Introduction
Sleep is an integral element of well-being that critically influences bodily and psychological skills. Within the army, enough sleep is vital to make sure the sufficient efficiency of particular person members, promote mission success in every army unit, and even improve nationwide safety.1,2 Enlisted personnel are inclined to have worse sleep high quality than officers as a result of they reside in additional crowded sleeping quarters.3,4 As well as, the variety of sufferers visiting the USA (US) army medical services for insomnia and obstructive sleep apnea (OSA) confirmed an inclination to extend over time.4,5 Moreover, there have been a number of research of army personnel reporting the affiliation of sleep problems with post-traumatic stress dysfunction,6 despair,7 and anxiousness.8–12
Epidemiological research assessing sleep circumstances have been carried out within the army throughout a number of international locations. A Korean army well being survey reported that 8.8–10.1% of the entire respondents had moderate-to-severe sleep issue.13,14 Equally, 8.1% of the examine inhabitants in a single Korean army hospital had a excessive threat of OSA.15 Contrarily, a examine involving US army personnel indicated that the incidence charges of insomnia and OSA had been 2.7% and three.3%, respectively.5 Moreover, the prevalence of subthreshold insomnia in a number of US military models ranged from 29.6 to 54.3%.16
In our earlier examine, most army personnel with insomnia had indigestion and had been prone to eat evening meals and snacks extra incessantly. After prescribing natural drugs that might improve digestive operate, their insomnia improved.17 In a earlier examine relating to sleep problems and related medical comorbidities, ache syndrome was discovered to extend the chance of insomnia.6 Because it has been noticed that many younger male sufferers within the Korean military with insomnia even have indigestion signs linked to dietary habits, a large-scale cross-sectional examine exploring the affiliation between dietary behaviors and sleep was deliberate. The affiliation between sleep and dietary behaviors has been examined in numerous populations, together with manufacturing unit staff18 and white-collar staff,19 however there may be restricted associated analysis amongst army personnel. Army service members share related sleep and dietary circumstances, and the impact of private dietary behaviors on sleep may be clearly assessed after adjusting for associated life-style and occupational components.
This examine, due to this fact, aimed to discover dietary components, together with skipping breakfast, overeating, snacking, and consuming evening meals, related to poor sleep high quality and excessive threat of OSA amongst army service members. Potential covariates of demographic and occupational components within the army had been additionally comprehensively evaluated.
Supplies and Strategies
Research Inhabitants
This cross-sectional survey was carried out amongst 5 models of the Republic of Korea’s military from August to September 2021. A hyperlink to the web survey was supplied to members on energetic responsibility, and the responses had been collected by 5 Korean medical docs. Eligible service members participated within the examine utilizing their mobile telephones. All members supplied knowledgeable consent and voluntarily participated within the examine. The collected information had been managed anonymously, and entry was restricted in order that solely the particular researchers might entry the private info of the enrolled members. The protocol and survey questionnaire had been accepted by the institutional evaluation board of the Armed Forces Medical Command (AFMC-202107-HR-054-02). This examine was carried out in accordance with the Declaration of Helsinki.
This examine included enlisted service members on energetic responsibility aged ≥19 years who had accomplished their fundamental army coaching course. They comprised solely enlisted service members within the following ranks: non-public, non-public first-class, corporal, and sergeant.
Definition of Poor Sleep High quality and Excessive Danger of OSA
Poor sleep high quality was outlined by the worldwide rating of the Pittsburgh sleep high quality index (PSQI), which is calculated by summing the seven element scores, together with subjective high quality, latency, length, effectivity, disturbance of sleep, use of sleep treatment, and daytime dysfunction.20 Two research validated the Korean model of the PSQI and reported cut-off values of > 8 and > 5, respectively.21,22 Herein, we outlined poor sleep high quality as a world PSQI rating > 5. An extra evaluation was additionally carried out with the upper PSQI threshold of > 9, based mostly on a earlier PSQI examine on army personnel.23 Excessive threat of OSA was outlined utilizing the Berlin Questionnaire,24 which contains three classes: loud night breathing and witnessed apnea, daytime sleepiness or tiredness, and presence of hypertension or weight problems. A excessive threat of OSA was reported when two or three classes had been current.25
Research Variables
Dietary habits info was collected utilizing the dietary behavior survey questionnaire,26 which included 25 gadgets used to judge dietary habits, and we chosen 4 gadgets based mostly on earlier analysis. The frequencies of skipping breakfast, overeating, snacking, and consuming evening meals had been included within the evaluation.17–19
Information on demographic, life-style, and occupational components had been additionally collected to be analyzed as covariates. Members’ age, academic degree, peak, and weight had been recorded. Way of life components included perceived stress degree, smoking historical past, frequency of ingesting, cardio train per week, and low consumption. Occupational components inside the army included rank (non-public, non-public firstclass, corporal, or sergeant), place (fight arms, driver, army chef, administration), and the frequency of evening shifts.
Statistical Analyses
Categorical variables had been introduced as frequencies (%), whereas steady variables had been introduced as means (normal deviation). To match the frequencies or means between the 2 teams (PSQI ≤ 5 and PSQI > 5) and (excessive threat or low threat of sleep apnea), the chi-square check or impartial t-test was carried out, respectively. Multivariable logistic regression evaluation was used to discover the affiliation between poor sleep high quality and dietary behaviors; and between excessive threat of OSA and dietary behaviors. Demographic, life-style, and occupational components had been additionally included within the mannequin as covariates. Unadjusted (univariate), and adjusted (multivariable) odds ratios, 95% confidence interval (CI), and p-value are introduced. For statistical significance, p < 0.05. All analyses had been carried out utilizing R model 4.1.3.27,28
Outcomes
Research Move and Traits of the Members
In complete, 4869 responses had been collected by way of the web survey. After eradicating 35 duplicate responses and 139 responses from members who didn’t meet the inclusion standards (aged beneath 19 years or members not on energetic responsibility), 4695 responses from eligible members remained. Of the 4695 eligible respondents, 4389 accomplished your complete survey with out lacking any sections.
The members had been males with a imply age of 20.8 ± 1.3 years. A PSQI world cutoff rating >5 indicated poor sleep high quality in 2579 (58.8%) respondents. The distribution of the PSQI world rating in all members is introduced in Determine 1. Moreover, 614 (14.0%) respondents had been assessed as having a excessive threat of OSA in response to the Berlin questionnaire. The members’ traits are introduced in Desk 1. In accordance with the existence of poor sleep high quality and excessive threat of OSA, the traits of the members confirmed variations in numerous demographic, life-style, occupational, and dietary components.
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Desk 1 Traits of Army Service Members |
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Determine 1 Distribution of world Pittsburgh sleep high quality index (PSQI) scores. |
Poor Sleep High quality and Related Elements
Dietary Behaviors
The adjusted odds ratios of dietary behaviors within the presence of poor sleep high quality are introduced in Determine 2 and Desk 2. Within the multivariable logistic regression, skipping breakfast 1–2 instances per week was associated to a higher probability of poor sleep high quality than not skipping breakfast (odds ratio: 1.23 [95% confidence interval (CI): 1.02–1.47], p<0.001). The outcomes of the univariable and multivariable logistic regression confirmed that the chances ratios tended to extend because the frequency of skipping breakfast elevated to five–6 instances per week. Moreover, overeating 1–2 instances or 3–4 instances per week was related to poor sleepers. Those that incessantly ate snacks confirmed a considerably higher probability of experiencing poor sleep high quality than those that didn’t (X2 = 13.6, df = 6, p = 0.035). Consuming evening meals 3–4 instances or 5–6 instances per week considerably elevated the probability of poor sleep high quality. Nevertheless, consuming evening meals each day didn’t seem like related to an elevated probability of poor sleep high quality. The general impact of evening meals on poor sleep high quality was important (X2 = 22.3, df = 5, p < 0.001). Additionally, extra outcomes of dietary behaviors for poor sleep high quality (outlined as the next PSQI threshold > 9), are proven in Desk 3. An identical tendency was noticed between the dietary behaviors and poor sleep high quality in each fashions for the 2 PSQI thresholds. The consequences of skipping breakfast, overeating, and consuming evening meals on poor sleep high quality appear distinctive when making use of the next PSQI threshold.
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Desk 2 Multivariable Logistic Regression of Dietary Behaviors for Poor Sleep High quality (PSQI > 5) |
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Desk 3 Multivariable Logistic Regression of Dietary Behaviors for Poor Sleep High quality (PSQI > 9) |
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Determine 2 Forest plot of the chances ratios of dietary behaviors on poor sleep high quality. Adjusted odds ratios and 95% confidence intervals (CI) had been calculated within the multivariable logistic mannequin utilizing demographic, life-style, and occupational components because the covariates. The dimensions of the sq. represents the variety of members in every merchandise. |
Different Way of life and Occupational Elements
The general outcomes of the multivariable logistic regression are introduced in Tables S1 and S2. The severity of stress was extremely related to an elevated probability of poor sleeping (X2 = 375.1, df = 4, p < 0.001). Moreover, espresso consumption greater than twice each day had distinct results on poor sleep high quality in comparison with ingesting espresso lower than as soon as per week (twice each day: odds ratio 1.35 [95% CI 1.02–1.81], ≥thrice each day: odds ratio 1.51 [95% CI: 1.02–2.27]). Amongst occupational components, servicemen with army chef positions confirmed a higher probability of poor sleep high quality than males in fight arms’ positions. In distinction, servicemen who had been drivers confirmed a decrease probability of being poor sleepers. No matter being off-duty after an evening shift, frequent evening shifts for greater than 5 instances a month had been related to poor sleep high quality, in contrast with no evening shifts.
Excessive Danger of OSA and Related Elements
Dietary Behaviors
The adjusted odds ratios of dietary behaviors within the presence of a excessive threat of OSA are introduced in Determine 3 and Desk 4. The outcomes of the univariate and multivariable logistic regression confirmed that skipping breakfast each day led to a higher probability of being at excessive threat of OSA, in contrast with not skipping breakfast. Furthermore, overeating 3–4 instances per week was related to a excessive threat of OSA. Frequent overeating was related to a higher probability of being at excessive threat of OSA, as proven within the univariate logistic regression. Nevertheless, this tendency decreased after adjusting for demographic components, primarily physique mass index (BMI). Snacking didn’t seem like related to a excessive threat of OSA after adjusting for covariates. In distinction, consuming evening meals was related to a excessive threat of OSA. The general impact of evening meals on excessive threat of OSA was statistically important (X2 = 13.2, df = 5, p = 0.021).
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Desk 4 Multivariable Logistic Regression of Dietary Behaviors for Excessive Danger of OSA |
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Determine 3 Forest plot of the chances ratios of dietary behaviors on excessive threat of obstructive sleep apnea (OSA). Adjusted odds ratios and 95% confidence interval (CI) had been calculated within the multivariable logistic mannequin utilizing demographic, life-style, and occupational components because the covariates. The dimensions of the sq. represents the variety of members in every merchandise. |
Different Way of life and Occupational Elements
The general outcomes of the multivariable logistic regression are introduced in Desk S3. Exercising for greater than 3–4 instances per week was negatively correlated with a excessive threat of OSA. Moreover, stress and ingesting espresso greater than thrice a day had distinct results on excessive threat of OSA. Amongst occupational components, servicemen in administrative positions confirmed a decrease probability of being at excessive threat of OSA than males within the fight arms division. The frequency of evening shifts didn’t appear to be related to high-risk OSA.
Dialogue
On this cross-sectional examine carried out amongst army service members in Korea, we explored poor sleep high quality, excessive threat of OSA, and related dietary components. Amongst numerous dietary behaviors, the next frequency of snacking and frequent and irregular consuming of evening meals had been related to poor sleep high quality. As well as, the next frequency of skipping breakfast, overeating, and having evening meals appeared to be related to a excessive threat of OSA.
Dietary Behaviors and Poor Sleep High quality
Evening Meals
The time of consuming has a significant influence on circadian rhythms, and consuming at evening could shift and even disrupt such rhythms.29,30 In a earlier examine, increased caloric consumption throughout dinner and late within the evening was related to longer sleep latency and decrease sleep effectivity in girls.31 In one other examine, late dinner was positively related to poor sleep high quality when in comparison with having an early dinner.32 In our examine, we discovered that the upper frequency of consuming evening meals was related to an elevated tendency for poor sleep high quality. Particularly, the chances ratio dramatically elevated when consuming evening meals 5–6 instances per week. Curiously, the impact of consuming evening meals on poor sleep high quality was partially eradicated by consuming evening meals each day, 7 instances per week. Frequent and irregular consuming of evening meals seems to be negatively related to sleep high quality. Along with circadian rhythm disruptions, having to digest meals or indigestion which may come up from consuming evening meals could negatively have an effect on sleep high quality.31,33 On the identical time, the potential for reverse causation additionally exists, in that members with poor sleep high quality could are inclined to eat evening meals. In the meantime, the idea of “evening consuming syndrome” has been proposed as a stress-related consuming dysfunction, which is principally characterised by evening consuming patterns and sleep disturbance.34,35 The pathophysiology of “evening consuming syndrome” describes the stress-induced lower within the nocturnal secretion of melatonin and leptin as inflicting each consuming evening meals and insomnia.36 Consuming evening meals and poor sleep high quality appears to be extremely related. The attainable mechanism associated to the affiliation requires additional analysis.37
Snacks/Overeating
In an epidemiological examine of Japanese males aged 20–59 years, snacking habits had been associated to inadequate hours of sleep.18 Herein, the calculated odds ratio of poor sleep high quality elevated because the frequency of snacking and overeating elevated. Moreover, overeating 1–4 instances per week additionally elevated the probability of poor sleep. Snacking and overeating habits may trigger indigestion.38 Moreover, consuming high-fat diets has been reported to worsen sleep/wake fragmentation in mice fashions.39 As well as, stress-induced consuming in people with poor sleep high quality could improve snacking habits, with a desire for consuming energy-dense gadgets.40 Additional, sleeping for a brief length is understood to have an effect on urge for food regulatory hormones, lowering leptin and elevating ghrelin,41 which can induce overeating. A current randomized trial reported that interventions to extend sleep length considerably decreased power consumption in chubby sufferers.42 Poor sleep high quality and habits of snacking and overeating appear to have a reciprocal relationship.
Skipping Breakfast
Earlier research on the connection between skipping breakfast and sleep patterns generally reported that late sleepers usually are inclined to skip breakfast and a late bedtime is related to the tendency to skip breakfast.43,44 This may very well be a confounding issue within the relationship between skipping breakfast and sleep high quality.30 We collected information from army service members whose bedtime and meal instances had been virtually similar since their common sleep time was set from 10 pm to six am and the identical meal was supplied thrice a day. Subsequently, the info may very well be comparatively impartial of those confounding components. In different research, skipping breakfast was related to shorter sleep length in male staff aged 40–59 years,19 and each day breakfast consumption was related to enough sleep in youngsters.44 As well as, an intervention examine reported that consuming breakfast for seven days improved perceived sleep high quality in contrast with skipping breakfast.45 In our examine, we collected the frequency of skipping breakfast in the course of the week, and the next frequency of skipping breakfast was typically related to a higher probability of poor sleep high quality. Nevertheless, responders who skipped breakfast each day confirmed a decrease tendency of being poor sleepers. Evidently skipping breakfast irregularly adversely impacts the upkeep of circadian rhythms.
Occupational Elements and Poor Sleep High quality
Some fascinating occupational components related to poor sleep high quality had been noticed within the members. Our examine included solely enlisted personnel, most of them being in fight arms, and others being drivers, army cooks, or working within the administration. Poor sleepers had been comparatively frequent amongst army cooks since they’re anticipated to get up early at daybreak to organize the meals and due to this fact get further sleep time within the late morning after work. Attainable causes for frequent poor sleep high quality in these army cooks could also be associated to the truth that splitting sleep might negatively have an effect on subjective sleep high quality.46 Contrarily, drivers had decrease sleep disturbances, which may be defined by the efforts of the army to forestall car accidents that may very well be brought on by drowsy driving.47,48 In Korea, drivers are hardly ever assigned to nighttime sentry duties, and even when assigned, they’re positioned early within the evening or early within the morning reasonably than in the course of the evening. The probability of decrease sleep disturbances in drivers was important, even after adjusting the frequency of evening shifts. Insurance policies applied by the army appear to have been comparatively efficient in stopping sleep problems amongst drivers.
Army rank was additionally associated to sleep disturbances, with a non-public rank resulting in a decrease probability of experiencing poor sleep high quality. Within the Korean military, mandatorily enlisted personnel are of the non-public rank till the eighth week, they usually obtain fundamental army coaching programs in the course of the first 5 to seven weeks. Throughout these programs, enlisted personnel obtain intensive bodily coaching, keep a relentless schedule for sleep and meals, and can’t eat snacks or evening meals. Within the current examine, these with non-public ranks who had simply accomplished this coaching course confirmed a decrease probability of experiencing poor sleep high quality. Roughly 5–7 weeks of normal sleep/meal rhythms and intensive bodily coaching could also be associated to a lowered variety of poor sleepers. In help of this, regularizing the sleep-wake schedule was reported to enhance subjective sleep effectivity in an experimental examine.49 Nevertheless, a earlier examine confirmed that the length of army service was an element that elevated the chance of insomnia signs.50 This may increasingly partially clarify the concluded outcomes that first-class privates, corporals, and sergeants confirmed the next tendency of experiencing sleep disturbances, in comparison with privates.
The evening shift was a significant component concerned within the improvement of sleep disturbances in earlier research.51,52 When the frequency of evening shift was > 5 instances in a single month, the probability of poor sleep high quality considerably elevated on this examine.
Dietary Behaviors and Excessive Danger of OSA
Overeating
Overeating was clearly related to a excessive threat of OSA within the univariate logistic regression, however the tendency was diminished within the multivariable logistic regression. The affiliation between overeating and the excessive threat of OSA appeared to be primarily defined by BMI as a result of the energy of the affiliation decreased after adjusting for BMI. Being chubby is a threat issue for OSA,53,54 and frequent overeating can result in the next BMI.
Evening Meals
The impact of consuming evening meals on the excessive threat of OSA was important after adjusting for BMI. Moreover, the chances ratio elevated because the frequency of evening meals elevated. Earlier research have additionally reported that consuming evening meals adversely impacts symptom severity in sufferers with OSA. Elevated meals consumption within the night was associated to decreased sleep high quality in sufferers with sleep apnea.55 Moreover, sufferers with OSA who had a late dinner confirmed the next apnea-hypopnea index (AHI) than those that had an early dinner.32 Additional, consuming fatty meals earlier than bedtime considerably elevated the AHI in contrast with mild meals, in sufferers with OSA.56 Contemplating the Republic of Korea military setting the place this survey was carried out, army service members normally eat calorific meals corresponding to fried rooster and pizza for evening meals. Each the timing and traits of evening meals seem to have a destructive impact on OSA. Avoiding evening meals seems to be an vital dietary habits that performs a job in stopping or assuaging sleep apnea.
Skipping Breakfast
Skipping breakfast each day was clearly related to a excessive threat of OSA. This habits is totally different from the one related to poor sleep high quality, which concerned irregular skipping behaviors. In a earlier examine that researched meal timing and sleep parameters in sufferers with OSA, skipping breakfast didn’t affect the severity of sleep apnea.32 In distinction, in a distinct examine of sufferers with weight problems and OSA, increased caloric consumption at breakfast was related to decrease AHI.55 The explanation for this affiliation between skipping breakfast and excessive threat of OSA is unclear, however the potential components embrace being chubby,57 having hypertension,58 and insulin resistance,58 that are recognized to be associated to the behavior of skipping breakfast. Being chubby and having hypertension or insulin resistance are each threat components for OSA.59,60 Additional analysis is required to discover the results and mechanisms of skipping breakfast on OSA.
Occupational Elements and Excessive Danger of OSA
Within the current examine, sedentary staff in administrative positions confirmed a decrease probability of being at excessive threat of OSA, in contrast with personnel in fight arms whose foremost duties had been particular {qualifications}’ coaching. In a examine carried out in Korea, the prevalence of excessive threat of OSA was 10.7% within the white-collar group and 13.4% within the blue-collar group, however the distinction between the 2 teams was not important.61 When evaluating the traits of personnel in administration and fight arms, older age, increased academic degree, and destructive smoking standing had been noticed within the administrative group (Desk S4). Though the chances ratio of the administration group in comparison with the fight arms group was nonetheless under one after adjusting for all covariates, some experiences recommend {that a} increased academic degree is related to a decrease threat of OSA.62–64 The traits of personnel in administrative positions could clarify the decrease threat of OSA; thus, additional research are required.
Limitations and Implication
This examine has a number of limitations. First, solely males of their early 20s had been included. Subsequently, generalizing the outcomes of this examine to different intercourse and age teams is proscribed. Second, as a result of limitations imposed by a cross-sectional design, it’s troublesome to exhibit causality, and solely an affiliation may be derived. Third, poor sleep high quality and excessive threat of OSA had been outlined utilizing self-reported questionnaires. Fourth, goal sleep parameters weren’t included on this examine.
Nonetheless, we efficiently obtained sensible information from a big inhabitants to know the connection between dietary behaviors and sleep high quality. Though the affiliation between sleep and dietary circumstances needs to be comprehensively examined with numerous potential covariates, it’s difficult when the sort and quantity of knowledge are restricted.65 Subsequently, our large-scale examine utilizing numerous symptom examination instruments could present a deep and broad understanding of the affiliation between sleep and different components, which may very well be a milestone for future research (Desk S5).
Moreover, these outcomes could present insights for army policymakers relating to the event of well being promotion packages for army personnel. Primarily based on our findings and associated earlier analysis, the dietary behaviors of army service members ought to obtain consideration to enhance their sleep high quality and forestall the chance of OSA. Particularly, a coverage to keep away from frequent modifications in meal timings (increased frequency of consuming evening meals or skipping breakfast) needs to be thought-about to enhance sleep high quality. As well as, an academic program to lower the frequency of snacking and overeating may be developed to forestall the chance of OSA.
Conclusion
On this large-scale cross-sectional examine that included 4389 Korean army service members, consuming an evening meal 5–6 instances/week, skipping breakfast irregularly, and consuming snacks incessantly had been related to poor sleep high quality. Whereas, consuming evening meals and skipping breakfast each day had been related to a excessive threat of OSA. Irregular dietary behaviors seem like associated to poor sleep high quality and a excessive threat of OSA. To find out the attainable mechanisms associated to the associations between sleep and dietary behaviors wants additional analysis.
Funding
This analysis was supported by a grant from the Korea Institute of Oriental Drugs [KSN2022210].
Disclosure
The authors report no conflicts of curiosity on this work.
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