Lin YP, Hsu YC, Lin KH, Tsai KZ, Chu CC, Lin YC, Lin GM. Nocturnal sentry duty and cardiometabolic characteristics in armed forces personnel. World J Cardiol 2024; 16(12): 751-759 [DOI: 10.4330/wjc.v16.i12.751]
Corresponding Author of This Article
Gen-Min Lin, FACC, FAHA, FESC, MD, PhD, Academic Fellow, Chief Physician, Department of Medicine, Hualien Armed Forces General Hospital, No. 100 Jinfeng Street, Hualien City 970, Taiwan. farmer507@yahoo.com.tw
Research Domain of This Article
Cardiac & Cardiovascular Systems
Article-Type of This Article
Observational Study
Open-Access Policy of This Article
This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Author contributions: Lin YP and Hsu YC wrote the article and contributed equally; Lin KH collected the data; Tsai KZ analyzed the data; Chu CC and Yen-Chen Lin reviewed the data, edited and made critical revisions related to important intellectual content. Lin GM and Lin KH contributed to conception and design of the CHIEF Sleep study, and acquired and interpreted the data; all authors approved the final version of the article to be published.
Supported byMedical Affairs Bureau Ministry of National Defense, No. MND-MAB-D-113200 and Hualien Armed Forces General Hospital, No. HAFGH-D-113008.
Institutional review board statement: The study design was approved by the Ethics Committee of the Mennonite Christian Hospital (No. 16-05-008), Hualien City, Taiwan, and was performed in accordance with the Helsinki Declaration, as revised in 2013.
Informed consent statement: All participants were informed of the protocol of this study and gave written informed consent.
Conflict-of-interest statement: The authors declare that they have no conflicts of interest.
Data sharing statement: As the CHIEF study materials were obtained from the military in Taiwan, the data were confidential and not allowed to be opened in public. If there are any needs for clarification, the readers can contact Dr. Lin, the corresponding author, for sharing the data.
STROBE statement: The authors have read the STROBE Statement—checklist of items, and the manuscript was prepared and revised according to the STROBE Statement—checklist of items.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Gen-Min Lin, FACC, FAHA, FESC, MD, PhD, Academic Fellow, Chief Physician, Department of Medicine, Hualien Armed Forces General Hospital, No. 100 Jinfeng Street, Hualien City 970, Taiwan. farmer507@yahoo.com.tw
Received: March 26, 2024 Revised: September 8, 2024 Accepted: October 8, 2024 Published online: December 26, 2024 Processing time: 245 Days and 1.8 Hours
Abstract
BACKGROUND
Sleep deprivation can lead to increased body weight and blood pressure (BP), but the latent effects of partial sleep deprivation related to required night sentry duties within a short-term period on cardiometabolic characteristic changes in military personnel are unclear.
AIM
To investigate the association between night sentry duty frequency in the past 3 months and cardiometabolic characteristics in armed forces personnel.
METHODS
A total of 867 armed forces personnel who were aged 18-39 years and did not take any antihypertensive medications in Taiwan in 2020 were included. The frequency of night sentry duty was self-reported via a questionnaire (average number of night sentry shifts per month for the past 3 months). Hemodynamic status was assessed via the resting BP and pulse rate (PR). Cardiometabolic risk factors were defined according to the International Diabetes Federation criteria. Multivariable linear regression analyses of the associations between night sentry duties and PR, BP, and other metabolic syndrome (MetS) marker levels were performed, with adjustments for age, sex, substance use, body mass index and aerobic fitness. Multiple logistic regression analysis was carried out to determine the associations between night sentry duties and the prevalence of each MetS feature.
RESULTS
There was an association between night sentry duties and PR [standardized β (standard error) = 0.505 (0.223), P =0.02], whereas there was no association with systolic and diastolic BP. In addition, there was an inverse association between night sentry duties and high-density lipoprotein cholesterol (HDL-C) levels [standardized β = -0.490 (0.213), P = 0.02], whereas there was no association with the other metabolic marker levels. Compared with personnel without night sentry duties, those with ≥ 1 night sentry shift/month had a greater risk of impaired fasting glucose (≥ 100 mg/dL) [odds ratio: 1.415 (confidence interval: 1.016-1.969)], whereas no associations with other MetS features were found.
CONCLUSION
Among military personnel, the burden of night sentry duty was positively associated with the resting PR but inversely associated with HDL-C levels. In addition, personnel with partial sleep deprivation may have a greater risk of impaired fasting glucose than those without partial sleep deprivation.
Core Tip: This study examined the associations between the mean frequency of night sentry duty in the past 3 months and cardiometabolic characteristics in armed forces personnel. We found an association between the frequency of night sentry duty and pulse rate [PR, standardized β (standard error) = 0.505 (0.223), P = 0.02] and an inverse association with high-density lipoprotein cholesterol levels [standardized β = -0.490 (0.213), P = 0.02], whereas there was no association with systolic or diastolic blood pressure or other metabolic biomarker levels. In addition, personnel with ≥ 1 night shift/month had a greater risk of impaired fasting glucose. In conclusion, the latent effects of partial sleep deprivation in military personnel may increase the resting PR and lead to metabolic abnormalities.
Citation: Lin YP, Hsu YC, Lin KH, Tsai KZ, Chu CC, Lin YC, Lin GM. Nocturnal sentry duty and cardiometabolic characteristics in armed forces personnel. World J Cardiol 2024; 16(12): 751-759
Sleep deprivation, also known as sleep insufficiency, is defined as an inadequate quality and/or duration of sleep to support decent performance, alertness and health[1]. In the U.S., sleep deprivation is estimated to affect one-third of Americans, with an increased prevalence in recent years[2]. Sleep deprivation can cause unstable moods, such as erratic behavior, anxiety, depression and irritability, and lead to poor cognitive function and psychotic episodes[3-5]. In addition, insufficient sleep has been linked to adverse somatic changes, e.g., obesity, diabetes, increased blood pressure (BP) and heart rate, and cardiovascular diseases[6-10]. These psychosomatic adverse effects of sleep deprivation may be related to the sympathetic nervous system[11] and hypothalamic-pituitary-adrenal system activation[12]. However, most of these previous studies highlighted the effects of total sleep deprivation, whereas few studies have investigated the effects of partial sleep deprivation, which is characterized by short-term interruptions (2-3 hours) during sleep at night, with a frequency of less than twice a week.
Armed forces personnel experience greater mental stress and receive regular training to maintain superior physical fitness. On military bases, armed forces personnel are required to take night sentry shifts with a span of a few hours, which interrupts their sleep at night. It is estimated that the frequency of night sentry duty for armed forces personnel in Taiwan is approximately once per week. In the United States and Taiwan, the prevalence of overweight or obesity and metabolic syndrome (MetS) has increased to over 40% among all military personnel[13,14]. Since the latent effects of partial sleep deprivation on cardiometabolic abnormalities are unclear, this study aimed to clarify the associations of night sentry duties with hemodynamic and metabolic characteristics in military personnel, who have rarely been investigated in Taiwan or other regions.
MATERIALS AND METHODS
Study population
This cross-sectional study included 867 military participants from the ancillary Cardiorespiratory Fitness and Health in Armed Forces sleep study conducted in Taiwan in 2020. The ancillary study has been described in detail previously[15,16]. In summary, this study aimed to examine the sleep behaviors and comorbidities of military personnel and their associations with cardiometabolic health. Those with any antihypertensive, lipid-lowering or antidiabetic medication use were excluded from this study. The study design was approved by the Ethics Committee of the Mennonite Christian Hospital (No. 16-05-008), Hualien City, Taiwan, and was performed in accordance with the Helsinki Declaration, as revised in 2013. All participants were informed of the protocol of this study and provided written informed consent.
Night sentry duty assessment
The participants responded to a questionnaire concerning their frequency of night sentry duty (days per month) in the past 3 months, which was reported as 0, 1, 2, 3, 4, or 5 days. The span of each night sentry shift was limited to 2-4 hours, which was between a quarter and a half of the total nocturnal sleep time (8 hours) according to the regulation of each military base. Participants who had to work at night and had total nocturnal sleep deprivation were excluded from this study.
Definitions of cardio-metabolic characteristics
The participants were asked to have an uninterrupted nocturnal sleep duration of 8 hours and fast without any caffeine-containing or sympathomimetic agent use for longer than 12 hours before the health examination in 2020. The participants’ BPs and pulse rates (PRs) were measured once on the right upper arm by an automatic device via the oscillometric method (FT201 Parama-Tech Co., Ltd., Fukuoka, Japan) after a 15-minute rest period and with the participant in a seated position[17-20]. If the initial systolic BP level was ≥ 130 mmHg and/or diastolic BP was ≥ 80 mmHg, a second BP measurement was performed, and the final BP level was defined as the average of the initial and second BP measurements. In addition, if the initial PR was < 50 beats/min or ≥ 100 beats/min, the participant was asked to take a second break for 15 minutes, and the PR was rechecked directly by a physician for one minute, which was treated as the final value. Echocardiography was performed to assess the left ventricular mass (LVM), left ventricular ejection fraction (LVEF) and left atrium (LA) diameter according to the latest United States guidelines[21] in selected participants (n = 280).
According to the International Diabetes Federation's criteria for Chinese individuals[21], MetS is defined as having three or more of the following clinical features: (1) Central obesity defined by a waist circumference (WC) ≥ 80 cm for women and ≥ 90 cm for men; (2) An impaired fasting plasma glucose (FPG) level ≥ 100 mg/dL; (3) Hypertriglyceridemia defined by a plasma triglyceride level ≥ 150 mg/dL; (4) A high-density lipoprotein cholesterol (HDL-C) level < 50 mg/dL for women and < 40 mg/dL for men; and (5) Hypertension defined by a systolic BP ≥ 130 mmHg and/or a diastolic BP ≥ 85 mmHg at rest[22]. Triglyceride, FPG, and HDL-C levels were analyzed via an automated analyzer (Olympus AU640, Kobe, Japan)[23-25].
Covariates
The body height and body weight of each participant were measured while they were standing during the health examination in 2020. Body mass index (BMI) was defined as the body weight (kg) divided by the body height squared (m2). Body surface area was calculated to assess the LVM index according to the Dubois formula[26]. The participants self-reported their habits for substance use, such as smoking, betel nut chewing and alcohol consumption (active vs former/never)[27,28]. Notably, betel nut consumption is prevalent in Southeastern Asian individuals and has been associated with several metabolic disorders[29,30]. In addition, the aerobic fitness of each participant was evaluated via the time to complete a 3000-m run test following the health examination in the same year.
Statistical analysis
The clinical characteristics of the participants who were classified into 3 groups by night sentry duty frequency (0, 1-2, and ≥ 3 shifts/month) were compared via the chi-square test for categorical variables and analysis of variance (ANOVA) for continuous variables. For the selected participants who underwent echocardiography, the LVM index, LVEF and LA diameter were compared via analysis of covariance (ANCOVA), with adjustments for age, sex and systolic BP. Multivariable linear regression analyses of the associations of night sentry duty (treated as a continuous variable) with the PR, BP, and other MetS biomarkers were performed separately, with adjustments for age, sex and substance use (Model 1) and additionally for BMI and cardiorespiratory fitness (Model 2). Multivariate logistic regression analysis was carried out to determine the associations of night sentry duty (treated as a categorical variable) with the prevalence of MetS and its related features separately. The covariates in the models were selected because of their potential as contributors to MetS. Statistical analyses were performed via SPSS software for Windows (SPSS Inc., Chicago, IL, United States). A P value of < 0.05 was considered indicative of statistical significance.
RESULTS
Table 1 reveals the clinical characteristics of participants without night sentry shifts in the past 3 months (n = 506), those with 1-2 night sentry shifts/month (n = 220) and those with ≥ 3 night sentry shifts/month (n = 141) on the basis of their responses to the questionnaire. The mean age was approximately 28 years, and there were no significant differences in sex distribution between the groups. With respect to substance use status, participants with 0 and 1-2 night sentry shifts/month had a greater prevalence of active cigarette smoking than did participants with ≥ 3 night sentry shifts/month. For hemodynamics, a faster PR was found in individuals with ≥ 3 night sentry shifts/month than in individuals in the other two groups, while there were no differences in systolic BP, diastolic BP, or pulse pressure, defined as “systolic BP-diastolic BP”, between the groups. For BMI and metabolic biomarkers, no significant differences were found between the groups. For the echocardiographic characteristics of the selected participants, accounting for approximately one-third of the overall participants (32.3%), there were no differences in the LVM index, LVEF or LA diameter after adjustment for age, sex and systolic BP, although the mean values of the LVM index and LA diameter increased in those with a greater number of night sentry shifts/month.
Table 1 Clinical characteristics of military participants classified by night sentry duty frequency.
Table 2 shows the results of multivariable linear regression analyses of the association of the frequency of night sentry duty with the PR and BP separately. Although there was an association between night sentry duty and diastolic BP in the crude model, there were no multivariable-adjusted associations for systolic or diastolic BP or pulse pressure. In contrast, there was an association between night sentry duty and the PR after adjustment for the potential covariates [standardized β (standard error) = 0.505 (0.223), P = 0.02 in Model 2).
Table 2 Associations between night sentry duty frequency and levels of various hemodynamic parameters.
PR
SBP
DBP
PP
β (SE)
P value
β (SE)
P value
β (SE)
P value
β (SE)
P value
Crude model
0.558 (0.226)
0.01
0.300 (0.288)
0.29
0.482 (0.215)
0.02
-0.182 (0.221)
0.41
Model 1
0.569 (0.227)
0.01
0.054 (0.280)
0.84
0.251 (0.206)
0.22
-0.197 (0.218)
0.36
Model 2
0.505 (0.223)
0.02
0.086 (0.268)
0.74
0.266 (0.203)
0.18
-0.180 (0.214)
0.40
Table 3 shows the results of multivariable linear regression analyses of the association of the frequency of night sentry duty with each MetS biomarker level except BP. There were no associations of night sentry duty with WC, serum triglyceride levels or FPG levels in the crude or multivariable models, whereas there was an inverse association between night sentry duty and HDL-C levels in the crude and multivariable models [standardized β = -0.490 (0.213), P = 0.02 in Model 2].
Table 3 Associations between night sentry duty frequency and levels of metabolic syndrome biomarkers.
WC
HDL-C
TG
FPG
β (SE)
P value
β (SE)
P value
β (SE)
P value
β (SE)
P value
Crude model
0.321 (0.231)
0.16
-0.598 (0.230)
0.009
3.094 (1.705)
0.07
0.365 (0.205)
0.07
Model 1
0.075 (0.209)
0.72
-0.493 (0.221)
0.02
2.610 (1.623)
0.10
0.212 (0.204)
0.29
Model 2
0.147 (0.112)
0.18
-0.490 (0.213)
0.02
2.613 (1.577)
0.09
0.218 (0.202)
0.28
Table 4 shows the results of multivariable logistic regression analyses of the frequency of night sentry duty try duty for the prevalence of MetS and its related features. Compared with those without night sentry duties, participants with ≥ 1 night sentry shift/month were more likely to have impaired FPG [odds ratio (OR) and 95% confidence interval: 1.415 (1.016-1.969)] after adjustment for the potential covariates in Model 2. In contrast, the associations for prevalent MetS and other features were not significant. Moreover, there were no greater associations for hypertriglyceridemia or impaired FPG with a greater number of night sentry shifts. Compared with those without night sentry shifts, those with 1-2 night sentry shifts/month were more likely to have impaired FPG and hypertriglyceridemia [ORs: 1.481 (1.013-2.167) and 1.804 (1.131-2.879), respectively], which were greater than the association magnitudes in those with ≥ 3 night sentry shifts/month [ORs: 1.316 (0.839-2.062) and 1.053 (0.580-1.911), respectively].
Table 4 Associations of night sentry duty frequency categories with metabolic syndrome and related features.
The main findings of this study were that among armed forces personnel, there was a positive linear association between night sentry duty and the resting PR but an inverse linear association with HDL-C levels. In addition, participants with any night sentry shifts within a month may have a greater risk of impaired fasting glucose than those without any night sentry shifts.
Although many studies have demonstrated an association of sleep deprivation with increased BP and hypertension, most previous studies were performed to examine the acute and chronic impacts of sleep deprivation on BP levels and hypertension[6]. In some animal model studies, chronic sleep deprivation led to cardiac remodeling and dysfunction, which were confirmed by specific gene expression[31,32]. Notably, this study is the first to investigate the latent effects of partial sleep deprivation, e.g., night sentry duty, on the hemodynamic characteristics of young military personnel. This study revealed that the frequency of night sentry duty was positively associated with the PR or heart beat rather than with BP levels or hypertension. Mechanisms for the increased PR in response to acute or chronic sleep deprivation have been proposed to be associated with increased psychological stress and neurohormonal system activation[5-7]. It is possible that occasional partial sleep deprivation at night may not significantly affect the daytime resting BP or related cardiac structures and function if adequate nocturnal sleep or short-term sleep recovery follows[32]. However, the latent effect on the increased resting PR remains, which has been associated with cardiovascular health and longevity[33,34].
With respect to the latent effect of partial sleep deprivation at night on metabolic health, this study revealed a novel finding of a linear inverse association between the frequency of night sentry duty try duty frequency and HDL-C levels, which has not been previously reported. To the best of our knowledge, HDL-C levels are correlated with sex, body weight, plasma triglyceride levels, aerobic fitness, and inflammation[35-37]. The mechanisms underlying the inverse association with partial sleep deprivation are not fully understood, which may be explained in part by increased low-grade inflammation related to sleep deprivation[38]. In addition, there were greater associations for low HDL-C levels in those with a greater frequency of night shifts (ORs: 1.057 and 1.198, respectively, for 1-2 and ≥ 3 night shifts/month), which was related to the linear inverse association with HDL-C levels, despite statistical nonsignificance. In contrast, this study revealed that participants with any night shifts (≥ 1)/month had a greater possibility of impaired FPG than those without night shifts. Notably, the associations for impaired FPG were not significant; the highest probability was noted in participants with 1-2 night shifts/month, followed by those with ≥ 3 night shifts/month (ORs: 1.481 and 1.316, respectively). This finding may account for the insignificant linear associations for FPG. In a randomized crossover trial, restricting sleep to 6.2 hours or less per night, as measured by actigraphy over 6 weeks, was associated with a 14.8% increase in insulin resistance independent of adiposity in both pre- and postmenopausal women[8], which was consistent with the findings regarding partial sleep deprivation and the development of impaired FPG in this study. However, the effects of sleep deprivation on hypertriglyceridemia have been inconsistent in prior studies, which revealed a lower level of serum triglycerides in individuals with acute sleep deprivation[39,40], and the lipid paradox may be mediated by proinflammatory conditions[40]. Given that the latent effect of partial sleep deprivation in this study seems to have increased triglyceride levels despite borderline significance (P = 0.09 in the multivariable linear regression analysis and P = 0.08 in the multivariable logistic regression analysis), more evidence is needed to confirm the association with dyslipidemia.
There were several limitations in this study. First, this cross-sectional study could not establish causal associations. Second, the frequency of night sentry duty for each participant was assessed by a self-reported response to a questionnaire, which may not be accurate, although recall within 3 months should be acceptable. Third, this study included armed forces personnel who were required to have a regular schedule for nocturnal sleep (full time for 8 hours) for analysis; this provided the strength to unify the total sleep time at night, estimated to be 5-6 hours in those on night sentry duty, although no objective assessment for sleep time using a device for each participant was performed. Finally, obstructive sleep apnea could cause sleep deprivation, which may confound the results and lead to bias[41,42]. In contrast, there were several advantages in this study. To our knowledge, exercise training has been shown to reduce the PR and BP and improve metabolic profiles, which may attenuate the adverse effects of night sentry duty in military personnel revealed in our previous studies[43-45]. The benefits related to exercise training were also observed in military personnel in other regions and in the general population[46-49]. In this study, cardiorespiratory fitness levels were adjusted for in the models, which could largely diminish bias.
CONCLUSION
Among military personnel, night sentry duty was positively associated with the resting PR but inversely associated with HDL-C levels. Compared with those without night duties, individuals with partial sleep deprivation due to any number of night shifts per month may have a greater risk of impaired FPG, while the risk of hypertriglyceridemia was not confirmed. The clinical implications are that uninterrupted nocturnal sleep is crucial for maintaining both good hemodynamic and metabolic health, especially insulin sensitivity, in relatively healthy young adults. Sleep recovery for a few weeks following a night sentry shift should be implemented as a practical program to prevent the development of adverse hemodynamic, metabolic and cardiac dysfunction in military personnel.
Footnotes
Provenance and peer review: Unsolicited article; Externally peer reviewed.
Peer-review model: Single blind
Specialty type: Cardiac and cardiovascular systems
Country of origin: Taiwan
Peer-review report’s classification
Scientific Quality: Grade B, Grade C
Novelty: Grade B, Grade B
Creativity or Innovation: Grade B, Grade B
Scientific Significance: Grade C, Grade C
P-Reviewer: Niazi NUK; Zhong G S-Editor: Lin C L-Editor: A P-Editor: Zhao S
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