Usage of digital, social and goal-setting functionalities to support health behavior change: A mixed methods study among disadvantaged women during or after pregnancy and their healthcare professionals.

OBJECTIVE: We aimed to gain insight into how and to what extent social (i.e. private/group chat) and goal-setting (e.g. rewards) functionalities in digital interventions for health behavior change were used by clients and nurses in a preventive care program for disadvantaged women during or after pregnancy, and which factors influenced usage. METHODS: We collected quantitative and qualitative data on usage of these functionalities in 'Kindle', a mHealth intervention to prepare for health behavior change. RESULTS: We found that nurses (n = 5) and clients (n = 20) scarcely used both functionalities. They sent 862 messages in the social functionality whose security they appreciated, but habitually used WhatsApp likewise. Moreover, nurses were hesitant to let their clients interact in the group chat. Clients formulated 59 personal goals, which they found difficult to do. Nurses rewarded 846 points for clients' progress on goal attainment, but found it hard to determine how many points to reward. Clients and nurses indicated that the functionality made it more fun and easy to discuss clients' personal goals. CONCLUSIONS: To conclude, digital, social and goal-setting functionalities were used to a limited extent by nurses and clients, and need optimization before implementation to support disadvantaged groups to change their health behavior.

Surprising impact of stromal TIL's on immunotherapy efficacy in a real-world lung cancer study.

INTRODUCTION: Immune checkpoint inhibitors (ICI), such as anti-PD-1 agents, have become part of the standard of care treatment of advanced non-small cell lung cancer (NSCLC). Predictive biomarkers are needed to identify patients that benefit from anti-PD-1 treatments. Tumor infiltrating lymphocytes (TILs) and PD-L1 are major players in the ICI mechanism of action. In this study, we assess the impact of real-world clinicopathological variables, including TILs and PD-L1, on anti-PD-1 efficacy. METHODS: We performed a monocenter retrospective study in advanced NSCLC treated with nivolumab or pembrolizumab between January 2015 and February 2019. The impact of baseline clinical and pathological variables was assessed by univariate and multivariate models. TILs, defined as CD8+T-cells, and PD-L1 were scored in tumor and stroma, and correlated with progression free survival (PFS) and overall survival (OS). RESULTS: We included 366 patients of whom 141 were assessed for tumor and stromal TILs. The median follow-up time was 487 days. In the whole cohort, PFS was associated with high tumor PD-L1, high albumin and good performance. OS was associated with low LDH, high albumin, good performance and 'first-line treatment'. In the TILs subcohort, stromal TILs had the strongest impact on PFS and OS. Stromal TILs were a stronger marker for PFS and OS than tumoral TILs, tumoral PD-L1 or stromal PD-L1. Remaining factors for PFS and OS were albumin and albumin with LDH, respectively. CONCLUSIONS: This real-world study on clinicopathological features shows that stromal CD8 + TILs were the strongest predictor for PFS and OS in patients with advanced NSCLC on anti-PD-1 therapy. Other predictors for PFS and OS included albumin and albumin together with LDH, respectively. This study highlights the pivotal role of the stromal compartment in the mechanisms of action of ICI, and the need for further studies aiming to overcome this stromal firewall.

Development of a plain-language guide for discussing breast cancer genetic counseling and testing with patients with limited health literacy.

PURPOSE: Due to limited health literacy and resulting ineffective communication between healthcare professionals and patients, not all eligible patients are offered breast cancer genetic counseling and testing. We aimed to develop a plain-language guide to increase effective communication about genetic counseling and testing with breast cancer patients with limited health literacy. METHODS: Together with oncological healthcare professionals, we drafted a list of jargon words frequently used during (breast) cancer genetic counseling. In a focus group interview with breast cancer counselees with limited health literacy, who had received genetic counseling before, we reformulated these words in plain language. Low-literate individuals, who are not familiar with breast cancer care or genetic counseling, reflected on the draft of the guide. Completeness, acceptability, and perceived usability were tested in an online questionnaire among healthcare professionals. RESULTS: The result is a plain-language guide for genetic counseling and testing with 33 frequently used jargon words and a reformulation of these words in plain language. Acceptability and perceived usefulness of the guide among healthcare professionals (n = 58) were high. CONCLUSION: The plain-language guide provides opportunities to facilitate communication about genetic counseling and testing with patients with limited health literacy and could enhance opportunities for patients to make informed decisions to participate in genetic testing. As the intention from healthcare professionals to use the plain-language guide is high, implementation of the guide in a real-life setting seems promising.

Risk factors for pelvic girdle pain postpartum and pregnancy related low back pain postpartum; a systematic review and meta-analysis.

BACKGROUND: Although pelvic girdle pain postpartum and pregnancy related low back pain postpartum (combined and named PGPP in this study) have a natural favourable course, there is a subgroup of women who have persistent complaints. The objective of this study was to identify personal-, (pre)pregnancy-, obstetric-, and child related risk factors on PGPP by means of a systematic literature review and meta-analysis. METHODS: Literature searches of PubMed, EMBASE, CINAHL and Cochrane up to October 2018 were conducted. Prospective cohort studies in English or Dutch describing three or more risk factors for PGPP were included. We assessed articles for inclusion and risk of bias. Studies with high risk of bias were excluded from data extraction. Data was extracted and checked for accuracy confirming to the CHARMS-checklist. Homogeneous variables were pooled. RESULTS: Twelve full text studies were assessed. Seven studies were excluded due to high risk of bias. Data was extracted from five studies. Multivariate analysis was not possible due to heterogeneity in included risk factors as well as outcome measures on risk factor per study. Pooled univariate significant risk factors on PGPP were: a history of low back pain, pre-pregnancy body mass index >25, pelvic girdle pain in pregnancy, depression in pregnancy, and a heavy workload in pregnancy. No significant obstetric and child related risk factors were reported. CONCLUSIONS: Risk factors on PGPP have been identified. Since multivariate analysis was not possible the outcome should be treated with care, because interaction between risk factors could not be analysed.

Serious games for smoking prevention and cessation: A systematic review of game elements and game effects.

OBJECTIVE: Serious health games might have the potential to prevent tobacco smoking and its health consequences, depending on the inclusion of specific game elements. This review aimed to assess the composition of serious games and their effects on smoking initiation prevention and cessation and behavioral determinants. MATERIALS AND METHODS: We systematically searched MEDLINE, Embase, PsycINFO, and Web of Science for publications that evaluated serious games aimed at changing smoking behavior or behavioral determinants. A taxonomy by King et al was used to classify game elements. RESULTS: We identified 15 studies, evaluating 14 unique serious games. All games combined multiple game elements (mean 5.5; range, 3-10). Most frequently used were general and intermittent rewards, theme and genre features, and punishments. Six studies on smoking prevention together assessed 20 determinants and found statistically significant positive effects for 8 determinants (eg, attitude, knowledge, intention). Of 7 studies on smoking cessation, 5 found positive, statistically significant effects on smoking cessation or status. These studies found statistically significant positive effects for 6 of 12 determinants (eg, self-efficacy, attitude, intention). The majority of included studies had poor or fair methodological quality, lacked follow-up measures, and had fixed (as opposed to free, on-demand) play sessions. CONCLUSIONS: Serious games included multiple types of game elements. The evidence from a number of studies suggests that games may have positive effects on smoking-related outcomes, particularly smoking cessation. However, as most studies had important methodological limitations, stronger designs are needed to demonstrate, quantify, and understand the effects of serious games.

Health literacy and hypertension outcomes in a multi-ethnic population: the HELIUS study.

BACKGROUND: Hypertension disproportionately affects ethnic minority groups. Although health literacy may play role in these ethnic inequalities, little is known about the extent to which health literacy affects hypertension prevalence, awareness, treatment and control in different ethnic groups. Therefore, we assessed these associations in a multi-ethnic population. METHODS: Baseline data from the HELIUS study were used including participants of Dutch (n = 1948), South-Asian Surinamese (n = 2054) and African Surinamese (n = 1932) origin aged 18-70 years, who lived in Amsterdam, the Netherlands, were fluent in Dutch and underwent health literacy assessment through the Rapid Estimate of Adult Literacy in Medicine-Dutch (REALM-D). The REALM-D was categorized either as low (<60 sumscore) or adequate (≥60 sumscore) health literacy. Participants completed questionnaires and underwent physical examination. RESULTS: After adjusting for confounding variables, Dutch [odds ratio (OR) 2.02; 95% confidence interval (CI), 1.11-3.64] and African Surinamese (OR 1.36; 1.03-1.79) with low health literacy were more likely than those with adequate health literacy to have hypertension, whereas in South-Asian Surinamese this association was not significant. No significant associations were found between health literacy and hypertension awareness, treatment and control in any of the ethnic groups. CONCLUSION: Findings indicate that health literacy is associated with hypertension prevalence in selected ethnic groups, but not with hypertension awareness, treatment and control. Targeting health literacy might be an entry point for tackling ethnic inequalities in hypertension prevalence. To substantially reduce these inequalities, further research is needed to explore other factors and pathways through which health literacy may impact hypertension outcomes in different ethnic groups.

Validation of the short assessment of health literacy (SAHL-D) and short-form development: Rasch analysis.

BACKGROUND: Accurate measurement of health literacy is essential to improve accessibility and effectiveness of health care and prevention. One measure frequently applied in international research is the Short Assessment of Health Literacy (SAHL). While the Dutch SAHL (SAHL-D) has proven to be valid and reliable, its administration is time consuming and burdensome for participants. Our aim was to further validate, strengthen and shorten the SAHL-D using Rasch analysis. METHODS: Available cross-sectional SAHL-D data was used from adult samples (N = 1231) to assess unidimensionality, local independence, item fit, person fit, item hierarchy, scale targeting, precision (person reliability and person separation), and presence of differential item functioning (DIF) depending on age, gender, education and study sample. RESULTS: Thirteen items for a short form were selected based on item fit and DIF, and scale properties were compared between the two forms. The long form had several items with DIF for age, gender, educational level and study sample. Both forms showed lower measurement precision at higher health literacy levels. CONCLUSIONS: The findings support the validity and reliability of the SAHL-D for the long form and the short form, which can be used for a rapid assessment of health literacy in research and clinical practice.

Blood donation barriers and facilitators of Sub-Saharan African migrants and minorities in Western high-income countries: a systematic review of the literature.

OBJECTIVES: The present study aimed to gain more insight into, and summarise, blood donation determinants among migrants or minorities of Sub-Saharan heritage by systematically reviewing the current literature. BACKGROUND: Sub-Saharan Africans are under-represented in the blood donor population in Western high-income countries. This causes a lack of specific blood types for transfusions and prevention of alloimmunisation among Sub-Saharan African patients. METHODS/MATERIALS: Medline, EMBASE, PsycINFO and BIOSIS were searched for relevant empirical studies that focused on barriers and facilitators of blood donation among Sub-Saharan Africans in Western countries until 22 June 2017. Of the 679 articles screened by title and abstract, 152 were subsequently screened by full text. Paired reviewers independently assessed the studies based on predefined eligibility and quality criteria. RESULTS: Of the 31 included studies, 24 used quantitative and 7 used qualitative research methods. Target cohorts varied from Black African Americans and refugees from Sub-Sahara Africa to specific Sub-Saharan migrant groups such as Comorians or Ethiopians. Main recurring barriers for Sub-Saharan Africans were haemoglobin deferral, fear of needles and pain, social exclusion, lack of awareness, negative attitudes and accessibility problems. Important recurring facilitators for Sub-Saharan Africans were altruism, free health checks and specific recruitment and awareness-raising campaigns. CONCLUSION: The findings of this review can be used as a starting point to develop recruitment and retention strategies for Sub-Saharan African persons. Further research is needed to gain more insight in the role of these determinants in specific contexts as socioeconomic features, personal histories and host country regulations may differ per country.

[A verrucous plaque on the lower leg]. / Een wratachtige afwijking op het onderbeen.

A 10-year-old boy presented with an asymptomatic, congenital, dark brown coloured, well circumscribed, verrucous, hyperkeratotic plaque on his left leg. This was diagnosed as verrucous haemangioma.

Cardiovascular disease risk and secondary prevention of cardiovascular disease among patients with low health literacy.

OBJECTIVE: To explore the association between health literacy and the risk of cardiovascular disease (CVD), and to assess the differential effects by health literacy level of a nurse-coordinated secondary prevention program (NCPP) in patients with coronary artery disease (CAD). METHODS: Data were collected in two medical centres participating in the RESPONSE trial (Randomised Evaluation of Secondary Prevention by Outpatient Nurse SpEcialists). CVD risk profiles were assessed at baseline and 12-month follow-up using the Systematic Coronary Risk Evaluation (SCORE). Health literacy was assessed by the short Rapid Estimate of Adult Literacy in Medicine (REALM-D) and the Newest Vital Sign (NVS-D); self-reported health literacy was evaluated by the Set of Brief Screening Questions (SBSQ-D). RESULTS: Among 201 CAD patients, 18% exhibited reading difficulties, 52% had difficulty understanding and applying written information, and 5% scored low on self-reported health literacy. Patients with low NVS-D scores had a higher CVD risk [mean SCORE 5.2 (SD 4.8) versus 3.3 (SD 4.1), p < 0.01]. Nurse-coordinated care seemed to reduce CVD risk irrespective of health literacy levels without significant differences. CONCLUSION: Inadequate health literacy is prevalent in CAD patients in the Netherlands, and is associated with less favourable CVD risk profiles. Where many other forms of CVD prevention fail, nurse-coordinated care seems to be effective among patients with inadequate health literacy.

Knowledge and Informed Decision-Making about Population-Based Colorectal Cancer Screening Participation in Groups with Low and Adequate Health Literacy.

Objective. To analyze and compare decision-relevant knowledge, decisional conflict, and informed decision-making about colorectal cancer (CRC) screening participation between potential screening participants with low and adequate health literacy (HL), defined as the skills to access, understand, and apply information to make informed decisions about health. Methods. Survey including 71 individuals with low HL and 70 with adequate HL, all eligible for the Dutch organized CRC screening program. Knowledge, attitude, intention to participate, and decisional conflict were assessed after reading the standard information materials. HL was assessed using the Short Assessment of Health Literacy in Dutch. Informed decision-making was analyzed by the multidimensional measure of informed choice. Results. 64% of the study population had adequate knowledge of CRC and CRC screening (low HL 43/71 (61%), adequate HL 47/70 (67%), p > 0.05). 57% were informed decision-makers (low HL 34/71 (55%), adequate HL 39/70 (58%), p > 0.05). Intention to participate was 89% (low HL 63/71 (89%), adequate HL 63/70 (90%)). Respondents with low HL experienced significantly more decisional conflict (25.8 versus 16.1; p = 0.00). Conclusion. Informed decision-making about CRC screening participation was suboptimal among both individuals with low HL and individuals with adequate HL. Further research is required to develop and implement effective strategies to convey decision-relevant knowledge about CRC screening to all screening invitees.

The prevalence of patellofemoral osteoarthritis: a systematic review and meta-analysis.

OBJECTIVE: To determine the prevalence of radiographic patellofemoral osteoarthritis (OA) from population- and symptom-based cohorts and to evaluate if knee pain, physical function and quality of life (QOL) differ between people with isolated patellofemoral OA, isolated tibiofemoral OA and combined patellofemoral and tibiofemoral OA. METHOD: Terms associated with "patellofemoral OA", "prevalence" and "clinical features" were used to search Medline, EMBASE, CINAHL, SCOPUS, AMED and Web of Science databases with no language restriction' from inception to August 2014. Two independent reviewers screened papers for eligibility. Studies were included if they reported prevalence of compartmental patterns of radiographic knee OA in population- or symptom-based cohorts. Studies were excluded if they evaluated a targeted sample (e.g., occupation-specific participants) or repeated already reported data from the same cohorts. Point prevalence estimates of patellofemoral OA were extracted from eligible studies, pooled and quantitatively analysed. A critical appraisal tool was used to evaluate methodological quality. RESULTS: The search yielded 1891 records. The inclusion criteria were met by 32 studies. The crude prevalence of patellofemoral OA was 25% in the population-based cohorts (aged >20 years) and 39% in the symptom-based cohorts (aged >30 years). Eight studies reported knee pain, physical function and QOL in people with different compartmental disease; however no significant differences were found. CONCLUSION: These findings confirm the substantial prevalence of patellofemoral OA, demonstrating the need to specifically consider the patellofemoral joint in knee OA research and clinical settings.

On the effect of pressure and carrier gas on homogeneous water nucleation.

Homogeneous nucleation rates of water droplets were measured at a nucleation temperature close to 240 K in a Pulse-Expansion Wave Tube (PEWT). Several measures were taken to improve the data obtained with the PEWT. For instance, the molar water vapor fraction was determined with three independent techniques. The resulting standard uncertainty of the supersaturation was within 1.8%. Results are given for water nucleation in helium at 100 kPa and at 1000 kPa and in nitrogen at 1000 kPa. Two trends were observed: (i) the values of the nucleation rate of water in helium at 1000 kPa are slightly but significantly higher (factor 3) than its values at 100 kPa and (ii) nucleation rates of water in nitrogen at 1000 kPa are clearly higher (factor 10) than in helium at the same pressure. It is argued that the explanation of the two observed trends is different. For case (i), it is the insufficient thermalization of the growing water clusters in helium at the lowest pressure that has a reducing effect on the nucleation rate, although a full quantitative agreement has not yet been reached. For case (ii), thermal effects being negligible, it is the pressure dependency of the surface tension, much stronger for nitrogen than for helium, that explains the trends observed, although also here a full quantitative agreement has not yet been achieved.

A novel RIPK4-IRF6 connection is required to prevent epithelial fusions characteristic for popliteal pterygium syndromes.

Receptor-interacting protein kinase 4 (RIPK4)-deficient mice have epidermal defects and fusion of all external orifices. These are similar to Bartsocas-Papas syndrome and popliteal pterygium syndrome (PPS) in humans, for which causative mutations have been documented in the RIPK4 and IRF6 (interferon regulatory factor 6) gene, respectively. Although genetically distinct, these syndromes share the anomalies of marked pterygia, syndactyly, clefting and hypoplastic genitalia. Despite the strong resemblance of these two syndromes, no molecular connection between the transcription factor IRF6 and the kinase RIPK4 was known and the mechanism underlying the phenotype was unclear. Here we describe that RIPK4 deficiency in mice causes epithelial fusions associated with abnormal periderm development and aberrant ectopic localization of E-cadherin on the apical membrane of the outer peridermal cell layers. In Xenopus, RIPK4 depletion causes the absence of ectodermal epiboly and concomitant gastrulation defects that phenocopy ectopic expression of dominant-negative IRF6. We found that IRF6 controls RIPK4 expression and that wild-type, but not kinase-dead, RIPK4 can complement the gastrulation defect in Xenopus caused by IRF6 malfunctioning. In contrast to the mouse, we observed only minor effects on cadherin membrane expression in Xenopus RIPK4 morphants. However, gastrulation defects were associated with a virtual absence of cortical actin in the ectodermal cells that face the blastocoel cavity and this was phenocopied in embryos expressing dominant-negative IRF6. A role for RIPK4 in actin cytoskeleton organization was also revealed in mouse epidermis and in human epithelial HaCaT cells. In conclusion, we showed that in mice RIPK4 is implicated in cortical actin organization and in E-cadherin localization or function, which can explain the characteristic epithelial fusions observed in PPSs. In addition, we provide a novel molecular link between IRF6 and RIPK4 that unifies the different PPSs to a common molecular pathway.

Low subjective health literacy is associated with adverse health behaviors and worse health-related quality of life among colorectal cancer survivors: results from the profiles registry.

BACKGROUND: The objectives of the study were to examine the prevalence of health literacy (HL) among colorectal cancer (CRC) survivors and the relation between HL and health behaviors and to explore whether or not HL and health behaviors are independently associated with health-related quality of life (HRQoL) and mental distress. METHODS: This analysis is part of a longitudinal, population-based survey among CRC survivors diagnosed between 2000 and 2009 and registered by the Eindhoven Cancer Registry. Data collected during the second data wave was used (n = 1643; response rate 83%). Patients filled out a screening question on subjective functional HL, questions on health behaviors, HRQoL (European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire C30), and mental distress (Hospital Anxiety and Depression Scale). RESULTS: Subjective HL was low among 14%, medium among 45%, and high among 42% of the participants. CRC survivors with low HL were more often smokers and did not meet the prescribed physical activity guidelines compared with survivors with medium or high HL. CRC survivors with low HL reported statistically significantly lower levels of mental and physical HRQoL and higher distress levels compared with survivors with medium and high HL. HL, in addition to sociodemographic and clinical characteristics and health behaviors, significantly explained 1.5-6.2% of the variance in HRQoL and mental distress levels. Partial mediation is indicated for HRQoL and feelings of depression, but not for anxiety. CONCLUSION: Low subjective functional HL among CRC survivors is associated with lower levels of physical activity, higher frequency of smoking, poorer HRQoL, and more mental distress. HL and health behaviors have both a unique as well as an overlapping contribution to the explained variances of HRQoL and mental distress.

Risk factors associated with reduced work productivity among people with chronic knee pain.

OBJECTIVE: To determine the burden and risk factors associated with reduced work productivity among people with chronic knee pain. METHOD: A longitudinal study, nested within a randomised controlled trial (RCT) evaluating the long-term effects of dietary supplements, was conducted among people with chronic knee pain in paid employment (n = 360). Participants recorded days off work (absenteeism) and reduced productivity while at work (presenteeism) for seven days every two months over a 12-month period in a study specific diary. Examined risk factors included knee pain severity, occupational group, radiographic disease severity, physical activity, body mass index (BMI), health-related quality of life (SF-12) and co-morbidity. RESULTS: Over the 12-month follow up period, 50 (14%) participants reported one or more days off work due to knee problems, while 283 (79%) reported reduced productivity while at work (presenteeism <100%). In multivariate analysis, the only significant risk factor for absenteeism was having an SF-12 Mental Component Summary (MCS) score <40 (OR: 2.49 [95% CI: 1.03-5.98]). Significant risk factors for presenteeism included; reporting an; SF-12 Physical Component Summary (PCS) score <50 (OR: 1.99 [95% CI: 1.05-3.76]), semi-manual labour (OR: 2.23 [1.09-4.59]) or manual labour (OR: 6.40 [1.44-28.35]) or a high maximum knee pain (4-6 out of 10) (OR: 2.29 [1.17-4.46]). CONCLUSIONS: This longitudinal study found that among this cohort of people with chronic knee pain, the burden of reduced work productivity is mainly attributable to presenteeism rather absenteeism. This study demonstrated that effective strategies to increase work productivity should focus on reducing knee pain or physical disability especially among workers in manual or semi-manual labour.

Acute postoperative pain following hospital discharge after total knee arthroplasty.

OBJECTIVE: The increasingly shorter hospitalization following total knee arthroplasty (TKA) requires patients to assume earlier responsibility to self-manage their pain. Poorly managed acute pain increases the risk of persistent pain, reduces quality of life and increases unnecessary healthcare utilization. This study aims to examine post-discharge pain intensity, pain management behaviors and potential barriers to optimal self-management of pain. DESIGN: We administered a questionnaire at 2 weeks after discharge to 174 patients undergoing TKA in 10 Australian hospitals. Participants rated pain expectation and severity, use of analgesics and non-pharmacological methods, side-effects, walking and exercise times, perceptions of analgesics, adequacy of pain management information provided and satisfaction with pain relief. RESULTS: Of 171 (98%) participants who completed the questionnaire, 88 (52%) reported that the worst pain period occurred during the first 2 weeks at home. During the first 2 weeks at home, the average pain was 'severe/extreme' for 40 (23%) participants and 92 (54%) experienced severe pain at least some of the time. Many participants sought further medical help for their pain. Adequate information on analgesics and non-pharmacological methods for pain relief were reported by only 73% and 47%, respectively. Approximately 20% had negative perceptions about analgesic use. Higher pain severity was associated with lower satisfaction and less time spent walking daily. CONCLUSIONS: Effective pain relief after hospital discharge following TKA is a challenge. Many participants reported significant pain, sought further medical help for pain relief and had inadequate information at discharge to effectively self-manage their postoperative knee pain.

Sleep, blood pressure and obesity in 22,389 New Zealanders.

AIM: To determine the relationship of sleep disorders with blood pressure and obesity in a large, relatively healthy, community-based cohort. METHODS: A cross-sectional study was undertaken using data from 22,389 volunteer blood donors in New Zealand aged 16-84 years. Height, weight, neck circumference and blood pressure were measured directly, and data on sleep and other factors were ascertained using a validated self-administered questionnaire. RESULTS: Even in a relatively young, non-clinical cohort, lack of sleep (34%), snoring (33%), high blood pressure (20%) and obesity (19%) are common. After adjusting for relevant confounders, participants at high risk of sleep apnoea had double the odds of having high blood pressure but only in participants over 40 years. Very low and high quantities of sleep are also associated with high blood pressure. Even after controlling for neck circumference, self-reported sleep apnoea, sleep dissatisfaction and low amounts of sleep are associated with a higher body mass index. CONCLUSIONS: Obesity and hypertension have significant associations with a variety of sleep disorders, even in those less than 40 years of age and after adjusting for a wide range of potential confounders.