Is Being a Night Owl Unhealthy? CRC Screening Not Recommended Enough

— Also in TTHealthWatch: CVD death and obesity


TTHealthWatch is a weekly podcast from Texas Tech. In it, Elizabeth Tracey, director of electronic media for Johns Hopkins Medicine in Baltimore, and Rick Lange, MD, president of the Texas Tech University Health Sciences Center in El Paso, look at the top medical stories of the week.

This week's topics include colorectal cancer (CRC) screening recommendations, whether being a "night owl" is bad for your health, human papillomavirus (HPV) infection in men, and cardiovascular disease death and obesity in the last decade.

Program notes:

0:42 Chronotype and health

1:42 Included lifestyle factors

2:42 Circadian misalignment

3:20 Colorectal cancer screening recommendations

4:20 Just less than 27% had been recommended

5:20 Just so busy?

6:28 Obesity and cardiovascular deaths

7:30 Heart attacks often

8:11 Prevalence of HPV in men worldwide

9:15 45,000 men represented

10:15 Prevention with vaccination

11:20 End


Elizabeth: Who is getting recommended to get colorectal cancer screening?

Rick: Is being a night owl good for your health?

Elizabeth: What's the rate of human papillomavirus infection in men?

Rick: What's happened to obesity-related cardiovascular deaths in the last decade?

Elizabeth: That's what we're talking about this week on TTHealthWatch, your weekly look at the medical headlines from Texas Tech University Health Sciences Center in El Paso. I'm Elizabeth Tracey, a Baltimore-based medical journalist.

Rick: I'm Rick Lange, president of Texas Tech University Health Sciences Center in El Paso, where I'm also dean of the Paul L. Foster School of Medicine.

Elizabeth: Rick, since it's so super early for you, I'm going to ask you to turn first to Annals of Internal Medicine, this look at chronotype and, gosh, how does that impact on your health.

Rick: Many of our listeners may not be familiar with that word "chronotype." It's also what's known as the circadian preference. That's when people like to be night owls. They go to bed later at night. We're talking like about 3:00 am. They like to get up later in the day around noon and then they feel most energetic about 10:00 pm, when frankly you and I are ready to wind things down. The question is, how does that impact individuals' health?

There has been some concern that it increases the risk of metabolic disorder. These investigators looked at the Nurses' Health Study II, that was almost 64,000 nurses, ages 45 to 62 years old, and had no history of cancer or cardiovascular disease or diabetes. They enrolled them in 2009 and they followed them to 2017.

They looked at not only their chronotype -- were they night owls or regular daytime individuals -- but they looked at their lifestyle behaviors as well. Things like diet quality, their physical activity, their alcohol intake, their BMI [body mass index], whether they smoked or not, and what their sleeping patterns were like.

What they were trying to assess was is being a night owl associated with the incidence of diabetes. Night owls were 54% more likely to have an unhealthy lifestyle behavior. They were about 72% more likely to develop diabetes. Now, you might take a step back and say, "Wait a minute. You told me they have unhealthy lifestyles, so of course they're predisposed to diabetes." Even if you adjusted for all of those, it still appeared that there was a 20% increased risk of diabetes in being a night owl, evening chronotype.

Elizabeth: It's unclear to me because we have lots and lots of discussion, of course, about, for example, adolescents and how they do have a frank predilection for staying up later and for sleeping later. Societally, we've discussed trying to accommodate that particular proclivity by moving school time. I'm really interested in the antecedents of this behavior.

Rick: You bring up some good points. One is this is a partially genetically determined construct. The other thing I'm going to talk about is circadian misalignment.

When you look at these night owls, there are two groups. There is some who work at night and some who work during the day. It seems like this increased risk of diabetes was limited to those that work during the day -- i.e., their proclivity was to be night owls. What we did is we forced them to work during the day and the increased risk wasn't seen in those that had longtime night jobs.

Where do we go from here? One of the things we need is to confirm this in other studies, because this was just middle-aged women. What's the underlying cause of this? By improving lifestyles, do we actually reduce the risk? I'm going to call this foundational, and we need to build upon it.

Elizabeth: Let's remain in Annals of Internal Medicine and look at this issue of colorectal cancer screening. A couple of daunting statistics in here. Colorectal cancer is the second leading cause of cancer death in the United States. Colorectal cancer rates are increasing among younger adults. Recently, the recommendations for screening have been modified in a downward direction.

This study identifies that 1 in 3 U.S. adults are overdue for colorectal cancer screening. What they tried to do was say, "Well, all right, has your physician told you that you need to have colorectal cancer screening?" This analysis included adults who were overdue for screening who reported having had a wellness visit in the past year. They asked them, "Did your physician tell you that you needed to have this screening?"

There were over 5,000 adults who were eligible and overdue for the screening and who had had a wellness visit in the past year. Only just shy of 27% of these folks reported receiving a clinician recommendation for screening. This was a range that was represented from less than 10% for adults without a usual source of care to about a third (32%) who have a family income above 400% of the federal poverty level. Clearly, there is both an income and a racial disparity with regard to recommendations.

Rick: Why this is so incredibly important? As you mentioned, colorectal cancer is the second leading cause of cancer-related death in the United States, but it can be prevented by doing colonoscopy and removing polyps that become cancerous or detected at a very early stage when it's most treatable.

I was in the clinic yesterday, and even though I'm a cardiologist, as a part of what I do I make sure people have the routine vaccines and their routine cancer screening, regardless whether it's ... mammography for women, or colorectal cancer screening for both men and women. I was surprised. I think we need to dig down and figure out what it is. Are they just so busy they just don't have time to do it? Are they just so involved with the acute needs -- let's say they have a heart failure or pneumonia or other things -- that they're focused there? But knowing that 1 in 3 individuals in the United States is overdue for colorectal cancer screening, this really needs to be addressed.

Elizabeth: It's no longer just colonoscopy. There are multiple screening methods that are available, and the fecal tests are really very easy. People don't even have to leave their own homes in order to have that done.

I would tell you that I just saw something recently about if primary care physicians employed every single recommendation that's out there regarding screening and different assessments, they would see a single person every day. It would take that long, so there is clearly something we need to do about being able to automate that process.

Rick: I think you're right -- automated reminders to the physician and the patients. The thing that most determines whether a patient has colorectal cancer screening is a recommendation from the physician of all things.

Elizabeth: Let us move on to the Journal of the American Heart Association.

Rick: Elizabeth, we're going to talk about obesity in the United States between 2017 and 2020. The prevalence of obesity is about 42%. It's an almost 10% increase from the preceding decade. We have been focused over the last several decades on reducing cardiovascular death. Over decades, we've seen actually cardiovascular mortality decreasing. Now, however, we have obesity becoming more prevalent. What these investigators did was they asked has that actually affected obesity-related cardiovascular death.

They used a multiple cause of death database to identify individuals that had primary cardiovascular death and obesity recorded as a contributing cause of death. What they discovered is from 1999 to 2020 there has been a threefold increase in incidence of cardiovascular mortality related to diabetes.

Not surprisingly, there are some disparities. For example, Black individuals had the highest incidence. If you look at American Indians and Native Alaskans, they had a 415% increase ischemia-related. That's usually heart attacks or things of that nature. Secondly is hypertensive heart disease. Across the board, it more commonly affects men than women, except in the African American population, where Black women have some of the highest incidences of obesity-related cardiovascular mortality among all the groups.

Elizabeth: Pointing to a need for targeted interventions that are very sensitive and tuned into what's going to be operational for those populations.

Rick: Absolutely. It's really disappointing that we've done so well on the other fronts with reducing cardiovascular disease to have something like this, which is preventable and/or treatable. I agree with you -- we really need dedicated health strategies aimed at each of these individual communities.

Elizabeth: Finally, let's turn to The Lancet. This is a look at the prevalence of human papillomavirus, and now I'm going to call it HPV, among men worldwide.

We know that certain serotypes of the HPV virus are really important in cervical cancer deaths among women worldwide and less frequently here in the U.S. because of regular screening. We also know that this is preventable, and it's preventable with a vaccine. We have seen declining cervical cancer rates and I would also point out some of the history that even a single vaccine, although the scheduled dosage requires two of them, does result in a reduction in cervical cancer rates. All of that as background, what about men?

This study then is a systematic review and meta-analysis looking at the prevalence of genital HPV infection in men, and it is worldwide. They searched the literature from 1995 to 2022 and found a relative paucity of studies, I would say 65 studies, with just shy of 45,000 men included from 35 countries. The pooled prevalence of HPV positivity was 31%. It was 21% among those 18 to 24 years of age for high-risk HPV infections. Interestingly, these pooled prevalence estimates were similar all across the world except for Eastern and Southeastern Asia.

Rick: This particular study excluded people that were considered to be at high risk for HPV -- men who have sex with men, or sex workers. This is just the general population, and to think that 1 in 3 individuals is infected with HPV, I was really surprised by this.

You mentioned the prevalence in women I call the late teens and early 20s, but it starts as early as age 12 or 13. You mentioned its relationship to cervical cancer, but our listeners need to be reminded that 70% of oral pharyngeal cancers are now due to HPV. We have ways of preventing this -- HPV vaccinations not only to women but to young boys as well.

Elizabeth: Yeah, domestically, of course, we have extended it to young boys. Essentially, it's a cancer preventative, not any genuflection to, "Hey, you're going to be sexually active and we're going to help protect you." It's really let's protect you from cancer.

Rick: I couldn't have said that any better. Thirty years ago if you said, "Gosh, we have a vaccine that could prevent cancer, would you be interested?" -- the answer is yes. Unfortunately, we're oftentimes embroiled into the fact that there are certain high-risk populations in men that have sex with men, HIV status, sex workers. But, again, in the general population at large almost one-third of individuals have been HPV-infected, and we can prevent cancer related to that with these vaccinations.

Elizabeth: This is a great public health message. We'll end with that. That's a look at this week's medical headlines from Texas Tech. I'm Elizabeth Tracey.

Rick: I'm Rick Lange. Y'all listen up and make healthy choices.