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Contributions of the Women's Health Initiative to understanding associations between sleep duration, insomnia symptoms, and sleep-disordered breathing across a range of health outcomes in postmenopausal women

Published:November 04, 2019DOI:https://doi.org/10.1016/j.sleh.2019.09.005

      Abstract

      The Women's Health Initiative (WHI), a longitudinal study of more than 161,000 postmenopausal women across the United States, provides an opportunity to investigate the link between sleep health and healthy aging. The purpose of this paper was to systematically review all published WHI articles examining sleep as a predictor of health outcomes and health behaviors/quality of life outcomes. A strength of the WHI is that for most participants, sleep measures were completed before a major health diagnosis, with a significant portion of participants also providing sleep measures after diagnosis. Twenty-three WHI articles were identified and examined for this review. The combination of sleep duration and insomnia symptoms was the most commonly investigated sleep measure. The results indicated that both short (≤6 hours) and long (≥9 hours) sleep duration were associated with a higher risk of cardiovascular disease, colorectal cancer, mortality, cognitive decline, and poor diet. Insomnia symptoms, frequent snoring, and risk of sleep-disordered breathing (SDB) were also associated with increased risk for ischemic stroke and cardiovascular disease. However, many significant results were attenuated after multivariable adjustment. Limitations of these WHI examinations include the use of different categories for sleep measures across studies and a lack of examination by race/ethnicity. Owing to the longitudinal study design, large sample size, and long-term follow-up for health outcomes, the WHI serves as a rich resource for examining associations between sleep characteristics, demographics, and health in postmenopausal women.

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      References

      References with an asterisk (*) identify the articles included in this review.

        • Czeisler C.A.
        Duration, timing and quality of sleep are each vital for health, performance and safety.
        Sleep Health. 2015; 1: 5-8
        • Altman N.G.
        • Izci-Balserak B.
        • Schopfer E.
        • et al.
        Sleep duration versus sleep insufficiency as predictors of cardiometabolic health outcomes.
        Sleep Med. 2012; 13: 1261-1270
        • Hoevenaar-Blom M.P.
        • Spijkerman A.M.
        • Kromhout D.
        • van den Berg J.F.
        • Verschuren W.M.
        Sleep duration and sleep quality in relation to 12-year cardiovascular disease incidence: the MORGEN study.
        Sleep. 2011; 34: 1487-1492
        • Buxton O.M.
        • Marcelli E.
        Short and long sleep are positively associated with obesity, diabetes, hypertension, and cardiovascular disease among adults in the United States.
        Soc Sci Med. 2010; 71: 1027-1036
        • Leineweber C.
        • Kecklund G.
        • Akerstedt T.
        • Janszky I.
        • Orth-Gomer K.
        Snoring and the metabolic syndrome in women.
        Sleep Med. 2003; 4: 531-536
        • Knutson K.L.
        Sleep duration and cardiometabolic risk: a review of the epidemiologic evidence.
        Best Pract Res Clin Endocrinol Metab. 2010; 24: 731-743
        • Hurley S.
        • Goldberg D.
        • Bernstein L.
        • Reynolds P.
        Sleep duration and cancer risk in women.
        Cancer Causes Control. 2015; 26: 1037-1045
        • Zhang X.
        • Giovannucci E.L.
        • Wu K.
        • et al.
        Associations of self-reported sleep duration and snoring with colorectal cancer risk in men and women.
        Sleep. 2013; 36: 681-688
        • Wang P.
        • Ren F.M.
        • Lin Y.
        • et al.
        Night-shift work, sleep duration, daytime napping, and breast cancer risk.
        Sleep Med. 2015; 16: 462-468
        • Gallicchio L.
        • Kalesan B.
        Sleep duration and mortality: a systematic review and meta-analysis.
        J Sleep Res. 2009; 18: 148-158
        • Grandner M.A.
        • Hale L.
        • Moore M.
        • Patel N.P.
        Mortality associated with short sleep duration: The evidence, the possible mechanisms, and the future.
        Sleep Med Rev. 2010; 14: 191-203
        • Kripke D.F.
        • Garfinkel L.
        • Wingard D.L.
        • Klauber M.R.
        • Marler M.R.
        Mortality associated with sleep duration and insomnia.
        Arch Gen Psychiatr. 2002; 59: 131-136
        • Vgontzas A.N.
        • Fernandez-Mendoza J.
        • Liao D.
        • Bixler E.O.
        Insomnia with objective short sleep duration: the most biologically severe phenotype of the disorder.
        Sleep Med Rev. 2013; 17: 241-254
        • Irwin M.R.
        Why sleep is important for health: a psychoneuroimmunology perspective.
        Annu Rev Psychol. 2015; 66: 143-172
        • Riemann D.
        • Berger M.
        • Voderholzer U.
        Sleep and depression--results from psychobiological studies: an overview.
        Biol Psychol. 2001; 57: 67-103
        • Baglioni C.
        • Battagliese G.
        • Feige B.
        • et al.
        Insomnia as a predictor of depression: a meta-analytic evaluation of longitudinal epidemiological studies.
        J Affect Disord. 2011; 135: 10-19
        • Fernandez-Mendoza J.
        • Calhoun S.L.
        • Bixler E.O.
        • et al.
        Sleep misperception and chronic insomnia in the general population: role of objective sleep duration and psychological profiles.
        Psychosom Med. 2011; 73: 88-97
        • Palagini L.
        • Baglioni C.
        • Ciapparelli A.
        • Gemignani A.
        • Riemann D.
        REM sleep dysregulation in depression: state of the art.
        Sleep Med Rev. 2013; 17: 377-390
        • Vitiello M.V.
        Sleep in Normal Aging.
        Sleep Med Clin. 2006; 1: 171-176
        • Jehan S.
        • Masters-Isarilov A.
        • Salifu I.
        • et al.
        Sleep Disorders in Postmenopausal Women.
        J Sleep Disord Ther. 2015; 4
        • Kripke D.F.
        • Brunner R.
        • Freeman R.
        • et al.
        Sleep Complaints of Postmenopausal Women.
        Clin J Women's Health. 2001; 1: 244-252
        • Carpenter J.S.
        • Elam J.L.
        • Ridner S.H.
        • Carney P.H.
        • Cherry G.J.
        • Cucullu H.L.
        Sleep, fatigue, and depressive symptoms in breast cancer survivors and matched healthy women experiencing hot flashes.
        Oncol Nurs Forum. 2004; 31: 591-5598
        • Kravitz H.M.
        • Avery E.
        • Sowers M.
        • et al.
        Relationships between menopausal and mood symptoms and EEG sleep measures in a multi-ethnic sample of middle-aged women: the SWAN sleep study.
        Sleep. 2011; 34: 1221-1232
        • Kravitz H.M.
        • Zhao X.
        • Bromberger J.T.
        • et al.
        Sleep disturbance during the menopausal transition in a multi-ethnic community sample of women.
        Sleep. 2008; 31: 979-990
        • Joffe H.
        • Massler A.
        • Sharkey K.M.
        Evaluation and management of sleep disturbance during the menopause transition.
        Semin Reprod Med. 2010; 28: 404-421
        • Colditz G.A.
        • Manson J.E.
        • Hankinson S.E.
        The Nurses' Health Study: 20-year contribution to the understanding of health among women.
        J Womens Health. 1997; 6: 49-62
      1. Design of the Women's Health Initiative clinical trial and observational study. The Women's Health Initiative Study Group.
        Contr Clin Trials. 1998; 19: 61-109
        • Sowers M.
        • Crawford S.
        • Sternfeld B.
        • et al.
        SWAN: a multi-center, multi-ethnic, community-based cohort study of women and the menopausal transition.
        in: Menopause: biology and pathobiology. Academic Press, New York, NY2000: 175-188
        • Kravitz H.M.
        • Joffe H.
        Sleep during the perimenopause: a SWAN story.
        Obstet Gynecol Clin North Am. 2011; 38: 567-586
        • Hall M.H.
        • Casement M.D.
        • Troxel W.M.
        • et al.
        Chronic Stress is Prospectively Associated with Sleep in Midlife Women: The SWAN Sleep Study.
        Sleep. 2015; 38: 1645-1654
        • Colditz G.A.
        • Philpott S.E.
        • Hankinson S.E.
        The Impact of the Nurses' Health Study on Population Health: Prevention, Translation, and Control.
        Am J Public Health. 2016; 106: 1540-1545
        • Gangwisch J.E.
        • Feskanich D.
        • Malaspina D.
        • Shen S.
        • Forman J.P.
        Sleep duration and risk for hypertension in women: results from the nurses' health study.
        Am J Hypertens. 2013; 26: 903-911
        • Anderson G.L.
        • Manson J.
        • Wallace R.
        • et al.
        Implementation of the Women's Health Initiative study design.
        Ann Epidemiol. 2003; 13: S5-S17
        • Hays J.
        • Hunt J.R.
        • Hubbell F.A.
        • et al.
        The Women's Health Initiative recruitment methods and results.
        Ann Epidemiol. 2003; 13: S18-S77
        • Levine D.W.
        • Kaplan R.M.
        • Kripke D.F.
        • Bowen D.J.
        • Naughton M.J.
        • Shumaker S.A.
        Factor structure and measurement invariance of the Women's Health Initiative Insomnia Rating Scale.
        Psychol Assess. 2003; 15: 123-136
        • Levine D.W.
        • Kripke D.F.
        • Kaplan R.M.
        • et al.
        Reliability and validity of the Women's Health Initiative Insomnia Rating Scale.
        Psychol Assess. 2003; 15: 137-148
        • Levine D.W.
        • Dailey M.E.
        • Rockhill B.
        • Tipping D.
        • Naughton M.J.
        • Shumaker S.A.
        Validation of the Women's Health Initiative Insomnia Rating Scale in a multicenter controlled clinical trial.
        Psychosom Med. 2005; 67: 98-104
        • Rissling M.B.
        • Gray K.E.
        • Ulmer C.S.
        • et al.
        Sleep Disturbance, Diabetes, and Cardiovascular Disease in Postmenopausal Veteran Women.
        Gerontologist. 2016; 56 (*): S54-S66
        • Kling J.M.
        • Manson J.E.
        • Naughton M.J.
        • et al.
        Association of sleep disturbance and sexual function in postmenopausal women.
        Menopause. 2017; 24 (*): 604-612
        • Netzer N.C.
        • Stoohs R.A.
        • Netzer C.M.
        • Clark K.
        • Strohl K.P.
        Using the Berlin Questionnaire to identify patients at risk for the sleep apnea syndrome.
        Ann Intern Med. 1999; 131: 485-491
        • Mustafa M.
        • Erokwu N.
        • Ebose I.
        • Strohl K.
        Sleep problems and the risk for sleep disorders in an outpatient veteran population.
        Sleep Breath. 2005; 9: 57-63
        • Koo P.
        • McCool F.D.
        • Hale L.
        • Stone K.
        • Eaton C.B.
        Association of obstructive sleep apnea risk factors with nocturnal enuresis in postmenopausal women.
        Menopause. 2016; 23 (*): 175-182
        • Chen J.C.
        • Brunner R.L.
        • Ren H.
        • et al.
        Sleep duration and risk of ischemic stroke in postmenopausal women.
        Stroke. 2008; 39 (*): 3185-3192
        • Hale L.
        • Parente V.
        • Dowd J.B.
        • et al.
        Fibrinogen may mediate the association between long sleep duration and coronary heart disease.
        J Sleep Res. 2013; 22 (*): 305-314
        • Jiao L.
        • Duan Z.
        • Sangi-Haghpeykar H.
        • Hale L.
        • White D.L.
        • El-Serag H.B.
        Sleep duration and incidence of colorectal cancer in postmenopausal women.
        Br J Cancer. 2013; 108 (*): 213-221
        • Royse K.E.
        • El-Serag H.B.
        • Chen L.
        • et al.
        Sleep Duration and Risk of Liver Cancer in Postmenopausal Women: The Women's Health Initiative Study.
        J Womens Health (Larchmt). 2017; 26 (*): 1270-1277
        • Chen J.C.
        • Espeland M.A.
        • Brunner R.L.
        • et al.
        Sleep duration, cognitive decline, and dementia risk in older women.
        Alzheimers Dement. 2016; 12 (*): 21-33
        • Zaslavsky O.
        • LaCroix A.Z.
        • Hale L.
        • Tindle H.
        • Shochat T.
        Longitudinal changes in insomnia status and incidence of physical, emotional, or mixed impairment in postmenopausal women participating in the Women's Health Initiative (WHI) study.
        Sleep Med. 2015; 16 (*): 364-371
        • Huang T.
        • Zeleznik O.A.
        • Poole E.M.
        • et al.
        Habitual sleep quality, plasma metabolites and risk of coronary heart disease in post-menopausal women.
        Int J Epidemiol. 2018; (*)
        • Sands-Lincoln M.
        • Loucks E.B.
        • Lu B.
        • et al.
        Sleep duration, insomnia, and coronary heart disease among postmenopausal women in the Women's Health Initiative.
        J Womens Health (Larchmt). 2013; 22 (*): 477-486
        • Vogtmann E.
        • Levitan E.B.
        • Hale L.
        • et al.
        Association between sleep and breast cancer incidence among postmenopausal women in the Women's Health Initiative.
        Sleep. 2013; 36 (*): 1437-1444
        • Luo J.
        • Sands M.
        • Wactawski-Wende J.
        • Song Y.
        • Margolis K.L.
        Sleep disturbance and incidence of thyroid cancer in postmenopausal women the Women's Health Initiative.
        Am J Epidemiol. 2013; 177 (*): 42-49
        • Phipps A.I.
        • Bhatti P.
        • Neuhouser M.L.
        • et al.
        Pre-diagnostic Sleep Duration and Sleep Quality in Relation to Subsequent Cancer Survival.
        J Clin Sleep Med. 2016; 12 (*): 495-503
        • Soucise A.
        • Vaughn C.
        • Thompson C.L.
        • et al.
        Sleep quality, duration, and breast cancer aggressiveness.
        Breast Canc Res Treat. 2017; 164 (*): 169-178
        • Stern J.H.
        • Grant A.S.
        • Thomson C.A.
        • et al.
        Short sleep duration is associated with decreased serum leptin, increased energy intake and decreased diet quality in postmenopausal women.
        Obesity (Silver Spring). 2014; 22 (*): E55-E61
        • Carroll J.E.
        • Irwin M.R.
        • Levine M.
        • et al.
        Epigenetic Aging and Immune Senescence in Women With Insomnia Symptoms: Findings From the Women's Health Initiative Study.
        Biol Psychiatr. 2017; 81 (*): 136-144
        • Kabat G.C.
        • Xue X.
        • Kamensky V.
        • et al.
        The association of sleep duration and quality with all-cause and cause-specific mortality in the Women's Health Initiative.
        Sleep Med. 2018; 50 (*): 48-54
        • Grieshober L.
        • Wactawski-Wende J.
        • Blair R.H.
        • et al.
        A Cross-Sectional Analysis of Telomere Length and Sleep in the Women's Health Initiative.
        Am J Epidemiol. 2019; 188 (*): 1616-1626
        • Cauley J.A.
        • Hovey K.M.
        • Stone K.L.
        • et al.
        Characteristics of Self-Reported Sleep and the Risk of Falls and Fractures: The Women's Health Initiative (WHI).
        J Bone Miner Res. 2019; 34 (*): 464-474
        • Sands M.
        • Loucks E.B.
        • Lu B.
        • et al.
        Self-reported snoring and risk of cardiovascular disease among postmenopausal women (from the Women's Health Initiative).
        Am J Cardiol. 2013; 111 (*): 540-546
        • Kripke D.F.
        • Langer R.D.
        • Elliott J.A.
        • Klauber M.R.
        • Rex K.M.
        Mortality related to actigraphic long and short sleep.
        Sleep Med. 2011; 12 (*): 28-33
        • Grandner M.A.
        • Kripke D.F.
        • Naidoo N.
        • Langer R.D.
        Relationships among dietary nutrients and subjective sleep, objective sleep, and napping in women.
        Sleep Med. 2010; 11 (*): 180-184
        • Hoerster K.D.
        • Lehavot K.
        • Simpson T.
        • McFall M.
        • Reiber G.
        • Nelson K.M.
        Health and health behavior differences: U.S. Military, veteran, and civilian men.
        Am J Prev Med. 2012; 43: 483-489
        • Weitlauf J.C.
        • LaCroix A.Z.
        • Bird C.E.
        • et al.
        Prospective Analysis of Health and Mortality Risk in Veteran and Non-Veteran Participants in the Women's Health Initiative.
        Womens Health Issues. 2015; 25: 649-657
        • Vimalananda V.G.
        • Miller D.R.
        • Christiansen C.L.
        • Wang W.
        • Tremblay P.
        • Fincke B.G.
        Cardiovascular disease risk factors among women veterans at VA medical facilities.
        J Gen Intern Med. 2013; 28: S517-S523
        • Heppner P.S.
        • Crawford E.F.
        • Haji U.A.
        • et al.
        The association of posttraumatic stress disorder and metabolic syndrome: a study of increased health risk in veterans.
        BMC Med. 2009; 7: 1
        • Kitahara C.M.
        • Platz E.A.
        • Freeman L.E.
        • et al.
        Obesity and thyroid cancer risk among U.S. men and women: a pooled analysis of five prospective studies.
        Cancer Epidemiol Biomarkers Prev. 2011; 20: 464-472
        • Knutson K.L.
        Does inadequate sleep play a role in vulnerability to obesity?.
        Am J Hum Biol. 2012; 24: 361-371
        • Teng E.L.
        • Chui H.C.
        The Modified Mini-Mental State (3MS) examination.
        J Clin Psychiatr. 1987; 48: 314-318
        • Shumaker S.A.
        • Reboussin B.A.
        • Espeland M.A.
        • et al.
        The Women's Health Initiative Memory Study (WHIMS): a trial of the effect of estrogen therapy in preventing and slowing the progression of dementia.
        Contr Clin Trials. 1998; 19: 604-621
        • Shumaker S.A.
        • Legault C.
        • Kuller L.
        • et al.
        Conjugated equine estrogens and incidence of probable dementia and mild cognitive impairment in postmenopausal women: Women's Health Initiative Memory Study.
        JAMA. 2004; 291: 2947-2958
        • Burnam M.A.
        • Wells K.B.
        • Leake B.
        • Landsverk J.
        Development of a brief screening instrument for detecting depressive disorders.
        Med Care. 1988; 26: 775-789
        • Gottlieb D.J.
        • Redline S.
        • Nieto F.J.
        • et al.
        Association of usual sleep duration with hypertension: the Sleep Heart Health Study.
        Sleep. 2006; 29: 1009-1014
        • Chair S.Y.
        • Wang Q.
        • Cheng H.Y.
        • et al.
        Relationship between sleep quality and cardiovascular disease risk in Chinese post-menopausal women.
        BMC Womens Health. 2017; 17: 79
        • Li F.
        • Sun K.
        • Lin D.
        • et al.
        Longtime napping is associated with cardiovascular risk estimation according to Framingham risk score in postmenopausal women.
        Menopause. 2016; 23: 950-956
        • Kakizaki M.
        • Kuriyama S.
        • Sone T.
        • et al.
        Sleep duration and the risk of breast cancer: the Ohsaki Cohort Study.
        Br J Cancer. 2008; 99: 1502-1505
        • Wu A.H.
        • Wang R.
        • Koh W.P.
        • Stanczyk F.Z.
        • Lee H.P.
        • Yu M.C.
        Sleep duration, melatonin and breast cancer among Chinese women in Singapore.
        Carcinogenesis. 2008; 29: 1244-1248
        • Verkasalo P.K.
        • Lillberg K.
        • Stevens R.G.
        • et al.
        Sleep duration and breast cancer: a prospective cohort study.
        Cancer Res. 2005; 65: 9595-9600
        • White A.J.
        • Weinberg C.R.
        • Park Y.M.
        • et al.
        Sleep characteristics, light at night and breast cancer risk in a prospective cohort.
        Int J Cancer. 2017; 141: 2204-2214
        • Pinheiro S.P.
        • Schernhammer E.S.
        • Tworoger S.S.
        • Michels K.B.
        A prospective study on habitual duration of sleep and incidence of breast cancer in a large cohort of women.
        Cancer Res. 2006; 66: 5521-5525
        • Girschik J.
        • Heyworth J.
        • Fritschi L.
        Self-reported sleep duration, sleep quality, and breast cancer risk in a population-based case-control study.
        Am J Epidemiol. 2013; 177: 316-327
        • Thompson C.L.
        • Larkin E.K.
        • Patel S.
        • Berger N.A.
        • Redline S.
        • Li L.
        Short duration of sleep increases risk of colorectal adenoma.
        Cancer. 2011; 117: 841-847
        • Levi F.
        • Dugue P.A.
        • Innominato P.
        • et al.
        Wrist actimetry circadian rhythm as a robust predictor of colorectal cancer patients survival.
        Chronobiol Int. 2014; 31: 891-900
        • Palesh O.
        • Aldridge-Gerry A.
        • Zeitzer J.M.
        • et al.
        Actigraphy-measured sleep disruption as a predictor of survival among women with advanced breast cancer.
        Sleep. 2014; 37: 837-842
        • Scullin M.K.
        • Bliwise D.L.
        Sleep, cognition, and normal aging: integrating a half century of multidisciplinary research.
        Perspect Psychol Sci. 2015; 10: 97-137
        • Yaffe K.
        • Falvey C.M.
        • Hoang T.
        Connections between sleep and cognition in older adults.
        Lancet Neurol. 2014; 13: 1017-1028
        • Youngstedt S.D.
        • Kripke D.F.
        Long sleep and mortality: rationale for sleep restriction.
        Sleep Med Rev. 2004; 8: 159-174
        • Suzuki E.
        • Yorifuji T.
        • Ueshima K.
        • et al.
        Sleep duration, sleep quality and cardiovascular disease mortality among the elderly: a population-based cohort study.
        Prev Med. 2009; 49: 135-141
        • Cappuccio F.P.
        • D'Elia L.
        • Strazzullo P.
        • Miller M.A.
        Sleep duration and all-cause mortality: a systematic review and meta-analysis of prospective studies.
        Sleep. 2010; 33: 585-592
        • Jehan S.
        • Myers A.K.
        • Zizi F.
        • et al.
        Sleep health disparity: the putative role of race, ethnicity and socioeconomic status.
        Sleep Med Disord. 2018; 2: 127-133
        • Jackson C.L.
        • Redline S.
        • Emmons K.M.
        Sleep as a potential fundamental contributor to disparities in cardiovascular health.
        Annu Rev Public Health. 2015; 36: 417-440

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