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increased prevalence of IFG, compared with those sleep- missing information on sleep duration or sleep quality
ing 68 h/night, after adjustment for confounders, over were also excluded. Trained physicians and public
6 years of follow-up.5 Spiegel et al6 have demonstrated health workers conducted face-to-face interviews using a
that experimental restriction of sleep to <4 h/night for standardised questionnaire to collect sociodemographic,
six nights resulted in an IGT in young healthy adults. lifestyle and health-related information.
Our previous results suggest that poor quality of sleep The study protocol was approved by the Xuzhou
and sleep duration of <6 h/ night are independent risk Center for Disease Control and Prevention.
factors for type 2 diabetes, even after adjusting for a
large number of possible confounders.7 8 Our previous Key measurements
study also conrmed that relatively healthy individuals The FPG was determined by morning blood samples
with poor sleep quality and sleeping times of 6 h or less obtained by venipuncture after an overnight fast of at
had a higher risk of IFG, even after adjusting for a large least 12 h, and extracted plasma was stored at 70C for
number of confounding factors.3 later glucose determination by the hexokinase method.
Although these risk factors play a role in the develop- IFG is delimited according to the current American
ment of type 2 diabetes, the disease is the result of the Diabetes Association denition.11
interaction of genetic and environmental factors. There The PSQI is a 19-item self-report measure of sleep
is little understanding of multivariate explanations of quality and degree of sleep difculties over the past
IFG in relatively healthy individuals. To our knowledge, month, and contains 7 component scales: sleep quality,
there are no studies on the interaction of sleep quality sleep latency, sleep duration, sleep efciency, sleep dis-
and sleep duration on IFG in relatively healthy indivi- turbances, use of sleep medication, and daytime dysfunc-
duals. The primary aim of this cross-sectional study was tion. The 7 component scores are then added to yield a
to examine the combined effects of sleep quality and global PSQI score with a range of 021; higher scores
sleep duration on IFG in relatively healthy individuals in indicate worse sleep quality. A global PSQI score >5 has
a Chinese primary-care setting. A secondary aim was to a diagnostic sensitivity of 89.6% and specicity of 86.5%
assess the associations of sleep quality and IFG, and of in differentiating poor from good sleepers. The Chinese
sleep duration and IFG. version of the PSQI, used with permission from the ori-
ginal PSQI authors, has an overall reliability coefcient
of 0.820.83 and acceptable testretest reliability, with a
METHODS coefcient of 0.770.85.12 Accordingly, in this study
The study was a continuation of our previous work.9 The design, a PSQI score 5 was also conventionally dened
investigation was conducted from March to November as good sleep quality, and a PSQI score >5 was dened
2012 with a sample size of 15 145 volunteers (7557 men as poor sleep quality.
and 7588 women) aged 1875 years. Briey, the sam- Self-reported sleep measures of chronic sleep: two vari-
pling was selected with probability proportional to size ables were used to evaluate degree of chronic sleep
from all of the 11 regions in Xuzhou city. In the rst restriction by estimating average nightly sleep duration:
stage, ve subdistricts/townships in urban/rural areas (1) usual sleep (from questionnaires) and (2) average
were selected from each region. In the second stage, ve nightly sleep (from sleep diaries). Sleep quantity was
communities/villages were selected from each subdis- categorised as <6, 68 and >8 h/ night in accordance
tricts/townships. In the nal stage, one person who was with our previous study.3 7 8
at least 18 years old and lived in the current residence
for at least 5 years was selected from each household Covariates
using a Kish selection table. A total of 16 500 people Age, gender, current employment status, level of educa-
were selected assuming an estimation prevalence of dia- tion, cigarette smoking, alcohol intake, physical activity,
betes of 5.5% with 90% power and =0.05 and allowing family history of diseases including diabetes, hypertension,
for a drop out of 10%. All volunteers underwent a heart disease and cancer were assessed using a standar-
health check and completed a structured questionnaire dised questionnaire. Employment status was categorised as
covering demographic information, medical history, manual, non-manual, unemployed and retired. Education
medication history, sleep assessment, and smoking, was categorised into below high school, high school or
alcohol drinking and exercise habits. All volunteers above high school education. Lifestyle variables included
underwent 12 h overnight fasting and blood sampling cigarette smoking, alcohol drinking and physical activity
for basic fasting plasma glucose (FPG). After blood sam- level. Cigarette smoking was dened as having smoked at
pling, each volunteer completed the Pittsburgh Sleep least 100 cigarettes in a lifetime. Information was obtained
Quality Index (PSQI).10 We excluded volunteers who on the amount and type of alcohol that was consumed
were pregnant, had received antihypertensive medica- during the previous year, and alcohol drinking was
tion, or were suffering from any cardiovascular disease, dened as the consumption of at least 30 g of alcohol per
stroke, neuropathy, psychosis, depression, chronic week for 1 year or more. Regular leisure-time physical
obstructive pulmonary disease, obstructive sleep apnea, activity was dened as participating in moderate or vigor-
diabetes, ache or any other disease. Those who had ous activity for no less than 30 min/day at least 3 days a
week. Each volunteers body height (to the nearest interactions of poor sleep quality and short sleep dur-
0.1 cm) and weight (to the nearest 0.1 kg) in light indoor ation: relative excess risk owing to interaction (RERI),
clothing were measured. Body mass index (BMI; in kg/ the attributable proportion (AP) owing to interaction
m2) was calculated. BMI was categorised as underweight and the synergy index (S). The RERI is the excess risk
(<18.5 kg/m2), normal weight (18.524 kg/m2) and over- attributed to interaction relative to the risk without
weight/obese (>24 kg/m2).13 exposure to poor sleep quality and short sleep duration.
AP of disease is caused by interaction in individuals with
Statistical analysis exposure to both variables. S is the excess risk from
Statistical analysis was performed on a computer, using exposure to both variables when there is a biological
the statistical analysis program SPSS V. 13.0 (SPSS, interaction relative to the risk from exposure to both
Chicago, Illinois, USA). Mean differences of continuous variables without interaction. In the absence of additive
variables between groups were tested using analysis of interactions, RERI and AP are equal to 0.16 In the
variance. The 2- test was used to calculate the differ- current study, RERI>0, AP>0 and S>0 indicate statistical
ence in proportions between groups. Logistic regression signicance. A p value <0.05 (two tailed) was considered
analysis was performed to estimate the probability of statistically signicant.
having IFG and 95% CI for each risk factor category
stratied by sleep quality and sleep duration, adjusting
for age, residential areas, occupation, education and RESULTS
income levels, leisure-time physical activity, smoking General characteristics of participants
status, drinking status and hypertension status. The The response rate was 91.3%. Of the 16 584 initial parti-
observed prevalences of IFG were plotted and stratied cipants, 125 did not respond to the sleep items or blood
by sleep quality and sleep duration. glucose, 1314 did not meet our study criteria, 15 145
Biological interactions should be based on the sum of adults (7557 men and 7588 women) with complete data
the scale rather than multiplying the scale.14 15 were included in our analysis. The average sleep dur-
Therefore, we used three measures to estimate biological ation per night was 7.161.06 h. The average age was
Table 2 Comparison of characteristics between individuals with poor sleep quality and sleep duration <6 h and controls
Poor sleep quality with short sleep time (<6 h)
Reported variable All Yes No p Value
15 145 602 14 543
Age (years) 47.615.1 47.815.5 47.515.1 0.63
Sex (male) 7557 299 (3.96%) 7258 (96.04%) 0.91
Rural 10 965 435 (3.97%) 10 530 (96.03%) 0.94
Manual 10 833 421 (3.89%) 10 412 (96.11%) 0.38
Non-manual 1045 44 (4.21%) 1001 (95.79%) 0.69
Unemployed 677 35 (5.17%) 642 (94.83%) 0.10
Retired 2590 102 (3.94%) 2488 (96.06%) 0.92
Marred (living with partners; %) 13 403 535 (3.99%) 12 868 (96.01%) 0.77
Below high school 11 899 470 (3.95%) 11 429 (96.05%) 0.76
High school 1760 70 (3.98%) 1690 (96.02%) 1
Above high school 1486 62 (4.17%) 1424 (95.83%) 0.68
Smoker 3541 145 (4.09%) 3396 (95.91%) 0.68
Alcohol use 2872 121 (4.21%) 2751 (98.79%) 0.48
Regular exercise 2559 92 (3.60%) 2467 (96.40%) 0.28
Family history of diabetes 483 20 (4.14%) 463 (95.86%) 0.85
BMI, mean (SD) 23.94.7 24.04.9 23.94.6 0.60
Central obesity 4613 186 (4.03%) 4427 (95.97%) 0.81
Hypertension 3060 131 (4.28%) 2929 (95.72%) 0.33
BMI, Body mass index.
47.615.1 years. Among them, 634 had IFG; the remain- Comparison of PSQI scores between the volunteers
der had normal glucose tolerance (NGT). The with IFG and NGT
characteristics of the study population are presented in Volunteers with IFG had signicantly higher global PSQI
table 1. The characteristics between individuals with scores than those with NGT. For all PSQI items except
poor sleep quality and sleep duration <6 h and controls are sleep duration, there were signicant differences
presented in table 2. The proportion of volunteers with (p<0.05) in PSQI scores between the two groups (table 3)
poor sleep quality was 26%, the proportion with sleep dur- even after adjusted age.
ation <6 h was 12.5%, and the proportion with sleep
duration>8 h was 12.3%. The 6.7% prevalence of IFG in The association of sleep time and quality with IFG
volunteers with poor sleep quality was higher than that in Individuals with short sleep duration or long sleep duration
volunteers with good sleep quality (2=85.98, p<0.001). had signicantly increased risk of IFG compared with those
Individuals with sleep duration <6 h had a higher IFG with good sleep quality and sleep duration of 68 h (OR
prevalence compared with individuals with sleep duration 2.16, 95% CI 1.33 to 3.47; OR 1.89, 95% CI 1.50 to 2.34;
of 68 h (7.3% vs 3.3%; 2=72.20, p<0.001). Individuals respectively; all p<0.001), after adjusting for confounders
with sleep duration >8 h also had higher prevalence of IFG (see table 3). Individuals with poor sleep quality had signi-
(6.2% vs 3.3%; 2=37.78, p<0.001). cantly increased risk of IFG compared with those with good
Table 3 Comparison of Pittsburgh Sleep Quality Index scores between individuals with impaired fasting glucose and
controls (x SD)
IFG
Items No Yes F value p Value
Subjective sleep quality 0.4150.013 0.4630.03 31.823 0.000
Sleep latency 0.7420.004 0.8000.016 27.446 0.000
Sleep duration 0.1520.002 0.1590.001 0.503 0.478
Sleep efficiency 0.4440.003 0.3210.001 29.452 0.000
Sleep disturbance 0.5910.003 0.6580.012 28.259 0.000
Use of hypnotic 0.0510.002 0.0650.007 16.651 0.000
Daytime dysfunction 0.1470.011 0.1700.002 9.725 0.000
Global PSQI scores 2.3020.009 2.4950.041 20.957 0.000
Using analysis of covariance, covariates for age=47.6 years old.
IFG, impaired fasting glucose; PSQI, Pittsburgh Sleep Quality Index.
Table 5 ORs for the association between sleep quality and impaired fasting glucose by sleep duration among participants
Sleep duration Sleep quality IFG No IFG OR (95% CI) p Value
68 h Good 246 8743 1
Poor 127 2176 1.98 (1.76 to 2.52) <0.001
<6 h Good 53 1329 1.38 (1.12 to 1.61) <0.001
Poor 92 510 6.37 (4.66 to 8.67) <0.001
>8 h Good 70 768 3.17 (2.29 to 4.41) <0.001
Poor 46 985 1.59 (1.08 to 2.29) <0.001
Adjusted for age, sex, education, employment, BMI, family history of diabetes, smoking status, alcohol consumption and physical activity.
BMI, body mass index; IFG, impaired fasting glucose.
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