Day: 03/03/2022

Russia’s Invasion of Ukraine Strains International Space Station Partnership

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Russia's Invasion of Ukraine Strains International Space Station Partnership
International Space Station, photographed by an STS-133 crew member on space shuttle Discovery. Credit: NASA

Life onboard the ISS goes on in the wake of Russia’s attack against Ukraine, even as the space project faces an uncertain future.

When Russia launched a full-scale military invasion of Ukraine on Thursday, the whole world was watching. But another, much smaller audience was watching, too: the seven crew members onboard the International Space Station (ISS), orbiting hundreds of kilometers above the chaos below.

Across more than two decades of continuous operations, the ISS has been a steady beacon of hope for peaceful international collaboration. The massive space habitat is the product of a remarkable partnership among five space agencies (including NASA and Russia’s national space agency Roscosmos) representing 15 participating countries. Over the years, scientific study and international friendships have flourished onboard the ISS, prompting some to petition for the project to receive a Nobel Peace Prize.

But some fear Russia’s latest attack could throw that cooperation into jeopardy. In times of geopolitical upheaval on Earth, what happens to the ISS?ADVERTISEMENT

According to former ISS astronauts, nationality usually takes a back seat to the more practical matters of living and working in space. “During training, you spend a lot of time together, and so you form these deep friendships,” says Leroy Chiao, who flew on the 10th expedition to the ISS in 2004.

Rick Mastracchio, a retired NASA engineer who flew on the 38th and 39th expeditions to the ISS, echoes that sentiment. “You’re there to do a very specific job, and you’re well trained,” he says. Regardless of one’s homeland or political views, “you need to get along because you’re [part of] a team.”

Chiao says that the time he spent with his cosmonaut colleagues gave him a measure of insight into the Russian perspective on geopolitics. From Russia’s viewpoint, the prospect of Ukraine joining NATO could seems like a serious threat to national security. How would the U.S. have reacted, he wonders, if Mexico and Canada had signed the Warsaw Pact before the fall of the Soviet Union? “That would make us pretty edgy, too. So, I understand where Russia’s coming from,” he says, even though he firmly disagrees with the nation’s invasion of Ukraine.

Tensions between Russia and the U.S. also ran unexpectedly high when Mastracchio was onboard the ISS. In March 2014, not long into his orbital sojourn, Russia annexed Crimea in a political move that the U.S. condemned as a “violation of international law.”

“I won’t say it affected the atmosphere, but there was some discussion,” Mastracchio says. He mentions what he recalls as the distress of one of his Russian crewmates in particular, who was purportedly fearful for his family in a nearby region of Ukraine. For Mastracchio, the memory serves as a reminder that no culture is a political monolith. “You’re representing your country from the terms of the space agencies, but you’re not representing the political aspect of it,” he says. “It’s somewhat uncomfortable when your homeland does something that maybe you’re not proud of.”ADVERTISEMENT

So far, the U.S. and its NATO allies have pursued a policy of retaliatory sanctions targeting Russia’s economy and political leadership. Outlining the policy during a White House address, President Joe Biden noted that the sanctions will “degrade [Russia’s] aerospace industry, including their space program.”

How exactly this may affect life on the ISS remains unclear. The seven crew members currently onboard the habitat are four NASA astronauts, one German astronaut from the European Space Agency (ESA) and two Russian cosmonauts. Whatever their personal feelings, presumably the crew will continue normal operations in a “business as usual” approach. At least, that is the plan according to NASA.

“NASA continues working with all our international partners, including the State Space Corporation Roscosmos, for the ongoing safe operations of the International Space Station,” the agency wrote in an e-mailed statement. “The new export control measures will continue to allow U.S.-Russia civil space cooperation.”

Roscosmos did not respond to a request for comment. But in a series of tweets on Thursday afternoon, Roscosmos’s director general Dmitry Rogozin mocked the sanctions as foolhardy, adding that “if [the U.S.] blocks cooperation with us, who will save the ISS from an uncontrolled descent out of orbit and a fall on the United States or Europe?” Despite its threatening implications, Rogozin’s statement is, in some respects, reflective of simple facts: Russia’s Progress resupply spacecraft are currently responsible for periodically boosting the space station’s altitude, which decreases over time because of atmospheric drag. (A U.S.-built Cygnus cargo spacecraft presently docked at the station is scheduled to perform a test boost in April to demonstrate an independent capability to maintain the ISS’s altitude.)

Such comments are not terribly out of character for Rogozin, a Putin appointee. “He’s a bit of, you know, a personality,” says Asif Siddiqi, a historian at Fordham University, who specializes in Russian space activities.

When the U.S. enacted earlier rounds of sanctions after the Crimean annexation, Rogozin notoriously responded by suggesting that American astronauts could find their way to the ISS “with a trampoline.” (At the time, the U.S. was wholly dependent on sending crews to the ISS via launches of the Russian Soyuz spacecraft. Now SpaceX rockets and modules serve as U.S. crew transports, and Boeing is set to soon provide an additional domestic launch option.) Rogozin again raised hackles last year with statements implying that in 2018 NASA astronaut Serena Auñón-Chancellor drilled a tiny hole in a Soyuz vessel for purposes of sabotage. In an article by the Russian state-owned news agency TASS last year, a Russian space official again raised hackles with accusations that NASA astronaut Serena Auñón-Chancellor drilled a tiny hole in a Soyuz vessel so that she could return to Earth early. NASA has said it does not consider these allegations credible and that it stands by Auñón-Chancellor.

Although these periods of tension have strained administrative relations between Roscosmos and NASA in the past, they have never truly disrupted life on the ISS. During the height of the Crimean conflict, for example, a leaked internal memo instructed NASA employees to cease communications with their Russian colleagues. “However, there’s a little clause in that thing that says actual ISS operations will continue just as before,” Siddiqi says. He suspects a similar memo may be making the rounds now.

Even if a major ISS partner does decide to withdraw from the project, the transition may take months or even years to fully disentangle. “It’s not a simple off switch,” Siddiqi says. But unless the current political situation changes course, he does not see a future for U.S. and Russian collaboration in space beyond the ISS’s decommissioning, currently planned for 2031. NASA is already looking ahead to its ambitious Artemis program, which will partner with ESA, Japan’s space agency and the Canadian Space Agency to build an orbiting lunar outpost to support astronauts’ long-term return to the moon’s surface. Meanwhile Roscosmos has pledged to join forces with China in order to build a moon base of their own. The international schism in spaceflight seems set to grow—with the cooperation epitomized by the ISS only diminishing.

“It’s clear that this is a relationship that will not continue past a certain point,” Siddiqi says. “I can’t see it recovering from this.”

Muscle-strengthening activities may lower risk of mortality, non-communicable diseases

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According to published results, regular engagement in muscle-strengthening activities, such as resistance training, may lower the risk of all-cause mortality, cardiovascular disease, cancer and diabetes.

Using MEDLINE and Embase data from inception to June 2021, researchers performed a systematic review and meta-analysis of 16 prospective cohort studies which examined the association between muscle-strengthening activities and risk of noncommunicable diseases (NCDs) and all-cause mortality in adult patients. According to the study, muscle-strengthening activities included resistance, strength and weight training as well as calisthenics. Activities such as carrying heavy loads and heavy gardening were excluded.

After review, researchers found muscle-strengthening activities were associated with a 10% to 17% lower risk of all-cause mortality, cardiovascular disease (CVD), total cancer, diabetes and lung cancer. Compared with no physical activity, combined muscle-strengthening and aerobic activities were also associated with a lower risk of all-cause mortality, CVD and total cancer, the researchers noted. No associations were found between muscle-strengthening activities and the risk of site-specific cancers, such as colon, kidney, bladder and pancreatic cancer, they added.

Additionally, researchers observed a J-shaped association with the maximum risk reduction at approximately 30 to 60 minutes per week of muscle-strengthening activities for all-cause mortality, CVD and total cancer.

“These results suggest that optimal doses of muscle-strengthening activities for the prevention of all-cause death, CVD and total cancer may exist,” the researchers wrote in the study. “Promoting muscle-strengthening activities may help in reducing the risk of premature death and NCDs,” they concluded.

World Birth Defects Day

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March 3 is World Birth Defects Day. Join us in our effort to raise awareness of birth defects, their causes, and their impact around the world! Our theme is “Many birth defects, one voice.”

Every year, about 3-6% of infants worldwide are born with a serious birth defect. This means that life-altering conditions such as spina bifida and congenital heart defects affect millions of babies and families. Birth defects can affect babies regardless of where they are born, their socioeconomic status, or their race or ethnicity.

Tunu’s Story: An Update

Tunu smiling

Last year, we met Tunu. She lives in Nairobi with her family. Tunu is a vibrant 2-year-old who loves to smile, listen to music, and play with her toys. She was born with bilateral clubfoot resulting from a rare condition called arthrogryposis.

Through her experience of making sure that Tunu got the care she needed, Esther, her mother,  began “The Bold One Out” campaign to raise awareness about birth defects in her community and help other families who may have children born with birth defects. Esther shares birth defects information and lets other families know that resources and care are locally available. Even more, Esther fights the stigma about birth defects head-on.

The Bold One Out campaign addresses the flawed perception that children born with a birth defect are lesser than. Esther wants to change that narrative. She explains, “The Bold One Out is a movement of extraordinary mothers raising little angels with extraordinary conditions for an extraordinary purpose.” She continues, “The journey is long. We need to encourage these mothers to take the bold step for their extraordinary children. Just because Tunu has an issue with her foot, it does not define her wholly. She is still well able to accomplish that which she has been put here on earth to do.”

When we caught up with Esther this year, she described how care and treatment for her daughter as well as for many other children have been affected by the COVID-19 pandemic. Treatment for Tunu’s clubfoot was impacted as care facilities were sometimes not accessible, with hospital visits becoming fewer and fewer. For many families, a weekly hospital visit was a big challenge; hospitals closed or were a high-risk exposure for families. During the pandemic, Kenya experienced a shut down, like many other parts of the world, and people often experienced challenges earning income. Unfortunately, this caused delays in treatment for children because they couldn’t get to the hospital or couldn’t afford the needed treatments.

At the hospitals themselves, many healthcare providers were working in shifts because of COVID-19. This meant that the children living with birth defects who were used to getting care consistently from the same provider were now being seen by a variety of providers. Parents would often have to retell the child’s medical history, and at times, providers had never seen or had experience treating these types of conditions.

Getting social support was also a challenge during the pandemic. Families lacked caregivers. Parents weren’t able to meet with each other for peer support. Children and families felt isolated.

Esther continues to use The Bold One Out to fight for inclusivity, especially after the past few years. She wants people to see past the condition and appreciate the person fully. Through her campaign, Esther aims to: 1) raise awareness of birth defects and their prevention, 2) improve early detection of these conditions, and 3) increase early treatment and timely interventions. Esther emphasizes that these children are not “COVID babies.” Tunu is not a “clubfoot baby.” She’s a person first. She is strong. She can feed herself. She is capable. She’s a person first.

The Bold One Out is part of Esther’s charity, Tunu Afrika named for her daughter. Esther says that “Tunu” is a Swahili word meaning a treasured gift. This World Birth Defects Day and beyond, Esther continues to raise awareness of birth defects and remove barriers to treatment and care in her community. She does it for Tunu and the many other treasured children so that they can fulfill their extraordinary purposes.

CDC thanks Esther and Tunu for sharing their personal story.

Participate in World Birth Defects Day

Each year on March 3, NCBDDD partners with more than 120 organizations around the world to raise awareness of birth defects for World Birth Defects Dayexternal icon.

Together, we aim to raise awareness about the impact of birth defects, as well as increase opportunities for prevention of birth defects. We aim to do this by promoting the importance of birth defects monitoring programs and research to identify the causes of birth defects.

11 Things to Know about Cerebral Palsy

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Cerebral palsy (CP) is the most common motor disability in childhood, and children with CP and their families need support. Learn more about CP and what signs to look for in young children.

  1. Cerebral palsy (CP) is a group of disorders that affect a person’s ability to move and maintain balance and posture.
  2. CP is the most common motor disability of childhood. About 1 in 345 children has been identified with CP according to estimates from CDC’s Autism and Developmental Disabilities Monitoring (ADDM) Network.
  3. CP is more common among boys than girls, and more common among black children than among white children.
  4. Most (about 75%-85%) children with CP have spastic CP. This means that their muscles are stiff, and as a result, their movements can be awkward.
  5. Over half (about 50%-60%) of children with CP can walk independently.
  6. Young girl with cerebral palsy
  7. About 1 in 10 children identified with CP walk using a hand-held mobility device.Many children with CP have one or more additional conditions or diseases along with their CP, known as co-occurring conditions. For example, about 4 in 10 children with CP also have epilepsy and about 1 in 10 have autism spectrum disorder.
  8. Most CP is related to brain damage that happened before or during birth and it is called congenital CP. The following factors can increase the risk for congenital CP:
  9. A small percentage of CP is caused by brain damage that happens more than 28 days after birth. This is called acquired CP. The following factors can increase the risk for acquired CP:
    • Having a brain infection, such as meningitis
    • Suffering a serious head injury
  10. The specific cause of CP in most children is unknown.
  11. CP is typically diagnosed during the first or second year after birth. If a child’s symptoms are mild, it is sometimes difficult to make a diagnosis until the child is a few years older.
  12. With the appropriate services and support, children and adults with CP can stay well, active, and a part of the community. Read the stories of children, adults, and families living with CP.

Early Signs of CP

From birth to 5 years of age, a child should reach movement goals―also known as milestones―such as rolling over, sitting up, standing, and walking. A delay in reaching these movement milestones could be a sign of CP. It is important to note that some children without CP also might have some of these signs. The following are some other signs of possible CP.

In a baby 3 to 6 months of age:

  • Head falls back when picked up while lying on back
  • Feels stiff
  • Feels floppy
  • Seems to overextend back and neck when cradled in someone’s arms
  • Legs get stiff and cross or scissor when picked up

In a baby older than 6 months of age:

  • Doesn’t roll over in either direction
  • Cannot bring hands together
  • Has difficulty bringing hands to mouth
  • Reaches out with only one hand while keeping the other fisted

In a baby older than 10 months of age: 

  • Crawls in a lopsided manner, pushing off with one hand and leg while dragging the opposite hand and leg
  • Scoots around on buttocks or hops on knees, but does not crawl on all fours

World Hearing Day

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To hear for life, listen with care. CDC supports the World Health Organization’s World Hearing Day, on March 3rd. World Hearing Day promotes ear and hearing care across the world and raises awareness of how to prevent deafness and hearing loss.

This year we stress the following points:

  • It’s possible to have good hearing across your life.
  • Many common causes of hearing loss can be prevented. Learn how to prevent hearing loss caused by loud sounds.
  • Reduce your risk of hearing loss from loud recreational noise. Use hearing protection such as earplugs or earmuffs.
  • If you are concerned about your hearing, please see a doctor. Hearing loss is gradual and can go undetected unless checked.

There are many ways we can protect our ears and hearing from loud noise:

  • Turn down the volume down on personal listening devices such as headphones and earbuds.
  • Avoid loud noise whenever possible.
  • Give your ears a rest and take periodic breaks from noise.
  • Use hearing protection such as earplugs or noise-cancelling earmuffs.
Reduce your risk of hearing loss from loud recreational noise. Use hearing protection such as earplugs or earmuffs.

Reduce your risk of hearing loss from loud recreational noise. Use hearing protection such as earplugs or earmuffs.

Remember, good hearing and communication are important at all stages of life. To hear for life, listen with care. Hearing loss and related ear diseases can be avoided through preventative actions such as:

  • protection against loud sounds,
  • good ear care practices, and
  • immunization.

Hearing loss and related ear diseases can be addressed when early, and appropriate care is sought. People at risk of hearing loss should having their hearing checked regularly. People with hearing loss or related ear diseases should seek care from a health care provider.

According to the World Health Organization

  • More than 360 million people live with disabling hearing loss.
  • More than 1 billion people aged 12-35 years are at risk of hearing loss due to recreational noise exposure.
  • Globally, the overall cost of not addressing hearing loss is more than $750 billion.

Resources

World Health Organization (WHO):

CDC:

 AGA Clinical Practice Guideline on Systemic Therapy for Hepatocellular Carcinoma.

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Abstract

BACKGROUND & AIMS: Hepatocellular carcinoma (HCC), the most common primary liver cancer, remains a deadly cancer, with an incidence that has tripled in the United States since 1980. In recent years, new systemic therapies for HCC have been approved and a critical assessment of the existing data is necessary to balance benefits and harms and inform the development of evidence-based guidelines.

METHODS: The American Gastroenterological Association formed a multidisciplinary group consisting of a Technical Review Panel and a Guideline Panel. The Technical Review Panel prioritized clinical questions and outcomes according to their importance for clinicians and patients and conducted an evidence review of systemic therapies in patients with advanced-stage HCC. The Grading of Recommendations Assessment, Development and Evaluation framework was used to assess evidence. The Guideline Panel reviewed the evidence and used the Evidence-to-Decision Framework to develop recommendations.

RESULTS: The Panel reviewed the evidence, summarized in the Technical Review, for the following medications approved by the US Food and Drug Administration for HCC: first-line therapies: bevacizumab+atezolizumab, sorafenib, and lenvatinib; second-line therapies: cabozantinib, pembrolizumab, ramucirumab, and regorafenib; and other agents: bevacizumab, nivolumab, and nivolumab+ipilimumab.

CONCLUSIONS: The Panel agreed on 11 recommendations focused on systemic therapy for HCC in patients who are not eligible for locoregional therapy or resection, those with metastatic disease and preserved liver function, those with poor liver function, and those on systemic therapy as adjuvant therapy.

Oral Health for All — Realizing the Promise of Science

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Oral health is paramount to overall health and well-being, yet inequities in oral health continue to pose a major global public health threat. To bolster health throughout the United States, it’s essential that we acknowledge the factors driving the unequal burden of oral disease and leverage scientific and technological advances to guide responses. A new National Institutes of Health report,1 which was compiled by the National Institute of Dental and Craniofacial Research, aims to address these issues and offer solutions.

In 2000, Oral Health in America: A Report of the Surgeon General affirmed the importance of oral health for overall health and captured the attention of researchers, policymakers, practitioners, and the general public. Although the past two decades have seen progress in this area, dental and oral diseases remain problematic for many Americans. According to the Centers for Disease Control and Prevention (CDC), 47% of U.S. adults 30 years of age or older have periodontal disease. Oropharyngeal cancer associated with human papillomavirus (HPV) has become more prevalent than HPV-associated cervical cancer, with men more than five times as likely to be affected as women. Nine out of 10 adults 20 to 64 years of age have had dental caries, a figure that hasn’t meaningfully changed during the past 20 years. Caries in permanent teeth still rank among the most common childhood diseases. Untreated carious lesions cause pain and infections in bone and soft tissues, thereby perpetuating the cycle of lost productivity and use of emergency services in lieu of preventive care.

We believe a reform agenda should include strategies for tackling the high costs of, and unequal access to, oral health care. Over the past 20 years, per-person dental care costs have increased by 30% in the United States; in 2018, Americans paid $55 billion in out-of-pocket dental expenses, which constituted more than 25% of all health care out-of-pocket spending. The highest burden of dental and oral disease, nationally and globally, is shouldered by marginalized and chronically underserved populations.2

The Covid-19 pandemic has highlighted the need to reexamine health and well-being through the lens of social and systemic determinants. Groups that have been most affected by SARS-CoV-2 in the United States appear to be the same groups that have disproportionately high rates of oral disease. The oral cavity is a potential locus of SARS-CoV-2 infection and a site of Covid-19 symptoms,3 and altered immune status in people with periodontal disease can make oral tissues more prone to SARS-CoV-2 infection. Such observations support the longstanding argument that the links between the oral cavity and other body systems necessitate better integration of health care delivery practices. Covid-19 has permanently affected care delivery and has exacerbated existing inequities. Moving forward, we will need to forge a path for oral health care that prioritizes overall health, prevention, expanded access, affordability, and equity.

Communities that are disproportionately affected by dental and oral disease often have limited access to health services. Policy changes are needed to integrate oral, medical, and behavioral health care and prevention services in community health centers, schools, assisted-living facilities, primary health care settings, and dental clinics. Access to care has improved for children from low-income families thanks to strengthened collaborations between oral health professionals and pediatricians. Examples of these collaborations include the promotion of dental visits within the first 3 years of life, the execution of well-designed risk-assessment studies for dental diseases, and the use of sealants and fluoride varnishes — expenses that are covered by Medicaid and the Children’s Health Insurance Program. Along with broad policy initiatives such as fluoridation of public water supplies, these integrative approaches have the greatest potential for mitigating oral diseases of high public health importance and should be reinforced in health professional curricula and training.4

Collaboration among communities, dental professionals, and other clinicians is critical to eliminating inequities that impede access to culturally competent care.5 Community leaders are experts in the needs of their populations and must be included in the planning, design, and implementation of oral health care systems. An area in which community engagement is especially important is the intersection of dental care and opioid misuse. For many people, particularly adolescents and young adults undergoing wisdom-tooth extractions, a first exposure to opioids occurs in the context of oral surgery. Although dental practitioners have substantially changed their opioid-prescribing practices during the past 20 years, opioid prescriptions remain common when patients seek care for dental problems in hospital emergency departments. This phenomenon reflects the need for expanded, affordable, and equitable access to routine dental care, particularly in vulnerable communities. Opioid use disorder continues to be a serious public health problem: CDC data indicate that in the 12-month period ending in April 2021, more than 100,000 Americans died from drug overdoses, an increase of nearly 30% from the previous year.

Tobacco and other inhaled and consumable products can cause oral cancer, periodontal disease, and other oral health problems. In addition, the relationship between mental health and oral health warrants further investigation. People with schizophrenia, other psychoses, and bipolar disorder have particularly high rates of gum disease and decay and are three times as likely as people without mental disorders to become edentulous. Preventing and treating oral disease precipitated by mental disorders requires an understanding not only of the oral cavity, but also of overall health and the environmental, psychosocial, and behavioral factors that shape health and well-being.

Over the past 20 years, science has transformed our understanding of the molecular and cellular mechanisms that underlie disease and has sparked clinical applications that improve health and prevent disease. Newly proposed government initiatives are poised to propel “use-driven” research, which aims to solve practical, real-world public health problems. These approaches could lead to interventions to prevent, detect, and treat complex diseases including diabetes, cancer, and Alzheimer’s disease. Such innovation could also help mitigate inequities and improve precision in oral health care. Recent scientific and technological advances provide opportunities for tailoring oral health care on the basis of a person’s genomic, environmental, and socioeconomic risk factors.

Improved understanding of the oral and gut microbiomes, combined with other “omics,” will provide the basis for therapies such as probiotics and mouth rinses that can be used to address disease-associated oral microbial ecosystems and biofilms and create healthier ones. Deep-phenotyping approaches that integrate clinical data, digital biomarkers, imaging, tissue and biospecimen analyses, and advanced analytics could improve prevention and health-promotion efforts, prognostics, and treatment for inherited and acquired dental, oral, and craniofacial diseases.

Research advances cannot stand alone. It’s essential that we engage people and communities to address social, economic, and environmental determinants of poor oral health, such as lack of access to healthy food. Concurrently, health care systems should recognize inequities in oral health care and other services and resources in the context of the compounded challenges that affect marginalized populations, including structural and interpersonal racism. To substantially improve oral health throughout the United States, policy changes are needed to reduce or eliminate social, economic, and other systemic inequities. Oral diseases are preventable, and social and other determinants of health need to be considered in prevention and treatment strategies. Policymakers must make oral health care more accessible, affordable, and equitable. It will also be essential to diversify the country’s oral health workforce so that clinicians reflect the communities they serve, to address the rising costs of educating and training the next generation of oral health professionals, and to ensure a strong research enterprise dedicated to improving oral health.

This century began with the recognition that oral health is central to overall health. Now, it’s critical that we build on this knowledge and the scientific progress we’ve made to ensure that oral health is fully integrated into this new era of discovery and to harness policy changes and technological advances to disrupt systemic inequities. Only then will we truly improve the health of people, families, and communities.

Healthy Bedtime Snacks To Eat Before Sleep

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Choosing a nighttime snack can be complicated. Not only is research inconclusive about which are the best foods for sleep, but there is also discussion about whether or not it is healthy to eat too close to bedtime.

It is traditionally recommended to avoid eating too late at night1. Some studies show that eating before bed can contribute to obesity2, and a few studies also suggest that eating high-fat or high-carbohydrate meals close to bedtime3 might make it harder to fall asleep.

However, emerging research suggests that eating certain foods4 before bed may have some benefits. We share recommendations for some healthy bedtime snacks.

Healthy Bedtime Snacks

For many people, the ideal nighttime snack may consist of a simple 150-calorie option that is high in nutrients. One study showed that consuming a low-calorie carbohydrate or protein5 snack 30 minutes before sleep helped boost metabolism in the morning. You can choose from a variety of healthy snacks such as fruit, nuts, seeds, and oatmeal that require minimal preparation.

Banana with Almond Butter

Almonds and bananas are excellent sources of magnesium6. Magnesium is believed to play a role in regulating the timekeeping system7 of plants, animals, and humans, and it may have benefits for sleep8. A serving size of a banana and one ounce of almonds provides just over 100 milligrams of magnesium. Bananas are also rich in potassium9, which can improve sleep quality in women especially.

Protein Smoothie

For athletes, drinking a protein smoothie before bed may help with muscle repair. Research suggests that drinking whey or casein protein shakes before bed can spur a higher rate of muscle synthesis. These benefits may be even more pronounced when paired with an exercise routine earlier in the evening.

Most health food stores have a variety of protein powders to choose from. There are usually vegan options as well for those who do not want to consume dairy. If you are worried about eating too much before bed, you may want to try mixing your protein powder with almond milk or water for a lower-calorie option.

Oatmeal

Hot or cold oatmeal might help prepare your body for sleep and keep you full throughout the night. Oats contain magnesium as well as melatonin10, the sleep hormone. Consider making a batch of overnight oats with dried fruits and seeds for a simple nighttime snack option.

Fruit

Fruit is another way to get in your essential vitamins and minerals. Eating certain fruits before bed may also help you sleep better.

One study found that consumption of pineapple, oranges, and bananas 11increased melatonin production about two hours later.

Kiwis have also been shown to have some sleep-inducing properties. In one study, adults with self-reported sleep problems were instructed to eat two kiwis an hour before bedtime12. After four weeks of eating kiwis, participants were able to fall asleep faster, sleep for longer, and experience better sleep quality.

If you prefer to keep sugar consumption to a minimum, you may still find some fruits adequate for a bedtime snack. Tart cherries13 (and tart cherry juice) have been shown to improve sleep quality and reduce symptoms of insomnia. This is because they contain melatonin14 and other compounds that contribute to better sleep. You may want to try drinking a glass of tart cherry juice about an hour before bed, or you can add tart cherries to your protein smoothie, oatmeal or yogurt.

Nuts and Seeds

High-sodium diets are linked to poorer sleep quality. Unsalted nuts and or seeds might be a good substitute for salty snacks like potato chips.

Pistachios contain the highest amount of melatonin within the nut family. Pistachios also contain tryptophan15, an amino acid16 that is related to sleep quality. Tryptophan helps improve sleep by helping make melatonin and serotonin17. Pumpkin seeds and sesame seeds also contain tryptophan18. Sprinkling pumpkin seeds on your oats or yogurt give an added crunchy texture.

Cashews and walnuts are also considered good nut options for sleep. Cashews have high levels of potassium and magnesium, and walnuts may help synthesize serotonin19.

Yogurt

Yogurt is rich in calcium, and some research suggests that including calcium in your diet can make it easier to fall asleep and lead to more restorative sleep20. A 100-gram serving of plain whole milk yogurt contains about 121 milligrams of calcium21.

Yogurt also contains protein, as well as vitamin B6, vitamin B12, and magnesium22, which can all contribute to sounder sleep23. Additionally, yogurt contains gamma-aminobutyric acid (GABA)24, a key neurotransmitter that helps calm the body in preparation for sleep.

Try to find a plain or reduced sugar option as some yogurts can have high amounts of added sugar. You can also top your yogurt with berries or nuts.

Foods to Avoid Before Bed

Some foods could cause an upset stomach or keep you from falling asleep.

Sweets and Excessive Carbohydrates

Although meals that spike blood sugar25 might shorten the time it takes to fall asleep, research suggests that diets low in vegetables and fish but high in sugar and carbohydrates26 are generally linked to poor-quality sleep.

Fatty, Spicy, and Acidic Foods

Individuals who experience acid reflux27 should have their last meal several hours before bed and avoid common trigger foods such as mint or foods that are spicy, fatty, or highly acidic.

Caffeine

Caffeinated drinks such as soda, coffee, tea, and energy drinks have been shown to negatively impact mood and sleep28 in both adults and children. Try to limit caffeine to 400 milligrams or less per day, and avoid drinking caffeine too close to bedtime.

Alcohol

Alcoholic drinks may help you fall asleep initially, but alcohol29 can shorten your overall sleep duration, affect sleep quality, and potentially exacerbate symptoms of certain sleep disorders.

Try switching to herbal teas or water a few hours before bed.

The bidirectional relationship between exercise and sleep: Implications for exercise adherence and sleep improvement

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Abstract

Exercise has long been associated with better sleep, and evidence is accumulating on the efficacy of exercise as a nonpharmacologic treatment option for disturbed sleep. Recent research, however, has noted that poor sleep may contribute to low physical activity levels, emphasizing a robust bidirectional relationship between exercise and sleep. This article will briefly review the evidence supporting the use of exercise as a nonpharmacologic treatment for sleep disturbance, outline future research that is needed to establish the viability of exercise as a behavioral sleep treatment, describe recent research that has emphasized the potential influence of poor sleep on daytime activity levels, and discuss whether improving sleep may facilitate adoption and/or better adherence to a physically active lifestyle. With poor sleep and physical inactivity each recognized as key public health priorities, additional research into the bidirectional relationship between exercise and sleep has significant implications for facilitating greater exercise adherence and improving sleep in society.

Keywords: exercise, insomnia, obstructive sleep apnea, physical activity, sleep

Sufficient sleep is essential for optimum health—just a few of the numerous processes occurring during sleep include memory consolidation, clearance of brain metabolites, and restoration of nervous, immune, skeletal, and muscular systems.1 Virtually all bodily systems are impacted by poor or inadequate sleep, and chronic sleep disturbance predisposes an individual to cardiovascular disease, metabolic dysfunction, psychiatric disorders, and early mortality.1,2

Despite the significance of adequate sleep, insufficient or disturbed sleep is extremely common. For instance, thirty percent of employed adults report obtaining 6 or fewer hours of sleep per night,3 approximately one-third of all adults report significant sleep complaints,4 and the two most common sleep disorders, insomnia and sleep-disordered breathing (SDB), each have prevalence rates exceeding 10% in the adult population.5,6 Unfortunately, current approaches to treatment are limited. For poor sleep quality and insomnia complaints, prescription hypnotic medications offer short-term efficacy but are plagued by concerns about dependency, hazardous side effects, and long-term health risk.7 In contrast, cognitive-behavioral therapy for insomnia (CBT-I) provides greater long-term efficacy and fewer side effects than hypnotics; however, availability remains restricted.8 Meanwhile, the primary treatment option for SDB, continuous positive airway pressure (CPAP), significantly reduces SDB symptoms when used, but compliance remains problematic.9

Due to its wide-ranging health benefits, minimal cost and side effects, and accessibility, exercise is an attractive nonpharmacologic treatment option for disturbed sleep.10 Recent research, though, has shown that poor sleep may hamper efforts to be physically active, emphasizing the bidirectional relationship between exercise and sleep. This article will briefly summarize the current evidence supporting the use of exercise in the management of sleep problems, suggest future research that would help establish the viability of exercise as a behavioral sleep medicine treatment option, review recent research showing that sleep and sleep timing may contribute to physical inactivity, and discuss whether improving sleep may facilitate a physically active lifestyle.

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Exercise as a Treatment for Disturbed Sleep

Exercise has long been associated with better sleep.11 Despite surprisingly little experimental research involving patients with significant sleep disturbance or sleep disorders, the available evidence suggests that exercise holds promise as a nonpharmacologic therapy for adults with poor or disordered sleep.10

Most studies that have examined the effects of exercise training on general poor sleep quality (i.e., subclinical sleep complaints) have focused on older adults, among whom sleep complaints are extremely prevalent. A recent meta-analysis of six studies found that exercise training resulted in modest improvements in subjective sleep quality in middle- to older-aged adults with sleep problems.12 However, other trials have found minimal to no improvements in sleep following exercise training (e.g., 13) and objective sleep parameters have rarely been found to change in the few trials that have utilized actigraphy or polysomnography.14,15 Although there are only three published studies to date, research that has focused on adults diagnosed with chronic insomnia have provided much more consistent—and promising—results on the effect of exercise on sleep.16–18 As a prominent example, Reid and colleagues found that 4 months of aerobic exercise training in a sample of older adults with insomnia significantly improved sleep quality while also reducing daytime sleepiness and depressive symptoms.17 Thus, exercise may hold the most promise for those with more severe or more chronic sleep disturbance.

Exercise training also reduces SDB severity, with obstructive sleep apnea (OSA) the most common type of SDB examined. A recent meta-analysis of five studies found that exercise training reduced OSA severity by 32% despite a nonsignificant decrease in body mass index(BMI). 19 In the largest randomized trial to date, Kline and colleagues found that 12 weeks of moderate-intensity aerobic and resistance exercise resulted in a 25% reduction in OSA severity despite less than 1 kg of weight loss.20 Notably, exercise training also led to better subjective and objective sleep and improvements in daytime functioning (e.g., quality of life, depressive symptoms, vigor, fatigue) in this sample.21

It is less understood whether a single exercise bout impacts the corresponding night’s sleep in adults with poor sleep. Although a previous meta-analysis reported modest improvements in sleep following an acute bout of exercise, these results were based on studies that only included good sleepers.22 In contrast, only two studies have examined this question in poor sleepers, both involving adults diagnosed with chronic insomnia. Passos and colleagues found that an acute bout of moderate-intensity aerobic exercise, but not high-intensity aerobic exercise or high-intensity resistance exercise, improved sleep compared to a baseline night in a sample of middle-aged adults.23 In contrast, Baron and colleagues found no relationship between single sessions of moderate-intensity aerobic exercise and sleep during the corresponding night across a 4-month exercise intervention for 11 older adults.24 The exercise regimen did, however, result in significant improvements in sleep efficiency and sleep duration at post-intervention compared to baseline.24 Overall, then, the divergent findings from these two studies suggest that the sleep-enhancing effects of exercise may not manifest initially.

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Exercise to Improve Sleep: Future Research Needs

Overall, the available evidence certainly suggests that exercise could be a valuable behavioral therapy for poor or disordered sleep. However, many unanswered questions need resolved before exercise can be optimally prescribed as a behavioral treatment option for disturbed sleep. Perhaps the most pressing need is for larger-scale experimental studies to be conducted as, for both insomnia/poor sleep quality and SDB, the current evidence base is too small to provide well-informed recommendations. For instance, recent meta-analyses summarizing the effect of exercise training on subjective sleep quality and OSA severity included only 305 (6 trials) and 129 participants (5 trials), respectively.12,19 Larger sample sizes will also allow researchers to examine whether specific participant characteristics can predict the efficacy of exercise on sleep outcomes; while most studies have found that exercise, on average, modestly improves sleep parameters and OSA severity, it is plausible that individuals will respond differently depending upon specific attributes (e.g., sex, BMI, depressive symptoms).25

Little attention has been given to the possibility that the various components of an exercise regimen (e.g., dose, mode, timing) have differential effects on sleep. Experimental studies have typically employed moderate-intensity aerobic exercise or moderate-intensity resistance exercise at doses that approximate public health guidelines; however, direct comparisons between different exercise intensities have not been performed, and combining or directly comparing modes of exercise have been rare.20,26 There has also been minimal inquiry into the possible dose-response effects of exercise on sleep27,28—for instance, is there a minimal dose of exercise (integrating frequency, duration, and intensity) below which sleep is not improved? Conversely, are greater improvements in sleep observed with higher doses of exercise? Likewise, the time course of change in sleep with exercise is relatively unknown, as most studies have only examined sleep at baseline and post-intervention. Whether the timing of exercise matters in relation to sleep has received the most attention thus far, primarily due to the alleged sleep-disrupting effect of late-night exercise. While the optimal time of exercise for sleep remains equivocal,13,18 experimental evidence does not support the claim that late-night exercise disrupts subsequent sleep.29

The efficacy of exercise relative to standard sleep treatment options (e.g., hypnotics, CBT-I, CPAP therapy) is unknown as exercise has rarely been directly compared to these treatments.16 Accordingly, comparative-effectiveness trials could establish the true value of exercise to sleep medicine. Similarly, research examining the value of exercise as an adjunct to standard sleep treatment is needed. In particular, while exercise is unlikely to be a viable standalone OSA therapy, it may hold particular promise as an adjunct therapy due to its robust benefits on daytime functioning and cardiovascular risk, two prominent consequences of OSA.30

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Does Poor Sleep Contribute to Physical Inactivity?

A bidirectional relationship between exercise and sleep has long been assumed.11 Until recently, though, evidence to support the claim that poor sleep led to less exercise was limited to investigations that focused on group differences in physical activity between adults with and without significant sleep disturbances. These studies found, in general, that adults with poor sleep were less active than similar adults without sleep complaints. For instance, adults with insomnia symptoms are less active (e.g., 31) and have lower cardiorespiratory fitness32 than adults without insomnia, possibly due to daytime sleepiness and/or fatigue.33 Similarly, adults with SDB are less likely to be physically active than adults without SDB,34,35 with SDB severity inversely correlated with objective indices of physical activity.36 These low activity levels were commonly attributed to the excess weight, low energy, and high levels of fatigue and sleepiness that are characteristics of adults with SDB.37,38

Recent studies have attempted to examine the bidirectional relationship between exercise and sleep using more sophisticated statistical approaches. There are only a handful of these studies, and current evidence is limited to samples of older adults or adults with chronic pain. Nevertheless, two studies have shown that poor sleep (i.e., bad sleep quality or insomnia symptoms) predicts lower levels of physical activity 2-7 years later.39,40 Even more compelling, though, are studies that have found that nightly variations in various sleep parameters (i.e., sleep quality,41,42 subjective sleep latency,24 actigraphic sleep efficiency43) predict physical activity behavior the following day. Some of the observed associations may be of limited practical significance (e.g., a 30-min increase in the time to fall asleep associated with a 1-min decrease in next-day exercise duration,24 a 10% increase in sleep efficiency associated with a 5.4% increase in next-day MVPA minutes43). Regardless, it is notable that most of these studies found poor sleep to be a stronger predictor of subsequent physical activity than vice versa.24,39,40,43 These findings are also concordant with recent research that has found that experimentally imposed short sleep duration (e.g., < 6 hours per night) results in lower daytime activity levels.44,45

Initial evidence also suggests that one’s diurnal preference (i.e., morningness-eveningness) and the timing of sleep—independent of sleep quality and duration— is related to physical activity in adults. Specifically, greater morningness and an earlier habitual wake time were associated with greater levels of physical activity.46,47 As these two studies were cross-sectional analyses, it is possible that exercise (or lack thereof) alters diurnal preference and/or sleep timing. Exercise can shift the timing of circadian rhythms, though whether the timing is advanced or delayed likely depends upon the time of exercise.48

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Does Improving Sleep Lead to Increased Physical Activity?

The observational studies noted above allow the possibility that improving sleep may increase daytime activity levels. This is a logical supposition, as sleep and physical activity are both modifiable behaviors, and better sleep—by minimizing daytime impairment (e.g., sleepiness, fatigue/energy)—could facilitate an active lifestyle. However, experimental evidence to support this possibility is lacking. To my knowledge, only one study has examined this question in adults with poor sleep and/or insomnia. In a sample of older adults diagnosed with chronic insomnia, Kline and colleagues found that 4 weeks of behavioral treatment for insomnia did not change either self-reported or actigraphic measures of daytime activity despite significant improvements in subjective and actigraphic sleep at post-intervention.49

Similar results have been found in the three studies that have examined whether CPAP treatment increases daytime activity levels in patients with OSA. Across these studies, 1-6 months of CPAP treatment had no discernible impact on objective measures of physical activity despite significant improvement in daytime impairment (e.g., sleepiness, fatigue).50–52 Moreover, a recent study found that an intervention combining CPAP with tailored behavioral modification of eating habits and physical activity successfully improved eating behavior but was unable to change physical activity levels.53

The disappointing results of these studies—in particular, those involving OSA patients—suggest that improving sleep is insufficient to spontaneously change physical activity behavior. Traditional sleep treatments may need to be augmented with focused physical activity counseling to change activity levels in adults with poor sleep. Furthermore, identification of the specific barriers and facilitators to altering physical activity behavior in adults with disturbed sleep may be helpful. Although this has not been evaluated in adults with poor sleep quality or insomnia, studies focused on OSA patients have found that physical activity levels correspond to patients’ stage of behavior change readiness54 and fear of movement.55

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Conclusions

Both poor/insufficient sleep and physical inactivity are significant public health priorities. Interest in the bidirectional relationship between exercise and sleep has surged in recent years, presumably due to increased recognition of the value of sleep and the modifiability of both sleep and exercise behaviors. However, while intervening on physical activity levels has been shown to improve sleep, improving sleep has not resulted in increased levels of physical activity. Thus, additional research is needed to overcome the current conundrum—although exercise may be an important behavioral treatment for improving poor and/or disordered sleep, poor sleep may be a key impediment to initiating and/or maintaining a physically active lifestyle.

Exercise and Sleep

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The relationship between exercise and sleep1 has been extensively investigated over the years. Previous studies have noted that proper exercise can alleviate sleep-related problems and help you get an adequate amount of rest. Recent research also suggests insufficient or poor-quality sleep can lead to lower levels of physical activity the following day.

For these reasons, experts today believe sleep and exercise have a bidirectional relationship. In other words, optimizing your exercise routine can potentially help you sleep better and getting an adequate amount of sleep may promote healthier physical activity levels during the day.

How Does Exercise Impact Sleep?

There are many benefits to exercising regularly2. These include a lower risk of diseases like cancer and diabetes, improved physical function, and a higher quality of life. Exercising can also benefit certain groups. For example, pregnant women who engage in routine physical activity are less likely to gain an excessive amount of weight or experience postpartum depression, and elderly people who exercise are at lower risk of being injured during a fall.

Exercising also improves sleep for many people. Specifically, moderate-to-vigorous exercise can increase sleep quality for adults by reducing sleep onset – or the time it takes to fall asleep – and decrease the amount of time they lie awake in bed during the night. Additionally, physical activity can help alleviate daytime sleepiness and, for some people, reduce the need for sleep medications.

Exercise can also improve sleep in indirect ways. For instance, moderate-to-vigorous physical activity can decrease the risk of excessive weight gain, which in turn makes that person less likely to experience symptoms of obstructive sleep apnea (OSA). Roughly 60% of moderate to severe OSA cases3 have been attributed to obesity.

Numerous surveys have explored sleep and exercise habits among adults. These include the National Sleep Foundation’s 2003 Sleep in America poll, which surveyed adults between the ages of 55 and 84.

Among that survey’s respondents, about 52% said they exercised three or more times per week and 24% said they exercised less than once a week. Respondents in the latter group were more likely to sleep less than six hours per night, experience fair or poor sleep quality, struggle with falling and staying asleep, and receiving a diagnosis for a sleep disorder such as insomnia, sleep apnea, or restless legs syndrome.

The 2013 Sleep in America poll, which surveyed adults between the ages of 23 and 60 and focused on “Exercise and Sleep,” produced similar results. Roughly 76-83% of respondents who engage in light, moderate, or vigorous exercise reported very good or fairly good sleep quality. For those who did not exercise, this figure dropped to 56%. People who exercised were also more likely to get more sleep than needed during the work week.

Similar studies and surveys have focused on the effects of exercise for subjects in other demographic groups. One study profiled college students during their examination periods4 and found that exercise and physical activity can reduce test-related stress. Another study noted that sleep and exercise are “dynamically related” for community-dwelling older adults5. Additionally, a third study found that regular, mostly aerobic exercise reduced symptoms for people with OSA6, even if they didn’t lose any weight in the process.

Compared to exercise, jobs involving manual labor7 may not provide the same relief for sleep problems. One reason for this is that many laborious jobs often lead to musculoskeletal aches and pains that can negatively impact sleep. Moreover, manual labor involving long working hours can increase an employee’s risk for stress and fatigue8. In cases where manual labor or rigorous exercise negatively impact sleep quality, it may be beneficial to find the best mattress for your sleep preferences and body type to help alleviate pain or promote recovery.

Is It Harmful to Exercise Before Bed?

The question of whether exercise in the hours before bedtime contributes to poor-quality sleep has been hotly debated over the years. Traditional sleep hygiene dictates that intensive exercise9 during the three-hour period leading up to sleep can negatively impact sleep10 because it can increase your heart rate, body temperature, and adrenaline levels. On the other hand, some studies have noted exercising before bed may not produce any negative effects.

One survey found that the majority of people who exercise at 8 p.m. or later11 fall asleep quickly, experience an adequate amount of deep sleep, and wake up feeling well-rested. Respondents who exercise between 4 and 8 p.m. reported similar percentages for these categories, suggesting late-night exercise may actually benefit some people.

Other studies have yielded similar results. In one, subjects who exercised in the evening12 reported more slow-wave sleep and increased latency for rapid eye movement sleep compared to the control group, as well as less stage 1 (or light) sleep. However, researchers also noted that a higher core temperature – which can occur after intensive workouts – was associated with lower sleep efficiency and more time awake after sleep onset. So while exercising before bedtime may not be inherently harmful, vigorous workouts in the hour leading up to bed can affect sleep efficiency and total sleep time.

That said, some surveys have found the vast majority of people do not exercise in the hour before bedtime. One example is the National Sleep Foundation’s 2005 Sleep in America poll, which surveyed adults 18 and older. Of these respondents, 4% said they exercised within an hour of bedtime on a nightly basis, 7% said they did so a few nights a week, and 5% said they exercised before bed a few nights per month. The remaining respondents either rarely or never exercised an hour before bedtime, or refused to answer.

Since survey results among people who exercise late at night have been variable, you should base your exercise times and intensity on what best suits your sleep schedule. Certain exercises may be more beneficial for sleep than others. These include yoga, light stretching, and breathing exercises.

How Does Sleep Impact Exercise?

The role sleep plays in our physical activity levels has not been studied as thoroughly, and much of the research has focused on differences in physical activity between people with sleep disorders and healthy individuals.

However, most of these studies have concluded that those who experience poor sleep are less active than those with healthy sleep cycles. In particular, people with certain sleep disorders are not as likely to exercise during the day. Adults with insomnia tend to be less active than those without insomnia. The same is true for people with OSA and other types of sleep-disordered breathing, though excess weight may also be a factor for this population.

Some studies have noted that nightly shifts in sleep quality, latency, and efficiency can be used to predict physical activity levels. For example, one study found that a 30-minute increase in sleep onset was associated with a one-minute decrease in exercise duration the next day.

A person’s preference for morning or evening activity may also play a role. People who are early risers or “morning people” are more likely to engage in physical activity than those who sleep in or are more active in the evening. In fact, some studies have suggested that exercise can essentially alter one’s diurnal preference over time, and may even shift their circadian rhythms.

Although many studies to date have established a relationship between high-quality sleep and healthy physical activity levels, the research to date has not conclusively proven that better sleep leads to an increase in physical activity levels.

One series of studies noted that one to six months of continuous positive air pressure (CPAP) therapy – a first-line treatment for OSA – did not have any noticeable effect on a person’s physical activity levels, even though the therapy alleviated OSA symptoms and promoted better sleep. Another study explored the effect of CPAP therapy combined with modified eating habits. At the conclusion of this study, the subjects had successfully retooled their dietary patterns but had not adjusted their physical activity levels to a meaningful degree.

The takeaway here is that a good night’s sleep can help you feel well-rested and more motivated to exercise the following day, but healthy sleep alone may not be enough to spontaneously change how and how often you engage in physical activity.