Background
Recently, many studies have found inverse associations between sleep and both high adiposity [
1‐
6] and type 2 diabetes [
7] in adults. Two aspects of sleep were related to adverse health outcomes: duration and quality. Most of these studies focused on sleep duration. In the United States of America, the National Sleep Foundation recommends between 7 and 9 h of sleep per night for young adults and adults [
8]. However, definitions of short sleep duration vary from one study to another. Among adults, short sleep duration has been associated with overweight and obesity [
6,
9‐
13], either measured in terms of body mass index (BMI) [
1,
3] or waist circumference [
1,
5], and with impaired fasting glucose [
14,
15], prediabetes [
16], and type 2 diabetes [
7,
13,
15,
17].
Other adverse outcomes associated with short sleep duration are earlier mortality, hypertension, cardiovascular, and coronary heart diseases [
13]. The association between mortality and sleep duration occurred when people slept less than 6 h at night [
13]. Short sleep duration has also been linked to obesity in women [
18‐
22]. Maternal short sleep duration (≤5 h per day) in the first year postpartum was associated with higher adiposity at 3 years postpartum [
23], shorter sleep duration during pregnancy was linked to increased risk for gestational hyperglycemia [
24] and very short sleep (≤4 h per night) with gestational diabetes mellitus [
25].
A few studies have assessed sleep quality (i.e., number of awakenings at night or the subjective perception of how one’s sleep is restorative [
26]) and its impact on health. Similar to short sleep duration, poor sleep quality was associated with overweight/obesity [
27,
28], risk of diabetes [
29], prediabetes [
16], and type 2 diabetes [
30‐
32] in adults. Women seemed more at risk for poor sleep [
33] and insomnia [
34] compared to men, and poor sleep was linked with high adiposity in women [
19,
28]. Poor sleep quality was also associated with impaired fasting glucose in women with previous gestational diabetes mellitus [
35]. In the USA, women between the ages of 15 and 44 years (i.e., of childbearing age) were especially at risk for poor sleep when compared with pregnant women of the same age range [
36].
In sum, short and poor sleep are important risk factors for obesity and type 2 diabetes among adults, especially among women [
18,
20,
21]. Women represent an important target for interventions aimed at improving sleep given that they are especially at risk for short [
36] and poor sleep [
33]. Moreover, when women are of childbearing age, an intervention promoting sleep can impact both the woman’s and the child’s health by addressing prenatal predictors of obesity, such as pre-pregnancy BMI [
37]. Pre-pregnancy BMI can also be an independent risk factor for gestational diabetes mellitus [
38]. Therefore, interventions to promote adequate sleep have been advocated to enhance maternal, fetal, and infant health [
39].
Previous reviews of behavioral or non-pharmacological sleep interventions have either focused on underage populations, such as infants [
40,
41] or children [
42‐
44]; older people [
45,
46]; populations with health problems, such as youth with chronic health conditions [
47], children with autism spectrum disorders [
48], hospitalized patients [
49], oncology patients and family caregivers [
50], adults in intensive care units [
51]; or people with sleep disorders, such as apnea [
52‐
54] or insomnia [
55,
56]; or on specific interventions, such as stress reduction [
57].
These reviews included the following types of behavioral sleep interventions: educational interventions (e.g., providing parents information on safe sleep among infants [
40] or on positive routines to favor sleep in their child [
42,
44]), sleep education [
43,
50] or sleep hygiene education [
46,
49], cognitive behavioral therapy [
43,
50,
55,
56] or cognitive therapy [
46], environmental interventions (e.g., reducing environmental noise in aged care facilities [
45]), relaxation [
49,
51,
55,
56] or massage [
51] or aromatherapy [
51] or stress reduction [
57], and exercise [
50] or lifestyle, and dietary interventions [
52,
53].
Some reviews on behavioral sleep interventions conducted among adults have found somewhat conflicting results. For example, one review on the effects of mindfulness-based stress reduction conducted among adults—mostly female patients with chronic diseases, such as cancer and fibromyalgia—found that this technique was associated with statistically significant improvements in sleep quality or duration in studies with a pre-post design [
57]. However, this was no longer the case in randomized controlled trials; there were no significant differences in sleep between the experimental and the control groups [
57]. Some reviews also reported that the use of relaxation techniques—something akin to mindfulness-based stress reduction techniques—can improve sleep quality in hospitalized patients [
49] and in patients in intensive care units [
51]. It is therefore difficult to determine if behavioral interventions, such as relaxation or stress reduction techniques, are effective at improving sleep duration and/or quality; which types of behavioral interventions are the most effective at promoting sleep; and if the results of reviews conducted in adults apply specifically to women.
A search in MEDLINE/PubMed, the Cochrane Library, and PROSPERO on September 27, 2016 confirmed that there was no published systematic review/meta-analysis or published protocol for a systematic review on behavioral interventions to promote adequate sleep among women. This systematic review will fill this gap in the scientific literature by assessing the efficacy or effectiveness of behavioral interventions aimed at promoting adequate sleep among women. The review will answer the following questions:
-
What is the impact of behavioral interventions promoting sleep among women on sleep duration and/or sleep quality?
-
Which components of the interventions are effective at changing sleep duration and/or sleep quality?
-
What biases are present in the peer-reviewed published articles?
-
Do the effects of the interventions vary by the quality of the study or characteristics of the participants?