Associations between multidimensional sleep health and inflammatory bowel disease onset and activity: A systematic review of the RU-SATED framework

Table 1 Study characteristics

Ref.	Country	Design	Comparison	Sample size (n)	Mean age (years, mean)	Sleep assessment	Sleep dimension	Disease activity criteria	Main findings
Barnes et al[33], 2024	Australia	Cross-sectional	IBD active vs IBD inactive	CD = 17, UC = 3	Total sample = 41 (median)	PSG	Duration, efficiency	CD: HBI (active > 4, remission ≤ 4); UC: SCCAI (remission ≤ 2, active ≥ 3)	Active IBD: Shorter TST (466.8 minutes vs 489.0 minutes, P < 0.05), lower SE (79.0% vs 87.9%, P < 0.05)
Ananthakrishnan et al[23], 2014	United States	Cohort	IBD vs controls	Controls = 151450, CD = 191, UC = 230	NR	Questionnaire	Duration	-	Short sleep (< 6 hours/day): UC, HR = 1.51 (1.10-2.09); > 9 hours/day, HR = 2.05 (1.44-2.92) (all P < 0.05); no CD association (all P > 0.05)
Bazin et al[24], 2020	France	Cross-sectional	CD active vs CD inactive	CD active = 14, CD inactive = 20	CD active = 41, CD inactive = 35 (median)	Wrist actigraphy, PSQI, ESS	Duration, efficiency, alertness	HBI (remission ≤ 4, active ≥ 5), CDAI (remission < 150)	Active CD: Lower SE (85.0% vs 90.5%, P < 0.01), shorter subjective sleep (6.43 hours vs 7.97 hours, P < 0.01), higher ESS (11.1 vs 6.8, P < 0.05)
Chakradeo et al[44], 2018	United States	Cross-sectional	IBD vs controls	Controls = 76, IBD = 115	Controls = 34.13, IBD = 41.40	MEQ, MCTQ, PSQI	Timing	-	IBD: Greater social jetlag (1.32 hours vs 1.05 hours, P < 0.05); CD: Higher rate of social jetlag > 2 hours (40% vs 16%, P < 0.05)
Chrobak et al[43], 2018	Poland	Cross-sectional	CD vs controls UC vs controls	Controls = 57, CD = 34, UC = 38	Controls = 41.4, CD = 35.8, UC = 42.6	CSM	Timing	-	CD: Lower CSM (36.00 vs 39.54, P < 0.05)
Conley et al[34], 2021	United States	Cross-sectional	IBD active vs IBD inactive	CD = 18, UC = 19	Total sample = 38	Wrist actigraphy	Duration, efficiency, regularity	Physician global assessment	No significant differences (all P > 0.05)
Hirten et al[35], 2026	United States	Cohort	IBD active vs IBD inactive	CD = 63, UC = 38	Total sample = 41.45	Wearable devices	Duration, efficiency	PRO-2; FC > 150/CRP > 5/ESR > 30	No significant differences (all P > 0.05)
Iskandar et al[36], 2020	United States	Cross-sectional	CD vs controls CD active vs CD inactive	Controls = 60, CD = 61	Controls = 32, CD = 31 (median)	Wrist actigraphy, ESS	Duration, efficiency, timing	HBI (active > 4, remission ≤ 4)	No significant differences in TST or SE; active CD: Higher daytime sleepiness (45.5% vs 19.2%, P < 0.05)
Salwen-Deremer et al[37], 2023	United States	Cross-sectional	IBD vs controls	Controls = 8, CD = 9, UC = 5	Total sample = 43.65	PSG	Duration, efficiency, alertness	-	No significant differences (all P > 0.05)
Kani et al[50], 2020	Turkey	Cross-sectional	IBD vs controls	Controls = 168, CD = 72, UC = 64	Controls = 36.54, CD = 37.13, UC = 41.70	ESS	Alertness	-	IBD: Lower ESS than controls (3.14 vs 6.99, P < 0.001)
Keefer et al[25], 2006	United States	Cross-sectional	IBD vs controls	Controls = 7, CD = 8, UC = 8	Controls = 34.29, IBD = 41.44	PSG, wrist actigraphy, PSQI, ESS	Duration, efficiency, alertness	-	No significant differences in SE, TST, or ESS (all P > 0.05)
Kamp et al[26], 2023	United States	Cross-sectional	IBD active vs IBD inactive	CD = 21, UC = 7	Total sample = 33.4	Wrist actigraphy, PSQI	Duration, efficiency	CD: SES-CD (0-2 remission, 3-6 mild, 7-15 moderate, > 15 severe), HBI (remission ≤ 4, active > 4), UC: Mayo endoscopic score (0-1 remission, 2-3 active), SCCAI (remission ≤ 2, active ≥ 3)	No significant differences in TST or SE (all P > 0.05)
Şahbaz and Keskin[27], 2020	Turkey	Cross-sectional	IBD vs controls IBD active vs IBD inactive	Controls = 44, CD = 41, UC = 49	Controls = 40.3, CD = 33.7, UC = 40 (median)	MEQ, PSQI	Duration, efficiency, timing	NR	No significant differences in TST or SE (all P > 0.05); IBD: Higher eveningness prevalence (CD 12.2%, UC 18.4% vs controls 0%, P < 0.001)
Mokros et al[42], 2021	Poland	Cross-sectional	CD active vs CD inactive UC active vs UC inactive	CD = 47, UC = 37	CD = 37.3, UC = 46.0	CQ	Timing	CD: CDAI (< 150 remission, ≥ 150 active); UC: Mayo Score (≤ 2 remission, ≥ 3 active)	No significant correlation between chronotype and disease activity (all P > 0.05)
Paixão et al[38], 2019	Brazil	Cross-sectional	IBD active vs IBD inactive	CD = 9, UC = 11	CD = 30.89, UC = 46.36	PSG	Duration, efficiency	CDAI (≤ 150 remission, > 150 active)	No significant differences in TST or SE (all P > 0.05)
Qualqili et al[28], 2021	Jordan	Case control	IBD vs controls	Controls = 150, CD = 85, UC = 100	Controls = 41.4, CD = 41.2, UC = 39.8	Questionnaire	Duration	-	IBD patients had higher proportion of moderate sleep (6-8 hours) (P < 0.001)
Qazi et al[39], 2019	United States	Cross-sectional	CD active vs CD inactive	CD active = 44, CD inactive = 28	CD active = 34.5, CD inactive = 38 (median)	Wrist actigraphy, ESS	Duration, efficiency, alertness	HBI (remission ≤ 4)	Remission CD: Higher SE (89.9% vs 86.6%, P < 0.05)
Swanson et al[48], 2021	United States	Cross-sectional	IBD active vs IBD inactive vs controls	Controls = 10, CD active = 12, CD inactive = 8, UC active = 10, UC inactive = 12	Controls = 34.7, CD active = 33.5, CD inactive = 40.7, UC active = 38.3, UC inactive = 41.0	Wrist actigraphy	Regularity	HBI (remission ≤ 4)	Aggressive IBD: Lower IS (0.39 ± 0.15 vs 0.51 ± 0.10 non-aggressive and 0.55 ± 0.09 controls, P < 0.05); higher IV (vs non-aggressive, P < 0.05)
Chaemsupaphan et al[40], 2025	Thailand	Cohort	IBD active vs IBD inactive	CD = 48, UC = 50	Total sample = 46.2	Wrist actigraphy	Duration, efficiency	CD: HBI (remission ≤ 4, active > 4), SES-CD (0-2 remission); UC: Mayo score (≤ 2 remission, ≥ 3 active), MES (0-1 remission)	No significant differences in TST or SE (all P > 0.05)
Wu et al[29], 2020	China	Case control	CD vs controls UC vs controls	Controls = 671, CD = 380, UC = 188	Controls = 32, CD = 32, UC = 37 (median)	Questionnaire	Duration	-	CD: No significant differences in TST (P > 0.05), UC: Shorter weekend sleep (7 hours vs 8 hours, P = 0.05)
Yuan et al[30], 2023	China	Cohort	IBD vs controls	Controls = 485722, CD = 806, UC = 1798	Controls = 56.5, CD = 57.1, UC = 57.4	Questionnaire	Duration	-	Short sleep (≤ 5 hours/day): IBD, HR = 1.36 (1.17-1.59); CD, HR = 1.53 (1.17-2.00); UC, HR = 1.29 (1.07-1.56). 6 hours/day: IBD, HR = 1.17 (1.05-1.30); CD, HR = 1.23 (1.02-1.48); UC, HR = 1.14 (1.01-1.30) (all P < 0.05)
Zhang et al[31], 2019	China	Cross-sectional	IBD vs controls IBD active vs IBD inactive	Controls = 120, CD = 39, UC = 81	Controls = 36.28, IBD = 36.01	PSG, PSQI	Duration, efficiency	CD: HBI (≤ 4 remission, > 4 active); UC: Mayo endoscopic score (0-1 remission, 2-3 active)	IBD: Lower TST and SE (378 minutes vs 431 minutes; 76.45% vs 85.45%, P < 0.001); active IBD: Lower SE (64.88% vs 73.20%, P < 0.001)
Zhang et al[32], 2022	China	Cross-sectional	IBD vs controls	Controls = 4300, IBD = 56	Controls = 44.0, IBD = 51.8	Questionnaire	Duration	-	IBD: Shorter sleep (6.3 hours vs 6.8 hours, P < 0.01)

IBD: Inflammatory bowel diseases; CD: Crohn’s disease; UC: Ulcerative colitis; PSG: Polysomnography; HBI: Harvey-Bradshaw Index; SCCAI: Simple Clinical Colitis Activity Index; TST: Total sleep time; SE: Sleep efficiency; NR: Not reported; HR: Hazard ratio; PSQI: Pittsburgh Sleep Quality Index; ESS: Epworth Sleepiness Scale; CDAI: Crohn’s Disease Activity Index; MEQ: Morningness-eveningness Questionnaire; MCTQ: Munich ChronoType Questionnaire; CSM: Composite Scale of Morningness; PRO-2: Patient-Reported Outcome-2; FC: Fecal calprotectin; CRP: C-reactive protein; ESR: Erythrocyte sedimentation rate; SES-CD: Simple Endoscopic Score for Crohn’s Disease; IS: Interdaily stability; IV: Intradaily variability; MES: Mayo Endoscopic Score; CQ: Chronotype Questionnaire.

Table 2 Evidence summary

Indicator	Comparison	Measure type	Number of studies			Direction		Risk of bias		Level of evidence	Summary
			Cohort	Case-control	Cross-sectional	Positive	Negative	Low	Moderate
Sleep duration	Risk of developing IBD	Subjective	2	-	-	2	-	2	-	Moderate	Short sleep duration (≤ 5-6 hours/day) is associated with a significantly increased risk of developing IBD
Sleep duration	IBD vs controls	Subjective	-	2	4	3	3	3	3	Conflicting
Sleep duration	IBD vs controls	Objective	-	-	5	1	4	2	3	Limited	No significant difference in sleep duration between IBD patients and healthy controls
Sleep duration	IBD active vs IBD inactive	Subjective	-	-	4	1	3	1	3	Limited	No significant difference in sleep duration between active disease and remission
Sleep duration	IBD active vs IBD inactive	Objective	2	-	7	1	8	3	6	Moderate	No significant difference in sleep duration between active disease and remission
Sleep efficiency	IBD vs controls	Subjective	-	-	3	1	2	1	2	Conflicting
Sleep efficiency	IBD vs controls	Objective	-	-	4	1	3	2	2	Limited	No significant difference in sleep efficiency between IBD patients and healthy controls
Sleep efficiency	IBD active vs IBD inactive	Subjective	-	-	4	1	3	1	3	Limited	No significant difference in sleep efficiency between active disease and remission
Sleep efficiency	IBD active vs IBD inactive	Objective	2	-	8	4	6	4	6	Conflicting
Chronotype	IBD vs controls	Subjective	-	-	3	2	1	2	1	Conflicting
Chronotype	IBD active vs IBD inactive	Subjective	-	-	2	-	2	-	2	Limited	No significant association between chronotype and disease activity
Midpoint of sleep	IBD vs controls	Subjective	-	-	1	1	-	1	-	Insufficient
Social jetlag	IBD vs controls	Subjective	-	-	-	1	-	1	-	Insufficient
Social jetlag	IBD active vs IBD inactive	Subjective	-	-	-	1	-	1	-	Insufficient
Sleep regularity	IBD active vs IBD inactive	Objective	-	-	2	1	1	1	1	Conflicting
Alertness	IBD vs controls	Subjective	-	-	3	1	2	2	1	Conflicting
Alertness	IBD active vs IBD inactive	Subjective	-	-	2	2	-	1	1	Limited	Patients with active IBD exhibit significantly higher daytime sleepiness than those in remission

IBD: Inflammatory bowel diseases.

Table 3 Newcastle-Ottawa Scale ratings summary, n (%)/mean ± SD

Design	n	Low	Moderate	High	Median Newcastle-Ottawa Scale
Cohort/case control	6	4 (67)	2 (33)	0 (0)	7.50 ± 1.22
Cross-sectional	17	7 (41)	10 (59)	0 (0)	6.29 ± 1.05

Low ≥ 7; moderate = 5-6; high ≤ 4. Scores reflect reconciled, post-agreement ratings.