleep hygiene education on sleep indices in elite athletes. Nine elite male cricket players performed 3 weeks of baseline sleep monitoring (PRE), followed by group and individualized sleep hygiene education and a further 3 weeks of sleep monitoring (POST). Subjective sleep questionnaires included the Athlete Sleep Behaviour Questionnaire (ASBQ), the Epworth Sleepiness Scale (ESS) and the Pittsburgh Sleep Quality Index (PSQI). Objective sleep indices were monitored via wrist actigraphy. There were significant improvements (p < 0.05) in two of the sleep questionnaires (ESS and PSQI) and in sleep efficiency (+5%), sleep latency (-29 min) and sleep onset variance (-28 min) following the intervention, all associated with large or very large effect sizes (d= 1.38, -0.85 and -0.88, respectively). The current study reports that personalized sleep hygiene education using the ASBQ to target maladaptive sleep behaviours may be effective in acutely improving sleep indices in elite male athletes.

Effects of a Workplace-Based Sleep Health Program on Sleep in Members of the German Armed Forces.

STUDY OBJECTIVES: To develop and evaluate a brief manual-based sleep health program within the workplace health promotion of the German Armed Forces. METHODS: The sleep health program comprised four weekly group sessions. Sixty-three members (48 males) were randomly allocated to either a treatment group or a waiting control group matching for age, sex, and baseline Pittsburgh Sleep Quality Index (PSQI). The control group had to wait before participating in the sleep health program until the treatment group finished the intervention. Sleep was assessed by ambulatory polysomnography (PSG) as well as with evening and morning protocols at baseline (t0), directly after the treatment group participated in the sleep health program (t1), and after the control group finished participation (t2). The PSQI, the Insomnia Severity Index (ISI), and the Epworth Sleepiness Scale (ESS) were applied at the same three time points, and during a 3-month follow-up evaluation (t3). RESULTS: Fifty-seven out of the 63 randomized individuals (42 males, mean age = 40.6 years; complete PSG data: n = 36; complete questionnaire data: n = 39) participated in the sleep health program. Objective wake after sleep onset, sleep efficiency, latency to persistent sleep, self-reported sleep latency, restfulness, PSQI, and ISI scores improved with medium or large effects in both groups. ESS scores decreased with moderate effects in the treatment group only. CONCLUSIONS: The sleep health program had a positive and stable effect on objective and self-reported sleep parameters, and it is suitable as a preventive measure in members of the German Armed Forces. CLINICAL TRIAL REGISTRATION: Registry: ClinicalTrials.gov; Title: Development and Evaluation of a Sleep-coaching Program; Identifier: NCT02896062; URL: https://clinicaltrials.gov/ct2/show/record/NCT02896062.

An exploratory study examining the associations between sunlight exposure, sleep behaviours and sleep outcomes during an Arctic summer.

Few evidence-based recommendations exist for maintaining healthy sleep during Arctic summers. Our study aimed to examine associations between sleep hygiene, sunlight exposure and sleep outcomes in workers living in and/or near the Arctic Circle during a 24-h light period. A survey was administered July 2017 to 19 workers at 3 Arctic base camps in Northeastern Alaska. Participants with poorer sleep hygiene reported increased sleepiness (r=.62, p=0.01); this correlation remained moderately strong, albeit not statistically significant (NS), after controlling for shift work (r=.46, p=0.06). No other statistically significant correlations between sleep hygiene and sleep outcomes were found. Weekly daytime (<8pm) and evening (>8pm) sunlight exposures, estimated from daily self-reported sunlight exposures for a typical workday and day off, were dichotomised, based on means, into: longer (>45 h/week) versus shorter (<45 h/week) daytime exposures, and longer (>16 h/week) versus shorter (<16 h/week) evening exposures. Participants reporting longer, versus shorter, weekly daytime sunlight exposure had statistically significantly (Mann-Whitney U=18.00, Z=-1.98, p≤0.05) decreased median sleep duration (6 h, 18 min versus 8 h, respectively) during the past month. Correlations of r≥.3 for longer, vis-à-vis shorter, daylight sunlight exposure suggest it could be related to poorer sleep outcomes, such as insufficient sleep and sleep quality, yet, as these correlations were NS, future work is needed to determine this. Weak or no correlations (and NS differences) were found for longer, versus shorter, weekly evening sunlight exposure and sleep outcomes. Findings support previous research suggesting self-regulation behaviours alone are not protective against poor sleep in Arctic environments. Sleep outcomes did not differ statistically significantly by evening sunlight exposure length. Longer weekly daytime sunlight exposure, versus shorter, was significantly associated with decreased sleep duration. Results from this exploratory study should be confirmed in studies using larger sample sizes.

Peri-operative care pathways: re-engineering care to achieve the 'triple aim'.

Elective surgical pathways offer a particular opportunity to plan radical change in the way care is delivered, based on patient need rather than provider convenience. Peri-operative pathway redesign enables improved patient experience of care (including quality and satisfaction), population/public health, and healthcare value (outcome per unit of currency). Among physicians with the skills to work within peri-operative medicine, anaesthetists are well positioned to lead the re-engineering of such pathways. Re-engineered pre-operative pathways open up opportunities for intervention before surgery including shared decision-making, comorbidity management and collaborative behavioural change. Individualised, risk-adapted, intra-operative interventions will drive more reliable and consistent care. Risk-adapted postoperative care, particularly around transitions of care, has a significant role in improving value through peri-operative medicine. Improved integration with primary care providers offers the potential for minimising errors around transitions of care before and after surgery, as well as maximising opportunities for population health interventions, including lifestyle modification (e.g. activity/exercise, smoking and/or alcohol cessation), pain management and sleep medicine. Systematic data collection focused on quality improvement is essential to drive continuous clinical improvement and will be enabled by technological development in predictive analytics, systems modelling and artificial intelligence.

Effects of a sleep hygiene text message intervention on sleep in college students.

OBJECTIVE: To test the effectiveness of a text-message intervention to promote sleep hygiene to improve sleep in young adult college students. PARTICIPANTS: A convenience sample of undergraduate students from one Southwestern university (n = 96), 18-26 years old, recruited in August 2015. METHODS: A 2-group pretest-posttest experimental design assigned participants to receive biweekly text messages about sleep hygiene or healthy behaviors for 6 weeks. Survey questions addressed sleep knowledge, sleep hygiene, self-efficacy for sleep hygiene, and sleep quality at baseline and posttest. RESULTS: Though not significant, sleep quality, sleep hygiene, and sleep knowledge improved in both groups. CONCLUSIONS: Self-efficacy for sleep hygiene is a modifiable factor that may serve to improve sleep quality. Sleep quality improved in both groups. Text messaging is a feasible approach to delivering an intervention to promote healthy behaviors among young adults.

Factors associated with sleep in family caregivers of individuals with dementia.

PURPOSE: The study aimed to identify factors related to family caregivers' sleep. DESIGN AND METHODS: The study used a cross-sectional design with objective and subjective methods to measure sleep in the home setting over a 7-day period. FINDINGS: Findings indicated that poor sleep quality was found in 91.7% of the caregiver participants. Depression, sleep hygiene, burden, and care-recipients' sleep were significant predictors of various dimensions of caregivers' sleep. PRACTICE IMPLICATIONS: Our study suggests that sleep quality for family caregivers of individuals with dementia varies considerably from night to night. Understanding the complex interrelationships among caregivers' sleep and other contributing variables is an important first step toward the development of individualized and effective treatment strategies.

Prevalence of night sleep duration, sleep quality and sleep hygiene practices among children attending childcare services in New South Wales, Australia.

AIM: To describe parent-reported child: (i) sleep duration; (ii) sleep quality; (iii) sleep hygiene practices; and (iv) the proportion of children meeting sleep duration recommendations. METHODS: A convenience sample of parents of Australian pre-school-aged children (3-5 years) were surveyed from the Hunter New England region of New South Wales. The cross-sectional survey was conducted via computer-assisted telephone interview. The survey assessed parent and child demographic characteristics and parent-reported child sleep duration, quality and sleep hygiene practices. RESULTS: A total of 488 eligible parents or guardians took part in the study. Parents reported that children slept an average of 11.03 h per night. Approximately 96% of children met daily sleep duration recommendations from sleep guidelines for their age group. The majority of parents reported that their child had 'good' sleep quality (86.89%). Almost 40% reported that their child woke at least once a night. Sleep hygiene practices were relatively well established; however, a small proportion of parents indicated that they had no rules surrounding bedtime (13.52%) or television use before bed (14.52%). CONCLUSIONS: The current study describes the sleep duration, quality and sleep hygiene practices of a sample of pre-school-aged children in New South Wales, Australia. Future research using objective measures of sleep duration and hygiene, as well as assessing a broader spectrum of sleep hygiene practices, is needed.

Association of sleep with emotional and behavioral problems among abused children and adolescents admitted to residential care facilities in Japan.

BACKGROUND: The psychological care of abused children in the child protection system is an urgent issue in Japan. Child abuse has a serious impact on children's emotion and behavior, but there is virtually no evidence about how child abuse affects sleep, which is closely related to behavioral and emotional control. In this study, we sought to identify sleep habits and suspected sleep disorders among abused children and adolescents admitted to residential care facilities in Japan and to investigate their association with emotional and behavioral problems. METHODS: The study targeted 273 abused children and adolescents (age range: 4 to 15 years) who had been admitted to a residential care facility in Japan. They were assessed by physicians and other personnel at facilities with expertise in childcare and abuse. Respondents completed a brief sleep questionnaire on the incidence of problematic sleep habits and suspected sleep disorders as well as a questionnaire on emotional and behavioral issues. RESULTS: Approximately 40% of the abused children and adolescents had some sleep-related symptoms at bedtime and waking, and 19% had suspected sleep disorder. Abused children with emotional and behavioral problems had a significantly higher incidence of suspected sleep disorders than abused children without such problems, and this incidence was particularly high among those with antisocial behavior and depressive behavior. Our predictive model also showed that antisocial behavior and depressive behavior were significant predictors of suspected sleep disorders. CONCLUSION: Careful assessment and appropriate therapeutic intervention for sleep disorders are required in abused children and adolescents with emotional and behavioral problems.

Comprehensive assessment of the impact of life habits on sleep disturbance, chronotype, and daytime sleepiness among high-school students.

OBJECTIVE: Sleep affects adolescents in various ways. However, the effects of multiple factors on sleep hygiene remain unclear. A comprehensive assessment of the effects of life habits on sleep in high-school students was conducted. METHODS: A cross-sectional survey of 344 high school students (age range 15-17; 171 boys, 173 girls) in Tokyo, Japan was conducted in 2015. Complete responses were provided by 294 students. Demographic variables, Pittsburgh Sleep Quality Index (PSQI), diurnal type scale, Pediatric Daytime Sleepiness Scale (PDSS), and life habits such as dinnertime, viewing electronic displays, caffeine intake, sunlight in the morning, and the brightness of the room in the night were asked. RESULTS: The mean scores were PSQI: 5.9 (±2.3), PDSS: 19.0 (±5.8), and the diurnal type scale: 16.7 (±3.4). Using an electronic display in bed (OR = 3.01; (95%CI) 1.24-7.30), caffeine intake at night always (OR = 2.22; 1.01-4.90), and waking up before dawn (OR = 3.25; 1.34-7.88) were significantly associated with sleep disturbance. Irregular timing of the evening meal (OR = 2.06; 1.10-3.84) and display viewing within 2 h before bedtime (OR = 2.50; 1.01-6.18) or in bed (OR = 3.60; 1.41-9.21) were significantly associated with excessive daytime sleepiness. Using an electronic display within 2 h before bedtime (OR = 2.64; 1.10-6.38) or in bed (OR = 3.50; 1.40-8.76) and a living room which is bright at night (OR = 1.89; 1.06-3.36) were significantly associated with eveningness. CONCLUSION: Each type of sleep-related problem had its own associated life habit factors.

The Commander's Wellness Program: Assessing the Association Between Health Measures and Physical Fitness Assessment Scores, Fitness Assessment Exemptions, and Duration of Limited Duty.

INTRODUCTION: Air Force Medical Service health promotions staff have identified a set of evidenced-based interventions targeting tobacco use, sleep habits, obesity/healthy weight, and physical activity that could be integrated, packaged, and deployed as a Commander's Wellness Program. The premise of the program is that improvements in the aforementioned aspects of the health of unit members will directly benefit commanders in terms of members' fitness assessment scores and the duration of periods of limited duty. The purpose of this study is to validate the Commander's Wellness Program assumption that body mass index (BMI), physical activity habits, tobacco use, sleep, and nutritional habits are associated with physical fitness assessment scores, fitness assessment exemptions, and aggregate days of limited duty in the population of active duty U.S. Air Force personnel. METHODS: This study used a cross-sectional analysis of active duty U.S. Air Force personnel with an Air Force Web-based Health Assessment and fitness assessment data during fiscal year 2013. Predictor variables included age, BMI, gender, physical activity level (moderate physical activity, vigorous activity, and muscle activity), tobacco use, sleep, and dietary habits (consumption of a variety of foods, daily servings of fruits and vegetables, consumption of high-fiber foods, and consumption of high-fat foods). Nonparametric methods were used for the exploratory analysis and parametric methods were used for model building and statistical inference. RESULTS: The study population comprised 221,239 participants. Increasing BMI and tobacco use were negatively associated with the outcome of composite fitness score. Increasing BMI and tobacco use and decreasing sleep were associated with an increased likelihood for the outcome of fitness assessment exemption status. Increasing BMI and tobacco use and decreasing composite fitness score and sleep were associated with an increased likelihood for the outcome of limited duty status, whereas increasing BMI and decreasing sleep were associated with the outcome of increased aggregate days of limited duty. The observed associations were in the expected direction and the effect sizes were modest. Physical activity habits and nutritional habits were not observed to be associated with any of the outcome measures. CONCLUSIONS: The Commander's Wellness Program should be scoped to those interventions targeting BMI, composite fitness score, sleep, and tobacco use. Although neither self-reported physical activity nor nutritional habits were associated with the outcomes, it is still worthwhile to include related interventions in the Commander's Wellness Program because of the finding in other studies of a consistent association between the overall number of health risks and productivity outcomes.

Benefits of a bedtime routine in young children: Sleep, development, and beyond.

This paper presents a conceptual model and reviews the empirical evidence to support a nightly bedtime routine as a key factor in the promotion of not only healthy sleep, but also of broad development and wellbeing in early childhood. A bedtime routine embodies the characteristics of nurturing care and early child stimulation, which are deemed to be essential for positive outcomes, especially for at-risk children. Furthermore, common, adaptive components of a bedtime routine can contribute to an array of positive developmental outcomes beyond improved sleep, inclusive of language development, literacy, child emotional and behavioral regulation, parent-child attachment, and family functioning, among other outcomes. These bedtime routine components include activities in the broad domains of nutrition (e.g., feeding, healthy snack), hygiene (e.g., bathing, oral care), communication (e.g., reading, singing/lullabies) and physical contact (e.g., massage, cuddling/rocking). A bedtime routine can provide multiple benefits to child and family functioning at a time of day that many parents are present with their children. Although additional research on hypothesized routine-related child outcomes and mechanisms of action are needed, promoting a bedtime routine may be a feasible and cost-effective method to promote positive early childhood development worldwide, particularly for socioeconomically disadvantaged and other at-risk young children.