{"doi":"10.1093/sleep/zsab138","title":"Poor sleep behavior burden and risk of COVID-19 mortality and hospitalization","abstract":"Dear Editor, Despite the unprecedented efforts in vaccinations, the COVID-19 pandemic will likely continue to affect those most vulnerable [1], and the need to identify modifiable risk factors remains [2]. Poor sleep behavior traits have been linked to multisystemic disruptions [3], but whether this is linked to COVID-19 severity remains unknown. Using, the UK Biobank, a population-based cohort of >500 000 participants recruited between 2006 and 2010 [4], we determined the associations of poor sleep behavior burden with mortality, and need for hospitalization after a positive COVID-19 result. This study was restricted to 46 535 participants tested between March and December 2020 (age: 69.4 ± 8.3 years [mean ± standard deviation]; female: 53.3%). Sleep behavior traits (duration, daytime sleepiness, insomnia, and chronotype) were assessed between 2006 and 2010. Scores of 0 (if sleep duration between 6 and 9 h, “never/rarely” daytime sleepiness/insomnia, or non-evening chronotype), 1 (if short <6 h, or long sleeper >9 h, “sometimes” experience daytime sleepiness/insomnia, or evening chronotype), and 2 (if “often/all the time” experience daytime sleepiness, or “usually” have insomnia) were assigned, and summed to obtain a sleep behavior score ranging from 0 to 6, where higher scores are indicative of multiple domains of poor sleep behavior traits. We used this to classify poor sleep behavior burden as follows: “none” (0), “mild” (1), “moderate” (2–3), and “significant” (4–6). 8422 participants tested positive (COVID+), defined as the earliest result from PCR tests, provided by Public Health England. If tested but never positive (COVID−; n = 38 113), the earliest test date was used. Primary outcome was 30-day mortality, matched to death registry dates. The interaction effect between sleep behavior burden and COVID positivity/negativity on mortality was also tested. Finally, hospitalization within 7 days of a positive test was extracted by matching dates with hospital admission data (7146 positive cases available). We included test results that were reported up to 4 days after death or hospitalization, per the UK Biobank’s guidance over testing-to-result time frames; thus, we excluded 11 participants with a date of death and/or hospitalization more than 4 days before test results were released. Logistic regression models were used to determine the associations of sleep with binary COVID-19 outcomes (dead/alive, and separately, hospitalized/not). The primary model (A) was adjusted for age, sex, education, and ethnicity. We further adjusted for lifestyle factors including Townsend deprivation index (TDI), physical activity level, body mass index (BMI), alcohol, and smoking (model B), and comorbidities including presence/absence of cardiovascular risks/disease (CVD; hypertension, high cholesterol, diabetes, and ischemic heart disease), cancer, chronic obstructive pulmonary disease (COPD), and sleep apnea (model C). For mortality models, an interaction term between poor sleep behavior burden and COVID+/− groups was included. Statistical tests were two-sided and significance was defined as alpha <0.05). Cases of 30-day mortality were 499 (5.9%) and 670 (1.8%), respectively, in COVID+ and COVID− groups. In COVID+ participants, moderate (odds ratio [OR] = 1.50, 95% confidence interval [CI]: 1.09–2.07, p = 0.013) and significant (OR = 2.31, 95% CI: 1.47–3.63, p = 0.0003) poor sleep burdens were associated with increased mortality. The association was specific to COVID+ participants compared to COVID− patients (p for interaction <0.001; Figure 1). After adjusting for demographics and risk factors (socioeconomic status, physical activity, BMI, alcohol, and smoking), the significant burden group still saw an almost doubled mortality risk (OR 1.93, 95% CI: 1.22–3.06, p = 0.005), while the moderate group was borderline associated (OR 1.34, 95% CI: 0.97–1.86, p = 0.079). In the fully adjusted model C, the significant burden group remained signifi","journal":"SLEEP","year":2021,"id":167364,"datarank":0.0,"base_score":0.0,"endowment":0.0,"self_citation_contribution":0.0,"citation_network_contribution":0.0,"self_endowment_contribution":0.0,"citer_contribution":0.0,"corpus_percentile":null,"corpus_rank":null,"citation_count":32,"citer_count":0,"citers_with_citation_signal":0,"citers_with_endowment":0,"datacite_reuse_total":0,"is_dataset":false,"is_dataset_confidence":0.7366,"is_data_producer":false,"deposit_databanks":null,"is_oa":true,"file_count":0,"downloads":0,"has_version_chain":false,"published_date":"2021-01-01","fair_score":null,"fair_percentile":null,"algorithm_id":"datarank_citation_only_1hop_v6","ranking_scope":"data_only","authors":[{"id":694274,"name":"Xi Zheng","orcid":"0009-0001-9847-7063","position":1,"is_corresponding":false},{"id":667066,"name":"Ma Cherrysse Ulsa","orcid":null,"position":2,"is_corresponding":false},{"id":694275,"name":"Hui‐Wen Yang","orcid":"0000-0002-6847-3272","position":3,"is_corresponding":false},{"id":249994,"name":"Frank A. J. L. Scheer","orcid":"0000-0002-2014-7582","position":4,"is_corresponding":false},{"id":17006,"name":"Martin K Rutter","orcid":"0000-0001-6380-539X","position":5,"is_corresponding":false},{"id":396849,"name":"Kun Hu","orcid":"0000-0003-0350-3132","position":6,"is_corresponding":false},{"id":582193,"name":"Lei Gao","orcid":"0000-0003-1476-1460","position":7,"is_corresponding":false},{"id":396850,"name":"Peng Li","orcid":"0000-0002-4684-4909","position":0,"is_corresponding":true}],"reference_count":11,"raw_metadata":null,"created_at":"2026-07-18T23:45:54.042727Z","pmid":"34142713","pmcid":null,"fwci":null,"citation_percentile":null,"influential_citations":0,"oa_status":null,"license":null,"views":0,"total_file_size_bytes":0,"version_count":0,"fair_f":null,"fair_a":null,"fair_i":null,"fair_r":null,"fair_zscore":null,"fair_rationale":null,"fair_model":null,"fair_agent_version":null,"fair_fulltext_source":null,"fair_has_llm":null,"fair_computed_at":null,"clinical_trials":[],"software_tools":[],"db_accessions":[],"linked_datasets":[],"topics":[]}