key: cord-0760422-8wn68tqh
authors: Bruno, S.; Bazzani, A.; Marantonio, S.; Cruz-Sanabria, F.; Benedetti, D.; Frumento, P.; Turchetti, G.; Faraguna, U.
title: Poor sleep quality and unhealthy lifestyle during the lockdown: an Italian study
date: 2022-01-11
journal: Sleep Med
DOI: 10.1016/j.sleep.2022.01.002
sha: ae9407a2d3adaae13a5cd372ca8a7ea621acdcfd
doc_id: 760422
cord_uid: 8wn68tqh

BACKGROUND: The lockdown measures implemented to face the 2019 Coronavirus Disease (COVID-19) first wave deeply modified the lifestyle of the Italian population. Despite its efficacy in limiting the number of infections, forced home confinement was paralleled by sleep/wake cycle disruptions, psychological distress and maladaptive coping strategies (i.e., unhealthy behaviours, such as tobacco and alcohol consumption). Under these unprecedented stress conditions, we explored a possible association between poor sleep quality and increased likelihood of engaging in an unhealthy lifestyle. METHODS: A cross-sectional study was conducted by disseminating an online survey via social networks and e-mail. We collected information on demographics, COVID-19-related data, sleep quality, chronotype, circadian misalignment, and lifestyle before and during the lockdown (i.e., consumption of cigarettes, alcoholic beverages, coffee, hypnotics, comfort food and fresh food; practice of physical activity). A global healthiness score was computed to assess participants’ modifications in lifestyle since the beginning of the lockdown. RESULTS: 1297 respondents were included in the study: 414 (31.9%) from Northern Italy, 723 (55.8%) from Central Italy, 160 (12.3%) from Southern Italy. The following variables were found to be significant predictors of the adoption of an unhealthy lifestyle since the beginning of the lockdown: poor sleep quality, high BMI and considering the measures adopted by the government to fight the pandemic as excessive. Living in Northern Italy, instead, was associated with healthier habits compared to living in Central Italy. CONCLUSIONS: Poor sleepers may represent the share of the general population who paid the highest price for social isolation. Further investigations are required to explore the role of sleep quality assessment in the identification of individuals vulnerable to unhealthy behaviours under stressful conditions.

implemented an unprecedented lockdown measure on the whole national territory to limit 101 the spread of the disease. Italians were only allowed to leave their homes to satisfy essential 102

needs (e.g., buying food or seeking medical help), or for other limited documented purposes. 103

Only few working categories were granted permission to reach their workplace, while most 104 of working activities were carried out from home [4] . This measure was effective in reducing 105 the number of infections at the price of considerable, negative, socio-economic 106

consequences. From 2019 to 2020, Italian GDP decreased by 8%, deficit/GDP ratio 107 increased from 134.8% to 155.7%, unemployment raised from 10% to 11.6% of the 108 workforce [5] . 51.5% of the Italian company owners declared that, in 2020, they might not 109

have sufficient liquidity to cover the expenditure of the year [6] . Finally, the negative impact of COVID-19 emergency on mental health is likely to increase 118 the incidence of sleep disturbances, and vice-versa [12] [13] [14] . Sleep, indeed, is an important 119 regulator of humans' emotional functioning, and its role in emotion regulation might explain 120 the association between sleep disorders and poor mental health [15, 16] , as well as its 121 association with health-related habits [17] . Emotional dysregulation may contribute to the 122 onset and maintenance of unhealthy lifestyle habits under stressful conditions, such as 123 smoking or drinking alcohol [18, 19] . Moreover, acute stress is also associated with an 124 increase in coffee consumption, with potential negative consequences on cardiovascular 125

health [20] . Stress may also exert a negative influence on eating behaviour [21] . A clinical 126 trial showed that stressed emotional eaters are more likely to choose sweet high-fat foods 127

and energy-dense foods as compared to both unstressed and unemotional eaters [22] . 128

Some people also tend to increase high-calories comfort food intake when stressed, thereby 129

increasing their risk of developing obesity [23] . It is therefore possible that the systematic 130 adoption of unhealthy behaviours under stress conditions might lead to negative 131 consequences on health both in the short term and in the long run. 132

It is likely that forced home confinement acted as a chronic stressor for the general 133 population, favouring the spread of behaviours dangerous to health. Moreover, it is also 134 likely that the lockdown might have impacted each person differently, grounded on their 135

individual characteristics. In line with this hypothesis, results from the Italian population 136

showed that cigarettes consumption globally increased, and that the growth in tobacco use 137 was particularly pronounced in participants with higher psychological suffering and disturbed 138

sleep [24] .In parallel, a study conducted on Italian medical students showed that during the 139 lockdown participants practiced less physical activity, especially when affected by sleep 140 J o u r n a l P r e -p r o o f disturbances [25] . The increased prevalence in sleep disturbances is likely to explain the 141 increased use of hypnotic drugs reported during the lockdown [26] . [26] . 142

Forced home confinement also modified dietary habits. A decrease in fresh food intake and 143

an increase in comfort food intake have been observed during the lockdown both in the US 144 and in Italy [28, 29] . The Italian general population registered a worsening in eating behaviour 145 (e.g., in the frequency of snacking between meals), most apparent in participants with a high 146

Body Mass Index (BMI) [30] . Therefore, it is possible that both disturbed sleep and high BMI 147 might represent vulnerabilities in facing stress induced by COVID-19 emergency.

The aim of this study is to explore a possible association between poor sleep quality and 150 unhealthy lifestyle in the Italian population during the lockdown. We hypothesized that poor 151 sleepers represent the most vulnerable share of the general population whose lifestyle has 152 been globally and negatively affected by the COVID-19 emergency. 153 154 155 The COVID-19 section assessed:

-the perceived severity of the disease, evaluated on a 4-point Likert scale ("Very 203 severe", "Severe", "Fairly severe", "Not severe") [31] . Only seven participants 204

answered "Not severe": data analysis was therefore performed considering 205 participants who answered "Not severe" and "Fairly severe" as a single group;

-the economic impact of the lockdown, which could be rated as "Positive", "Negative", 207

or "Not significant"; 208

-the perceived efficacy of the measures adopted by Italian government to face 209 pandemic's spread, which could be rated as "Not effective", "Effective" or "Excessive". 210 211

Participants were asked to report their levels of consumption of coffee, alcohol, cigarettes, 213 hypnotics and their purchase habits for comfort food and fresh food products, both during 214

and before the lockdown. Caffeine and tobacco use was reported by participants as the daily 215 number of coffee drunk and cigarettes smoked both during and before the lockdown.

Hypnotics consumption was instead evaluated in terms of weekly frequency of use ("Never", 217

"Less than once a week", "Once a week", "More than once a week", "Every day", "More than 218 once a day"), including both medications available only by prescription and over-the-counter 219 sleep aids. Comfort food and fresh food purchase, as well as alcohol consumption, were 220 evaluated through a single item assessing modifications in these behaviours comparing the 221 pre-lockdown and the lockdown period. A set of healthy behaviour-related variables was 222

computed by comparing self-reported participants' lifestyle during the lockdown to their 223 lifestyle in the pre-lockdown period. The frequency of engaging in each behaviour might be 224 decreased, unchanged or increased. Participants were also asked whether they practiced 225 physical activity both during and before the lockdown. Questionnaire perceived efficacy of the anti-COVID-19 measures, sleep quality, chronotype and circadian 296 misalignment; and the global healthiness score as dependent variable. All statistical tests 297

were two-sided, and the level of significance was set at 0.05. 298 299 300

The descriptive statistics of the sample are displayed in which we incorporated potential predictors of the outcome, may improve the generalizability 315 of our results and alleviate possible self-selection of the respondents. 316

With respect to pandemic-related variables, nearly all participants considered COVID-19 a 317

severe or very severe disease (93.8%); 83.4% believed that the measure adopted by the 318

Italian government to counteract the spread of the virus were effective (10% Not effective, 319

6.6 % Excessive); and more than half of them reported that the lockdown had a negative 320

impact on their financial situation (59.1%).

Regarding sleep and chronobiological parameters, participants' sleep quality (PSQI) was 323 poor on average (5.52 ± 3.2), while chronotype (rMEQ) distribution did not appear to be 324 different from that reported by literature (29.7% morning types, 18.1% evening types) [41] . 325

Data on circadian misalignment suggest that the preferred time window dedicated to sleep 326 was on average delayed as compared to the actual one (00:40 ± 00:38). 327 328 329 

Overall, both sleep and circadian parameters were significantly associated with a change in 339 most of the behaviours taken into account (Figure 1 ). Sleep quality was significantly 340 associated with each health-related variable; chronotype with each healthy behaviour 341 change with the exclusion of physical activity and fresh food products; circadian 342 misalignment with each variable except for physical activity. According to standard criteria 343 used to interpret η 2 value (η 2 = 0.01, small effect size; η 2 = 0.06, medium effect size, η 2 = 344 0.14 large effect size) [42] , almost all the effect sizes of the associations between sleep and 345 chronobiological parameters and health-related variables are small. The association 346

between sleep quality and hypnotics use, instead, showed a medium effect size. 

Effect size is represented by eta squared (η 2 ) and its value is directly proportional to both size and colour intensity of the 355 circles. "X" stands for non-significant associations. rMEQ stands for "reduced Morningness/Eveningness Questionnaire".

PSQI stands for "Pittsburgh Sleep Quality Index".

PSQI score was consistently higher in participants who reported to adopt an unhealthier 359

lifestyle since the beginning of the lockdown across all behaviours as compared to people 360 who did not change their habits or even improved their behaviours (Figure 2) . To verify the 361 hypothesized association between poor sleep quality and unhealthy lifestyle change, we ran 362

the Tukey HSD test to compare the mean PSQI score of the groups identified by each 363

health-related variable. We found that sleep quality was significantly lower in participants 364 who adopted a less healthy behaviour. Moreover, PSQI score was positively and 365

significantly correlated with the global healthiness score (Pearson test; r = 0.21, p < 0.001), 366

so that the worse participants slept, the more their lifestyle became unhealthy. interest (such as fresh food home delivery). 508 509

The novelty of our study is twofold: 510 -highlighting the relationship between sleep quality and global healthiness changes 511 by gathering information on different lifestyle aspects at once; 512

-identifying clusters of participants on which quarantine, as well as other potential 513 chronic stressors, may impact most negatively. 514

Our results, indeed, suggest that poor sleepers could be those participants who paid the 515 highest price for forced home confinement. If this pattern of reaction (i.e., increasing 516 cigarettes and alcohol consumption, stop practicing physical exercise, etc.) would be 517 systematically applied to every stressful condition, it could explain, at least partially, some 518 of the negative consequences associated with poor sleep quality, such as cardiovascular 519 diseases [53] or metabolic disorders [54, 55] . 520 521

This study has some important limitations that should be highlighted. The cross-sectional 522 design makes it impossible to draw conclusions on causality. Moreover, results must be 523 confirmed by studies involving objective (e.g., wrist actigraphy) and not only subjective sleep 524 measures, although the use of self-report instruments is the only who could grant social 525

distancing, allowing us to conduct a study without violating quarantine rules. 526

The limited predictive power of the model suggests that could be other predictors of the 527 healthiness score not measured in the current study (e.g., the personal history of mental 528 disorder, that may act as a risk factor for a worse response to stress conditions). However, 529

sleep quality can be easily targeted by a preventive treatment which can reduce the impact 530 on health of behavioural maladaptive coping strategies. Finally, some of the items used to 531 explore health-related variables do not allow a direct estimate of participants' likelihood of 532 engaging in the behaviour of interest before the lockdown and during the lockdown. This 533 might represent a limitation as no conclusion can be drawn in terms of magnitude of change. 534 535 Sleep quality assessment might help identify people who could frequently react to stressful 540 events by engaging in unhealthy behaviours. Large-scale interventions for good sleep 541 quality promotion might contribute to better manage prolonged stressful situations, and 542

ultimately improve people's health. 543

Public health interventions focused on the improvement of the well-being during COVID-19 544 pandemic, should also take into account lifestyle behavioural dimension, which can be 545

negatively affected by stressful conditions, particularly in participants with poor sleep quality. 546 547 548 6. Disclosure statement 549 550

Ugo Faraguna is co-founder and president of sleepActa S.r.l, a spin-off company of the 551

University of Pisa operating in the field of sleep medicine. All other authors declare no 552 competing interest. 553 554 555

The authors would like to thank Gianni Andreozzi, Emanuele Bombardini, Virginia Casigliani, 558

Serena Ceccanti, Antonio Falco, Federico Ferri, Valentina Lorenzoni and Leopoldo Trieste 559

for their support in survey design and data collection. 560

The present study was supported by a grant from the Arpa Foundation, Pisa, Italy (Sonnolab 561

Grant to Ugo Faraguna). 562 563 564

[1] WHO. Data as reported by: 20 January 2020. https://www.who.int/docs/default-567 source/coronaviruse/situation-reports/20200121-sitrep-1-2019-568

ncov.pdf?sfvrsn=20a99c10_4 (accessed August 5, 2021). 569

[2] WHO Director-General's opening remarks at the media briefing on COVID-19 -11 570

March 2020 https://www.who.int/director-general/speeches/detail/who-director-571

general-s-opening-remarks-at-the-media-briefing-on-covid-19---11-march-2020 572

(accessed August 5, 2021).

[3] COVID-19/dati-regioni at master · pcm-dpc/COVID-19 · GitHub 574

https://github.com/pcm-dpc/COVID-19/tree/master/dati-regioni (accessed August 5, 

In the Appendix, the English translation and the original Italian version of the questionnaire item exploring health-related variables are provided.

1) Before the lockdown, did you regularly take medicines to help you sleep?

-No -Less than once a week -Once a week -More than once a week -Every day -More than once a day 2) How often do you take them now in a week?

-I don't take them -Less than once a week -Once a week -More than once a week -Every day -More than once a day 3) Since the beginning of the lockdown, your consumption of alcoholic beverages is:

-Decreased -Unchanged -Increased 4) Before the lockdown, how many cigarettes did you usually smoke per day?

-I did not smoke -1 -20 (multiple choice) -More than 20 5) Since the beginning of the lockdown, how many cigarettes do you smoke per day?

-I do not smoke -1 -20 (multiple choice) -More than 20 6) Before the lockdown, how many coffees did you usually drink per day?

-I did not drink coffee usually -Less than once a day -1 -2 -3 -4 -5 -More than 5 7) Since the beginning of the lockdown, how many coffees do you drink per day?

-I do not drink coffee usually -Less than once a day -1 -2 -3 -4 -5 -More than 5 8) Since the beginning of the lockdown, how often did you buy comfort food (e.g., pizza, chocolate, chips, candy...)?

-Less than before -As before -More than before 9) Compared to before the lockdown, how has your weekly purchase of fresh products (e.g., fruit and vegetables) changed?

-Definitely decreased -Reduced -Unchanged -Increased -Definitively increased 10) Before the lockdown, did you regularly practice physical activity? 

Sleep 615 and mental disorders: A meta-analysis of polysomnographic research

Sleep and emotion regulation: An organizing, integrative 618 review

Emotion 620 Regulation Failures Are Preceded by Local Increases in Sleep-like Activity

Lifestyle and habits. Sleepiness and human impact assessment

Emotional intelligence and addictions: A systematic review

Anxiety, depression, and cigarette smoking: A 627 transdiagnostic vulnerability framework to understanding emotion-smoking 628 comorbidity

The relationship between personality, 630 socio-economic factors, acute life stress and the development, spontaneous 631 conversion and recurrences of acute lone atrial fibrillation

The 634 determinants of food choice

Stress and food choice: A laboratory study

Proceedings of the National 641 Academy of Sciences of the United States of

Impact of COVID-644 19 lockdown on smoking consumption in a large representative sample of Italian 645 adults

COVID-19 lockdown: Physical activity, 647 sedentary behaviour and sleep in Italian medicine students

Covid-650 19 health crisis and lockdown associated with high level of sleep complaints and 651 hypnotic uptake at the population level

654 Escalation of sleep disturbances amid the COVID-19 pandemic: A cross-sectional 655 international study

Covid-19 and the subsequent lockdown modified dietary 658 habits of almost half the population in an Italian sample

Adherence to healthy food choices 661 during the COVID-19 pandemic in a U.S. population attempting to lose weight. 662 Nutrition, Metabolism and Cardiovascular Diseases 2021

Lifestyle 665 changes and body mass index during COVID-19 pandemic lockdown: An Italian 666 online-survey

Population-based 668 post-crisis psychological distress: An example from the SARS outbreak in Taiwan

The Pittsburgh sleep 672 quality index: A new instrument for psychiatric practice and research

Validity 675 of the Italian Version of the Pittsburgh Sleep Quality Index (PSQI). Neurological 676

Horne & Östberg morningness-eveningness questionnaire: A 678 reduced scale

A self assessment questionnaire to determine Morningness 681 Eveningness in human circadian rhythms

Validazione di una scala ridotta di Mattutinità (rMEQ) = Validation of a 684 reduced version of the Morningness-Eveningness Questionnaire (rMEQ). Giunti 685

Validity of the reduced version of the 687

Life between clocks: Daily temporal 690 patterns of human chronotypes

Development, validation and reliability 693 of the Chrononutrition Profile -Questionnaire

Gender differences in morningness-eveningness preference

Statistical Power Analysis for the Behavioral Sciences

The psychological impact of COVID-19 pandemic lockdowns: A 704 review and meta-analysis of longitudinal studies and natural experiments

The double-707 edged relationship between COVID-19 stress and smoking: Implications for smoking 708 cessation

Effect of covid-19 lockdown on dietary habits and 711 lifestyle of food science students and professionals from Spain

Changes in sleep 714 timing and subjective sleep quality during the COVID-19 lockdown in Italy and 715 Belgium: age, gender and working status as modulating factors

Sleep 718 quality mediates the effect of chronotype on resilience in the time of COVID-19

Lifestyle, self-reported morbidities, and poor sleep quality among Brazilian workers

Covid 19 pandemic; self-reported changes in eating behaviour, and associations with 726 BMI, eating style, coping and health anxiety

Sorveglianza Integrata Covid-19 in Italia

Functional 732 and dysfunctional fear of COVID-19: a classification scheme

Functional Fear Predicts Public Health 735 Compliance in the COVID-19 Pandemic

Verschuren 738 WMM. Sleep duration and sleep quality in relation to 12-year cardiovascular disease 739 incidence: The MORGEN study

Sleep quality and obesity in young subjects: a meta-741 analysis

The impact of sleep amount and sleep quality on glycemic 743 control in type 2 diabetes: A systematic review and meta-analysis

Poor sleep quality and unhealthy lifestyle during the lockdown: an Italian study

Writing -Original Draft, Writing -Review and Editing

Conceptualization, Methodology, Investigation, Writing -Review and Editing Sara Marantonio: Conceptualization, Methodology, Investigation, Writing -Original Draft, Writing -Review and Editing

Writing -Review and Editing, Visualization Davide Benedetti: Formal analysis, Writing -Review and Editing, Visualization Paolo Frumento: Formal analysis, Writing -Review and Editing

Conceptualization, Methodology, Investigation, Writing -Review and Editing

Conceptualization, Methodology, Investigation, Writing -Review and Editing