key: cord-0876562-bj18xpxz
authors: Werneck, André O.; Silva, Danilo R.; Malta, Deborah Carvalho; Lima, Margareth G.; Souza-Júnior, Paulo R.B.; Azevedo, Luiz O.; Barros, Marilisa B.A.; Szwarcwald, Célia L.
title: The mediation role of sleep quality in the association of the incidence of unhealthy movement behaviors due to COVID-19 quarantine and mental health
date: 2020-09-25
journal: Sleep Med
DOI: 10.1016/j.sleep.2020.09.021
sha: afcd642d5e72b88b22c781fade342149d2b36455
doc_id: 876562
cord_uid: bj18xpxz

BACKGROUND: Our aim was to investigate the mediating role of worsening sleep quality in the association of the incidence of physical inactivity, high TV-viewing, and high computer/tablet use with loneliness, sadness, and anxiety. METHODS: Data of 45,160 Brazilian adults from a nationwide behavior survey, conducted between April 24th and May 24th (2020), were used. Participants reported physical inactivity (PI; <150 min/week), high TV-viewing (TV; ≥4 h/day), and high computer/tablet use (PC; ≥4 h/day) before and during COVID-19 quarantine (exposures). For incidence indicators, we only considered participants without the risk behavior before quarantine. Changes in sleep quality during the quarantine period (maintained/got better or worsened) were treated as a mediator. Elevated frequencies of feelings of loneliness, sadness (feel sad, crestfallen, or depressed), and anxiety (feel worried, anxious, or nervous) during the pandemic period were the study outcomes. Analyses were adjusted for sex, age group, highest academic achievement, working status during quarantine, skin color, previous diagnosis of depression, and adherence to quarantine. Mediation models were created using the Karlson Holm Breen method. RESULTS: The incidence of PI, high TV, and high PC use was associated with loneliness, sadness, and anxiety feelings. Worsening sleep quality partly mediated the association of the incidence of PI, high TV, and high PC use with loneliness (PI:30.9%; TV:19.6%; PC: 30.5%), sadness (PI:29.8%; TV:29.3%; PC: 39.1%), and anxiety (PI:21.9%; TV:30.0%; PC:38.5%). CONCLUSION: The association of the incidence of physical inactivity and sedentary behaviors with mental health indicators is partly mediated by worsening sleep quality during the COVID-19 pandemic quarantine.

For physical activity, participants were asked "Before the COVID-19 pandemic, how many 105 days a week did you practice any type of physical exercise or sport? (do not consider 106 physical therapy)" and "During the COVID-19 pandemic how many days a week do you 107 practice any type of physical exercise or sport? (do not consider physical therapy)". 108

Possible answers were: 1) less than 1 day/week; 2) 1-2 days/week; 3) 3-4 days/week; 109 or 4) 5 or more days/week. For those reporting physical activity practice, we also 110 asked: "How long does this activity last?". Possible answers were: 1) less than 30 min; 2) 111 30-45 minutes; 3) 46-60 minutes; or 4) more than one hour. We defined "before the 112 pandemic" as before the initial restraint measures adopted in Brazil, in the middle of 113

March and "during the pandemic", as the period in which the participants were 114 completing the questionnaire. We classified physical inactivity using the 115 recommendation of 150 min/week [19] . For our analysis purpose, we created an 116 incidence indicator of physical inactivity, only considering participants who were active 117 before quarantine (those that remained physically active vs. those that became 118 physically inactive during quarantine). 119

For TV-viewing, participants were asked: "Usually, before the pandemic, how 120 many hours a day did you use to spend watching television?" and "During the pandemic, 121 how many hours a day have you been watching television?". Possible answers for both 122 were 1) none; 2) less than 1h/day; 3) between 1 and less than 2 h/day; 4) between 2 123 and less than 3 h/day; 5) between 3 and less than 4 h/day; 6) between 4 and less than 5 124 h/day; 7) between 5 and less than 6 h/day; 8) 6 h/day or more. In addition, 125 computer/tablet use was assessed using two questions "Usually, before the pandemic, 126 how many hours a day did you use to spend using a computer or tablet?" and "During 127 the pandemic, how many hours a day do you usually spend using a computer or tablet?" 128 with open answers. TV-viewing and computer/tablet use were classified using the cut-129 off point of 4h/day at both moments (before and during quarantine). For our analysis 130 purposes, we considered only TV-viewing and computer/tablet incidence, calculated 131 as: those without high TV-viewing or high computer/tablet use before quarantine 132 (those who maintained low TV-viewing/computer use vs. those who changed to present 133 high TV-viewing/computer use during quarantine). 2) "a few times", 3) "Often", or 4) "Always". We classified as positive for loneliness, 156 sadness, and anxiety those participants who answered "often" or "always". 157

158

Covariates 159

We used sex, age group, highest academic achievement, working status during 160 quarantine, skin color and adherence to quarantine as covariates. The highest academic 161 achievement was classified as incomplete high school, complete high school, and college 162 education or more. Working status during quarantine was classified as currently not 163 working, working in a normal routine, and home office. Skin color was classified as 164 white or other. Adherence to quarantine was classified as positive for those only going 165 to grocery stores and pharmacies or staying strictly at home, leaving only for health 166 care needs; and negative for those reporting that they continued a normal life or tried to 167 stay away from people, reducing contact a little, not visiting the elderly, but carrying on 168 working and leaving home as usual. Table 1 . 196

Participants who reported worsened sleep quality, and felt loneliness, sadness, and 197 J o u r n a l P r e -p r o o f anxiety were more frequent within the incidence of physical inactivity, TV-viewing, and 198 computer/tablet use groups. 199 The mediation models of the influence of worsening sleep quality in the 205 association between the incidence of unhealthy movement behaviors and mental health 206 indicators are presented in Table 3 . The incidences of physical inactivity, high TV-207 viewing, and high computer/tablet use were associated with loneliness, sadness, and 208 anxiety feelings. In addition, worsening sleep quality mediated part of the association of 209 the incidence of physical inactivity, high TV-viewing, and high computer/tablet use with 210 loneliness, sadness, and anxiety, with a higher mediation effect for the incidence of high 211 computer/tablet use. 212

We aimed to investigate whether changes in sleep quality mediate the associations 215 between the incidence of unhealthy movement behaviors and mental health during 216 COVID-19 quarantine. Our main finding was that worsening sleep quality mediated part 217 of the associations of the incidences of physical inactivity, high TV-viewing, and high 218 computer/tablet use and mental health. In addition, the mediation effect was higher for 219 the association of the incidence of high computer/tablet use with sadness and anxiety. such as sleep apnea, which is associated with lower sleep quality [30] . Similarly, higher 241

sedentary behavior, especially screen time can be associated with higher exposure to 242 blue light, which can affect mechanisms related to melatonin release, which is 243 detrimental to sleep quality [31] . In this sense, poorer sleep quality due to the incidence 244 of unhealthy movement behaviors could explain part of the association of the incidence 245 of unhealthy movement behavior and mental health. In addition, the mediation can be 246 explained by sharing some mechanisms, as poorer sleep quality can be associated with 247 higher inflammation, which is associated with poorer mental health indicators [32] [33] [34] . 248

We highlight that, to our knowledge, this is the first study to explore the 249 mediation role of worsening sleep quality in the association of the incidence of physical 250 inactivity, high TV-viewing, and high computer/tablet use with mental health during 251 COVID-19 pandemic quarantine. Therefore, the promotion of physical activity practice 124. Geneva, Switzerland: 2020.

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Effects quarantine due to the COVID-19 on sleep quality, anxiety, and psychological 296 distress in the Italian population. Sleep Medicine 2020:S1389945720302136. 

Effects of Exercise Training on Sleep Apnea: A 395 Meta-analysis

The inner clock-Blue light 398 sets the human rhythm

Sleep Disturbance, Sleep Duration, and 401 Inflammation: A Systematic Review and Meta-Analysis of Cohort Studies and 402 Experimental Sleep Deprivation

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Self-initiated physical activity is associated with high sensitivity C-reactive 410 protein: A longitudinal study in 5,030 adults

Domain-416 Specific Physical Activity and Mental Health: A Meta-analysis

Values are presented in frequencies and 95% confidence intervals. No or yes refers to the incidence or not of the risk behavior. 427 *represents p<0