Cited by 345Sleep and related disordersPhysical Activity and HealthCircadian rhythm and melatonin

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Sleep and physical activity in relation to all-cause, cardiovascular disease and cancer mortality risk

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Huang, Bo-Huei, Duncan, Mitch J, Cistulli, Peter A, Nassar, Natasha, Hamer, Mark, Stamatakis, Emmanuel·2022·British Journal of Sports Medicine

DOI 10.1136/bjsports-2021-104046

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Abstract

OBJECTIVES: Although both physical inactivity and poor sleep are deleteriously associated with mortality, the joint effects of these two behaviours remain unknown. This study aimed to investigate the joint association of physical activity (PA) and sleep with all-cause and cause-specific mortality risks. METHODS: 380 055 participants aged 55.9 (8.1) years (55% women) from the UK Biobank were included. Baseline PA levels were categorised as high, medium, low and no moderate-to-vigorous PA (MVPA) based on current public health guidelines. We categorised sleep into healthy, intermediate and poor with an established composited sleep score of chronotype, sleep duration, insomnia, snoring and daytime sleepiness. We derived 12 PA-sleep combinations, accordingly. Mortality risks were ascertained to May 2020 for all-cause, total cardiovascular disease (CVD), CVD subtypes (coronary heart disease, haemorrhagic stroke, ischaemic stroke), as well as total cancer and lung cancer. RESULTS: After an average follow-up of 11.1 years, sleep scores showed dose-response associations with all-cause, total CVD and ischaemic stroke mortality. Compared with high PA-healthy sleep group (reference), the no MVPA-poor sleep group had the highest mortality risks for all-cause (HR (95% CIs), (1.57 (1.35 to 1.82)), total CVD (1.67 (1.27 to 2.19)), total cancer (1.45 (1.18 to 1.77)) and lung cancer (1.91 (1.30 to 2.81))). The deleterious associations of poor sleep with all outcomes, except for stroke, was amplified with lower PA. CONCLUSION: The detrimental associations of poor sleep with all-cause and cause-specific mortality risks are exacerbated by low PA, suggesting likely synergistic effects. Our study supports the need to target both behaviours in research and clinical practice.

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“As an emerging lifestyle, the increased risk of cardiovascular death from inadequate sleep duration has been demonstrated in multiple cohorts [29,30], and maintaining a healthy sleep duration reduced the risk of all-cause mortality from NAFLD by 36%.”
Background
Association of Sleep Duration with Risk of All-Cause and Cause-Specific Mortality Among American Adults: A Population-Based Cohort Study
Gu, J., Wu, H., Diao, W., Ji, Y., Li, J., & Huo, J. (2024) · Nature and Science of Sleep · doi:10.2147/nss.s469638 · Cited by 14
Distinct sleep disturbance and cognitive dysfunction profiles in oncology outpatients receiving chemotherapy
Huang, V., Mackin, L. A., Kober, K. M., Paul, S. M., Cooper, B. A., Conley, Y. P., Hammer, M. J., Levine, J. D., & Miaskowski, C. A. (2022) · Supportive Care in Cancer · doi:10.1007/s00520-022-07350-6 · Cited by 14
Diurnal patterns of accelerometer-measured physical activity and sleep and risk of all-cause mortality: a follow-up of the National Health and Nutrition Examination Surveys (NHANES)
Zhang, Y., Mika Kivimaki, B., Carrillo-Larco, R. M., Cheng, Y., Zhou, Y., Wang, H., Yuan, C., & Xu, X. (2024) · International Journal of Behavioral Nutrition and Physical Activity · doi:10.1186/s12966-024-01673-9 · Cited by 15
“The observed joint associations of PA and sleep with cognitive decline and all-cause, CVD and cancer mortality [21, 22] support this hypothesis.”
Background
Interactive Associations between Physical Activity and Sleep Duration in Relation to Adolescent Academic Achievement
Brown, D. M. Y., Porter, C. D., Hamilton, F., Almanza, F., Narvid, C., Pish, M., & Arizabalo, D. (2022) · International Journal of Environmental Research and Public Health · doi:10.3390/ijerph192315604 · Cited by 16
“We hypothesized that we would observe: (1) a positive linear relationship between physical activity and academic achievement [29]; (2) an inverted-U relationship between sleep and academic achievement with optimal grades occurring at the public health recommended range of 8–10 h of sleep each night [30]; and (3) based…”
Background
Reduced left hippocampal perfusion is associated with insomnia in patients with cerebral small vessel disease
Yan, W., Hou, D., Li, Z., Tang, W., Han, X., & Tang, Y. (2023) · CNS Spectrums · doi:10.1017/s1092852923002250 · Cited by 13
Hypoxia Induces Alterations in the Circadian Rhythm in Patients with Chronic Respiratory Diseases
Castillejos-López, M. D. J., Romero, Y., Varela-Ordoñez, A., Flores‐Soto, E., Romero-Martínez, B. S., Velázquez‐Cruz, R., Vázquez-Pérez, J. A., Ruiz, V., Gómez-Verján, J. C., Rivero-Segura, N. A., et al. (2023) · Cells · doi:10.3390/cells12232724 · Cited by 13
Health and Economic Value of Eliminating Socioeconomic Disparities in US Youth Physical Activity
Powell‐Wiley, T. M., Martinez, M. F., Heneghan, J. L., Weatherwax, C., Baah, F. O., Velmurugan, K., Chin, K. L., Ayers, C. R., Cintron, M., Ortiz-Whittingham, L. R., et al. (2024) · JAMA Health Forum · doi:10.1001/jamahealthforum.2024.0088 · Cited by 13
Traumatic brain injury persistently increases the incidence of both ischemic and hemorrhagic strokes: Potential mechanisms
Barbour, M. A., Whitehead, B. J., Gumbo, C. T., Karelina, K., & Weil, Z. M. (2025) · Progress in Neurobiology · doi:10.1016/j.pneurobio.2025.102749 · Cited by 12
Effects of different Chinese traditional exercises on sleep quality and mental health of adults: systematic review and meta-analysis
Dong, J., Wang, D., Li, H., & Ni, H. (2023) · Sleep And Breathing · doi:10.1007/s11325-023-02881-6 · Cited by 12
Sleep, physical activity, and sedentary behaviors in relation to overall cancer and site-specific cancer risk: A prospective cohort study
Zhang, R., Lu, Y., Bian, Z., Zhou, S., Xu, L., Jiang, F., Yuan, S., Tan, X., Chen, X., Ding, Y., et al. (2024) · iScience · doi:10.1016/j.isci.2024.109931 · Cited by 12
Validation of intrinsic capacity and healthy sleep pattern in middle-aged and older adults: a longitudinal Chinese study assessing healthy ageing
Chen, X.-L., Li, J., Sun, S., Zhang, X., Chen, J., Wang, L., Yang, Z.-Q., Ni, S.-H., & Lu, L. (2024) · The journal of nutrition health & aging · doi:10.1016/j.jnha.2024.100365 · Cited by 14
Intranasal Dexmedetomidine for the Management of Preoperative Anxiety-Related Insomnia: A Randomized, Three-Blinded, Clinical Trial Compared with Lorazepam and Placebo
Yang, W., Huang, K.-T., Lin, Z.-J., Zeng, W., Liu, X., Liu, H.-B., Zhong, M., Wei, J., Liang, W., Wang, L.-F., et al. (2024) · Drug Design Development and Therapy · doi:10.2147/dddt.s487463 · Cited by 15
Development and validation of a novel screening tool for osteoporosis in older US adults: The NHANES cross-sectional study
Tang, Y., Liu, Z., Wang, S., Yi, Q., Xia, Y., & Geng, B. (2022) · Endocrine · doi:10.1007/s12020-022-03001-2 · Cited by 12
“Twelve candidate predictors selected included: age (continuity variable; years); sex (categorical variable; male or female); race (categorical variable; Mexican American, other Hispanic, non-Hispanic white, non-Hispanic black, or other races); body mass index (BMI; categorical variable; normal: <25 kg/m2, overweight:…”
Method
Physical, Mental, and Health Empowerment Disparities Across Chronic Obstructive Pulmonary Disease, Asthma, and Combined Groups and the Moderating Role of eHealth Literacy: Cross-Sectional Study
Li, J., Wu, X., Wu, Y., Fong, D., Song, Y., Xu, S., Kim, C., Lin, X., & Pandian, V. (2025) · Journal of Medical Internet Research · doi:10.2196/70822 · Cited by 11
“For each activity level, METs were multiplied by the average daily duration and the number of days per week, and total weekly MET minutes were calculated [29].”
Associations Among Sleep Duration, Sleep Quality, and Age-Related Ocular Diseases: Insights From Longitudinal and Mediation Analyses
Huang, Z., Chen, C., Meng, J., Liu, S., Zhang, K., Du, Y., & Zhu, X. (2025) · Investigative Ophthalmology & Visual Science · doi:10.1167/iovs.66.11.15 · Cited by 11
Relationship between diet-related inflammation and bone health under different levels of body mass index
Zeng, G., Chen, X., Jiang, Z., Lin, J., Wu, Y., & Wei, J. (2023) · Journal of Orthopaedic Surgery and Research · doi:10.1186/s13018-022-03481-y · Cited by 11
“PA < 600 METmins/week was defined as low, 600-1200MET-mins/ week as medium and ≥ 1200 MET-mins/week as high [29].”
Background
Rest–activity rhythm as a clinical biomarker: what are the next steps?
Brito, L. C., & Thosar, S. S. (2023) · The Lancet Healthy Longevity · doi:10.1016/s2666-7568(23)00065-x · Cited by 11
“9 Despite its potential for widespread use and its importance for clinical practice and public health, the development of rest–activity rhythm amplitude as a clinical biomarker is still in the early stages.”
Background
Associations of sleep disorders with all-cause and cause-specific mortality in cancer survivors: a cross-sectional analysis of the NHANES 2005–2016
Nong, J., Tong, J., Wang, R., Shi, K., & Zhang, Y. (2024) · BMC Psychiatry · doi:10.1186/s12888-024-05589-3 · Cited by 11
“For the general population, a study of 380,055 general participants from the UK Biobank demonstrated that poor sleep was associated with increased risk for total cancer mortality [9].”
Background
Association of methyl donor nutrients dietary intake and sleep disorders in the elderly revealed by the intestinal microbiome
Chen, Q., Fan, R., Song, L., Wang, S., You, M., Cai, M., Wu, Y., Li, Y., & Xu, M. (2024) · Food & Function · doi:10.1039/d4fo01303d · Cited by 12
Depressive symptoms mediate the association between dietary inflammatory index and sleep: A cross-sectional study of NHANES 2005–2014
Ren, R., Huang, R., Li, Y., Wang, W., Ye, X., Li, X., Zhang, R., Peng, Y., & Wang, D. (2024) · Journal of Affective Disorders · doi:10.1016/j.jad.2024.12.020 · Cited by 11
Association between physical activity, trouble sleeping, and obesity among older Americans: a cross-sectional study based on NHANES data from 2007 to 2018
Hou, X., Wang, H.-H., Yang, Z., Jia, Y., Lv, Y., & Dong, X. (2025) · BMC Geriatrics · doi:10.1186/s12877-025-05832-w · Cited by 12
“Total weekly energy expenditure was calculated by multiplying the MET value by the number of PA minutes per week (MET-minutes/week) [45].”
Self-Reported Sleep Disturbance is an Independent Predictor of All-Cause Mortality and Respiratory Disease Mortality in US Adults: A Population-Based Prospective Cohort Study
Hou, X., Hu, J., Wang, E., Wang, J., Song, Z., Hu, J. H., Shi, J., & Zhang, C. (2023) · International Journal of Public Health · doi:10.3389/ijph.2023.1605538 · Cited by 12
Causal associations of sleep traits with cancer incidence and mortality
Tian, S., Huangfu, L., Bao, Y., Ai, S., Chang, S., Wang, Q., Zhu, X., Yan, W., Shi, J., Shi, L., et al. (2023) · Frontiers in Genetics · doi:10.3389/fgene.2023.1309069 · Cited by 11
Age Differences in the Association of Sleep Duration Trajectory With Cancer Risk and Cancer-Specific Mortality: Prospective Cohort Study
Liu, C., Zhang, Q., Liu, C., Liu, T., Song, M., Zhang, Q., Xie, H., Lin, S., Ren, J., Chen, Y., et al. (2024) · JMIR Public Health and Surveillance · doi:10.2196/50836 · Cited by 12
“For subgroup analysis, previously reported potential modifiers, such as snoring, sex [19], BMI [20], and regular physical exercise [21], were selected.”
Post-Operative Poor Sleep Quality and Its Associated Factors Among Non-Small Cell Lung Cancer Patients: A Cross-Sectional Study
Chen, X., Hu, Y., Fan, J., & Li, Y. (2023) · Cancer Management and Research · doi:10.2147/cmar.s430436 · Cited by 14
“42 Therefore, an accurate assessment of factors leading to poor post-operative sleep quality is crucial for risk stratification and planning of post-operative care of NSCLC patients.”
Background
The association between physical activity and sleep in adult ADHD patients with stimulant medication use
Zhu, F., Liu, B., Kuang, D., Zhu, X., Bi, X., Song, Y., Quan, T., Yang, Y., & Ren, Y. (2023) · Frontiers in Psychiatry · doi:10.3389/fpsyt.2023.1236636 · Cited by 11
Association between healthy lifestyle on life course and multimorbidity in adults: results from two national prospective cohort studies
Ye, X., Liang, M., Chen, Z., Jiang, X., Xie, M., Xie, X., Lan, G., Lu, X., Huang, Z., Xu, T., et al. (2024) · BMC Public Health · doi:10.1186/s12889-024-20443-7 · Cited by 13
“Low PA exacerbated the harmful association of sleep deprivation with the risk of all-cause and cause-specific mortality [31].”
Background
Combined healthy lifestyle behaviors and all-cause mortality risk in middle-aged and older US adults: A longitudinal cohort study
Qiao, L., Wang, Y., Deng, Y., Peng, J., Li, Y., Li, M., & Tang, Z. (2024) · Archives of Gerontology and Geriatrics · doi:10.1016/j.archger.2024.105702 · Cited by 10
A Closer Look at Paediatric Sleep: Sleep Health and Sleep Behavioural Disorders in Children and Adolescents
Meneo, D., Gavriloff, D., Cerolini, S., Baldi, E., Schlarb, A. A., Nobili, L., & Baglioni, C. (2025) · Journal of Sleep Research · doi:10.1111/jsr.70078 · Cited by 14
“…between poor sleep health and disordered eating behaviours (e.g., Cerolini 2023; da Luz et al. 2023; Degasperi et al. 2024), (e) studies documenting the relationship between sleep duration or eating patterns and physical activity/sedentary activity (e.g., Huang et al. 2022; Keane et al. 2017).”
Physical activity and sleep moderate the relationship between stress and screen time in college-aged adults
Chandler, M. C., Ellison, O. K., McGowan, A. L., Fenn, K. M., & Pontifex, M. B. (2022) · Journal of American College Health · doi:10.1080/07448481.2022.2077110 · Cited by 13
Association Between Bedroom Light Pollution With Subjectively and Objectively Measured Sleep Parameters Among Chinese Young Adults
Xu, Y.-X., Huang, Y., Zhou, Y., Wan, Y., Su, P., Tao, F., & Sun, Y. (2023) · Journal of Adolescent Health · doi:10.1016/j.jadohealth.2023.08.010 · Cited by 11
Physical Activity, Sleep, and Risk of Late-Onset Severe Mental Illness: A Prospective Cohort Study From UK Biobank
Zheng, X., Jiang, M., Ren, X., Han, L., Yang, P., Jia, Y., Sun, L., Wang, R., Shi, M., Zhu, Z., et al. (2024) · Schizophrenia Bulletin · doi:10.1093/schbul/sbae070 · Cited by 9
Influence of Regular Physical Activity on Sleep
McGranahan, M. J., & O’Connor, P. J. (2024) · Current topics in behavioral neurosciences · doi:10.1007/7854_2024_503 · Cited by 11
Interaction between sleep duration and physical activity on mortality among cancer survivors: findings from National Health and Nutrition Examination Surveys 2007–2018
Chen, R., Han, J., Li, S., Deng, H., Jian, T., Huang, Z., Wei, Y., & Fu, Z. (2025) · Frontiers in Public Health · doi:10.3389/fpubh.2025.1532320 · Cited by 9
Sleep duration and quality, physical activity and cardiometabolic multimorbidity: findings from the English Longitudinal study of Ageing
Kunutsor, S. K., & Laukkanen, J. A. (2025) · Scandinavian Cardiovascular Journal · doi:10.1080/14017431.2025.2550279 · Cited by 9
“Emerging evidence suggests that physical activity may mitigate the adverse effects of common cardiovascular risk factors, including poor sleep patterns [20].”
Physical activity and sleep quality among Chinese college students: the serial mediating roles of anxiety and depression
Zhang, Z., Liu, Z., Lin, Y., Guo, M., Xu, X., & Peng, L. H. (2025) · Frontiers in Psychology · doi:10.3389/fpsyg.2025.1635406 · Cited by 13
Combined variations in sleep, physical activity, and nutrition and the risk of major adverse cardiovascular events
Koemel, N. A., Biswas, R. K., Simpson, S., Rezende, L. F. M., Wang, T., Bauman, A. E., Raubenheimer, D., Allman-Farinelli, M. A., Cistulli, P. A., Ahmadi, M. N., et al. (2026) · European Journal of Preventive Cardiology · doi:10.1093/eurjpc/zwag141 · Cited by 10
Association of baseline Life’s Essential 8 score and trajectories with carotid intima-media thickness
Liu, Q., Cui, H., Chen, S., Zhang, D., Huang, W. C., & Wu, S. (2023) · Frontiers in Endocrinology · doi:10.3389/fendo.2023.1186880 · Cited by 11
“Due to the role of sleep health in cardiometabolic health and health outcomes, sleep health was added as a new component of LE8 (26, 27).”
Background
The Causal Association Between Blood Lead and Sleep Disorders: Evidence from National Health and Nutrition Examination Survey and Mendelian Randomization Analysis
Chen, S., Zhang, M., Zhang, W., Shao, X., Yang, X., Yang, Z. G., & Nan, K. (2024) · Journal of Epidemiology and Global Health · doi:10.1007/s44197-024-00199-4 · Cited by 9
“Nonetheless, poor sleep has become a worldwide public health issue in today’s society [3–5].”
Background
Night shift work, genetic risk, and the risk of depression: A prospective cohort study
Chen, Y., Yang, H., Zhang, Y., Zhou, L., Lin, J., & Wang, Y. (2024) · Journal of Affective Disorders · doi:10.1016/j.jad.2024.03.134 · Cited by 10
Associations of light exposure patterns with sleep among Dutch children: The ABCD cohort study
Stefanopoulou, M., Ruhé, N., Portengen, L., van Wel, L., Vrijkotte, T. G. M., Vermeulen, R. C. H., & Huss, A. (2024) · Journal of Sleep Research · doi:10.1111/jsr.14184 · Cited by 8
“Sleep problems have been associated with, for example, obesity (Mercy et al., 2022), cardiovascular disease (Huang et al., 2022), cancer (Peeri et al., 2022), and depressive or anxiety symptoms (Joo et al., 2022; Oakes et al., 2022).”
Sleep duration and leisure activities are involved in regulating the association of depressive symptoms, muscle strength, physical function and mild cognitive impairment
Chen, L., Li, D., Tang, K., Li, Z., & Huang, X. (2024) · Heliyon · doi:10.1016/j.heliyon.2024.e33832 · Cited by 8
Joint association of sleep quality and physical activity with metabolic dysfunction-associated fatty liver disease: a population-based cross-sectional study in Western China
Wang, Y., Zhao, Q., Yang, J., Wang, Y., Deng, L., Hamulati, X., Gulijiehere, T., Mutalifu, M., Liu, F., Li, X., et al. (2024) · Nutrition and Diabetes · doi:10.1038/s41387-024-00312-3 · Cited by 8
Examining the factor structure of the Pittsburgh Sleep Quality Index and its determinants among GI cancer patients
Sohrabi, M., Gholami, A., Hassanzadeh, P., Hatami, S., Ajdarkosh, H., Zamani, F., & Doustmohammadian, A. (2024) · BMC Cancer · doi:10.1186/s12885-024-13347-7 · Cited by 8
Multidimensional sleep impairment predicts steatotic liver disease spectrum risk
Wang, D., Zhang, X. L., Cai, Y., Dong, H., & Zhang, Y. (2025) · Scientific Reports · doi:10.1038/s41598-025-95336-9 · Cited by 8
Sleep deprivation-induced sympathetic activation promotes pro-tumoral macrophage phenotype via the ADRB2/KLF4 pathway to facilitate NSCLC metastasis
Yin, S., Wang, J., Jia, Y., Wang, X., Zhao, Y., Liu, T., Lv, W., Duan, Y., Song, Z., Wang, S., et al. (2025) · iScience · doi:10.1016/j.isci.2025.112321 · Cited by 8

Authors: Huang, B.-H., Duncan, M. J., Cistulli, P. A., Nassar, N., Hamer, M., & Stamatakis, E.
Affiliations: The University of Sydney (AU)
University of Newcastle Australia (AU)
University College London (GB)
Corresponding author: Stamatakis, Emmanuel
ORCID: Huang, Bo-Huei
Duncan, Mitch J
Cistulli, Peter A
Nassar, Natasha
Hamer, Mark
Stamatakis, Emmanuel
Venue: British Journal of Sports Medicine
Publisher: BMJ
Published: 2021-06-29
Volume: 56
Issue: 13
Pages: 718-724
ISSN: 0306-3674 (ISSN-L)
1473-0480
DOI: 10.1136/bjsports-2021-104046
OpenAlex: W3173761420
Cited by: 345
References: 33
Citations by year: 2026: 57 · 2025: 111 · 2024: 87 · 2023: 52 · 2022: 36 · 2021: 2
FWCI: 42.77
Type: journal article
Language: en
Open access: hybrid
doi.org
Licence: other-oa
Locations: British Journal of Sports Medicine (publishedVersion, other-oa)
PubMed (publishedVersion)
UCL Discovery (University College London) (submittedVersion)
NOVA (University of Newcastle Australia) (submittedVersion)
Funders: National Health and Medical Research Council (APP1141606, APP1194510)
Topics: Social Sciences › Psychology › Experimental and Cognitive Psychology › Sleep and related disorders
Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Physical Activity and Health
Life Sciences › Neuroscience › Endocrine and Autonomic Systems › Circadian rhythm and melatonin
Keywords: sleep, physical activity, all-cause mortality, cardiovascular mortality, cancer mortality, lung cancer, ischemic stroke, coronary artery disease, hemorrhagic stroke, moderate-to-vigorous physical activity, insomnia, snoring, daytime sleepiness, chronotype, sleep duration, synergistic effect, older adults
MeSH terms: Ischemic Stroke, Cardiovascular Diseases, Brain Ischemia, Female, Humans, Sleep Initiation and Maintenance Disorders, Lung Neoplasms, Male, Prospective Studies, Risk Factors, Sleep, Exercise, Stroke

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Sleep and physical activity in relation to all-cause, cardiovascular disease and cancer mortality risk

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