Sleep Apnea Linked to Poor Aerobic Fitness

Published on November 24, 2014

People with moderate to severe obstructive sleep apnea may have an intrinsic inability to burn high amounts of oxygen during strenuous aerobic exercise, according to a new study led by researchers at University of California, San Diego School of Medicine.

The study, reported in the current issue of Journal of Clinical Sleep Medicine, shows that people with sleep apnea, in which breathing repeatedly starts and stops during slumber, have a lower peak oxygen uptake during aerobic activity than those who do not suffer from the sleep disorder.

People who suffer from apnea are more likely to be obese and thus would be expected to be less fit as well. The researchers, however, found that apnea patients had a reduced aerobic fitness, even compared with those of similar body mass indices.

“Encouraging patients to exercise more is part of the story, but that is not the whole story,” says lead author Jeremy Beitler, MD, assistant clinical professor in pulmonary and critical care medicine, in a release. “We believe the sleep apnea itself causes structural changes in muscle that contributes to their difficulty exercising.”

For the study, researchers performed sleep studies of men and women with a range of apnea symptoms. The sleep studies were performed to clinically evaluate the severity of the patients’ apnea and to screen participants for sleep disorders besides apnea that could confound the study results.

Fifteen men and women with moderate to severe apnea and 19 with mild or no apnea were then asked to pedal a stationary bike at incrementally harder resistance levels–similar to what a person would experience climbing up a progressively steeper hill. The participants were directed to pedal to exhaustion.

From the exercise test results, and previous measurements of participants’ resting metabolic rates, scientists calculated each person’s VO2 max–a measure of the maximum amount of oxygen the person can uptake during strenuous exercise–and its deviance from the expected VO2 max for a person of the same age, gender, and body mass index.

After adjusting for baseline differences, scientists showed that people with sleep apnea had on average a 14% lower VO2 max than control subjects. Furthermore, the number of times a person stopped breathing, for 10 seconds or more, per hour of sleep, could predict 16% of the variability observed in the group’s peak VO2.

“This is a big discrepancy,” Beitler says.

Researchers believe that VO2 max measurements may be an early marker for those who are at higher risk of stroke and heart attack and that VO2 max measurements could motivate early interventions to treat apnea.

Poor sleep tied to inflammation in teens

Notes from Dr. Norman Blumenstock:

Teens who don’t get enough sleep may be at risk for chronic problems later in life from increased inflammation throughout the body, according to a new study.

BY KATHRYN DOYLE

Thu Nov 20, 2014 3:29pm EST

(Reuters Health) – Teens who don’t get enough sleep may be at risk for chronic problems later in life from increased inflammation throughout the body, according to a new study.

Those who didn’t get enough sleep during the week and especially those who slept longer on weekends had higher inflammation levels tied to heart disease and diabetes, researchers report in Sleep Medicine.

Investigators used blood tests to measure kids’ C-reactive protein (CRP) levels. High levels indicate that the body is in “inflammation mode,” said lead author Martica Hall of the psychiatry department at the University of Pittsburgh in Pennsylvania.

“Frankly, high CRP over a long period of time is bad for everything,” Hall said. “We say it increases the risk of ‘all things bad.’”

This study only measured CRP levels at one point in time, but “folks that have chronically high CRP are at risk for heart disease and diabetes,” Hall told Reuters Health by phone. “For adults we know that short sleep is associated with CRP levels.”

The researchers also had the 244 healthy high school students wear wrist monitors that recorded how much they slept.

Most kids had CRP levels in the low to moderate risk range, below 3 milligrams per liter, but 33 students qualified as “high risk” by scoring above that threshold.

On average, the kids got less than six hours of sleep per night during weekdays and between seven and eight hours on the weekends.

Teens who slept the least during the week were most likely to be in the high-risk group. Additionally, those who slept at least two hours longer on the weekends were more than twice as likely to be in the high-risk group, compared to those who had more consistent sleep times throughout the week.

Kids in the high-risk group also tended to have a higher body mass index, which is a measure of weight in relation to height.

Sleep duration was still linked to CRP levels even when the authors accounted for depression, sex, race, parental education and body mass index, which is usually an important predictor of CRP levels, Hall said.

“The kids who have a big discrepancy between the amount of sleep they get between weekdays and weekends, as well as those who have short sleep during the school day, that’s associated with higher level of CRP,” Hall said.

Similar results have been seen in adults and the elderly, but these studies that look at one moment in time can’t prove cause and effect, Dr. Francesco Cappuccio told Reuters Health in an email.

“In other words, is sleep deprivation causing an activation of inflammation or is an underlying reason for raised inflammatory markers the cause of reduced sleep?” said Cappuccio, a cardiovascular physician at the University of Warwick in Coventry, U.K. who was not involved with the new study.

Caution is always a good approach for results like these, but there are plenty of reasons for believing that sleep deprivation could be harmful, he said.

CRP levels can be lowered, but it would take a separate experiment to determine if changing sleep patterns would effect that change, Hall said.

“The cool thing about sleep is that it’s changeable,” she added.

Hall said kids and parents should focus on lengthening sleep times during the school week and not worry so much about the weekend. Other studies have found that highly variable sleep lengths are associated with health risks, so standardizing and lengthening sleep for five of the seven days of the week is a good start, she said.

“One of the reasons why there is such a move for trying to change high school start times is this is a population which is biologically predisposed to be awake at night,” Hall said.

In August, the American Academy of Pediatrics recommended schools delay start times to at least 8:30 a.m. to improve the physical and mental health of students (see Reuters Health story of August 25, 2014 here: reut.rs/1F7MWwc).

“They are predisposed to be awake at night then have really early start times, and that may increase the risk for way downstream disease,” she said.

The vicious cycle: Sleep loss can lead to diabetes and vice versa

Snoring may just be a sign of worse things to come from sleep deprivation and diabetes. (Tetra Images, Getty Images)

October 23, 2014, 4:28 p.m.
By Leslie Mann, Chicago Tribune

David Lombrozo was never a good sleeper. "Then I started my own company, and it got worse," said the Marietta, Ga., owner of an information-technology management company. "I got to bed later, got up earlier, wasn't eating well. I gained 15 pounds, which made me snore and woke me up even more."

As a result, Type 2 diabetes, which had been lurking in his family genes, caught up with him. Now Lombrozo must give himself a daily insulin injection and test his blood-sugar levels several times a day to keep the disease in check.

Like the 27 million other Americans afflicted with Type 2 diabetes, Lombrozo learned the sleep deprivation and diabetes feed on each other: Diabetes symptoms disturb sleep, while sleep loss contributes to diabetes. Add obesity and stress, and you have a vicious circle.

Formerly known as adult-onset diabetes, Type 2 means having too little insulin (a hormone that helps the body use sugar) and too much glucose (sugar). As Americans' average number of sleep hours has decreased, Type 2 diabetes has become more common.

Seven to nine hours of sleep per night is ideal, according to the American Diabetes Association, but 35 percent of us get less.

Thanks to diabetes complications such as restless-leg syndrome and neuropathy (nerve pain or numbness), many diabetics cannot sleep well, causing their condition to worsen. But the road to diabetes can start from the other direction too, meaning sleep deprivation.

The No. 1 sleep enemy is apnea, a breathing interruption caused by obstructed airways.

"Sleep apnea and diabetes go hand in hand," said Dr. Florence Comite, a New York City endocrinologist. About 36 percent of Type 2 diabetics have sleep apnea, according to the diabetes association.

Adequate sleep allows HGH (human-growth hormone) and IGF-1 (insulin-like growth factor 1) to grow cells and repair tissues."Sleep helps our bodies restore themselves," Comite explained. "Without enough sleep, we can actually bring on diabetes." It's all about hormones, she explained, starting with insulin, the hormone that's in short supply for diabetics.

With enough sleep, the body produces leptin, the hormone that depresses the appetite. Without enough sleep, it produces more ghrelin, which stimulates the appetite.

Sleep deprivation increases cortisol, the "stress hormone" that prevents insulin from getting into the cells ("insulin resistance").

In addition to preventing sleep, apneas reduce the amount of oxygen going to the brain and heart. "The pressure from trying to breathe stretches the heart, which puts out a diuretic," explained Robert Rosenberg, DO, a Prescott Valley, Ariz., sleep specialist . "Men blame their prostates, and women blame menopause, but really it's their sleep apnea that's causing them to have to go to the bathroom at night."

Sleep apnea is more common among people who are male, older, have thick necks or sunken chins, and among those who carry their excess weight at their waists.

Though being overweight elevates sleep apnea risk, even diabetics who are not obese are at risk.

The doctor diagnoses apnea with a home monitor or by sending you to a sleep center for the night.

OSA (obstructive sleep apnea) is the most common form of apnea and causes breathing to stop briefly. With the less common but more dangerous type, CSA (central sleep apnea), breathing stops completely for longer periods. This can be fatal.

The first line of sleep apnea treatment is weight loss. If that doesn't help, the doctor prescribes a mask or nose plugs that feed pressurized air into the airways. If this fails, surgery to unblock obstructions might be an option.

If obesity is not part of the diabetes-sleep equation to start, it often becomes one. A hormone imbalance causes the diabetic to eat the wrong foods and be too tired to exercise. The threat of heart disease causes worry, which makes comfort foods like cookies more enticing.

"No wonder people just give up," said Dr. Charlie Seltzer, a Philadelphia obesity medicine physician who lost 75 pounds by following his own advice: "Figure out how many calories you take in, and eat less."

For Seltzer, having diabetes in his family scared him into a healthier lifestyle, he said. Others can prevent Type 2 diabetes with his multipart prescription of more sleep, more hours at the gym, and healthy foods instead of sugary and salty foods.

Because restaurant meals encourage overeating, Seltzer offers this tip: "Before you go to the restaurant in the evening, look at the menu and calorie count online. Choose your entree before you go so you won't order on impulse. Then you work backward to wear off the calories by evening."

Lombrozo can shrug off stress, which affects sleep and diabetes prevention, even if he gets a late-night call from a client. "I'm one of those people who can turn it off," he said. But others must consciously de-stress to keep their cortisol levels down.

Following are ways to fight the battle:

• Exercise in the morning so your body can wind down before bedtime, advised the doctors. Avoid drinking alcohol, caffeine and big meals in the evening. Go to bed at the same time, even on weekends, but sleep late on weekends if you need to catch up.

• Make your bedroom relaxing, dark and free of electronic devices including computers, TVs, tablets and cellphones. "They emit blue light, which destroys melatonin production," Rosenberg explained.

• If your partner must have a bedroom TV, use an eye mask and earplugs to block light and noise. "Or get a separate room," Rosenberg said.

• Parents know what helps their kids sleep but seldom indulge themselves in the routine, Comite said. "Take a warm bath and talk quietly," she said. "Then wear out a melodic book like 'Goodnight Moon.' "

Notes from Dr. Norman Blumenstock
Athletes, Take Note: Sleeping More Can Give You a Competitive Edge

Visit the Fitness Video Library

By Dr. Mercola

Athletes, take note: if you want to optimize your athletic performance, be sure to get your zzz’s. As noted by The Atlantic:1

“Without proper sleep, whether it’s a short-term or long-term deficit, there are substantial effects on mood, mental and cognitive skills, and motor abilities. When it comes to recovery from hard physical efforts, there’s simply no better treatment than sleep, and a lot of it.”

Not surprisingly, sleep deprivation has a detrimental effect on sports performance across the board, but certain types of athletes see a particularly marked drop in performance if they skimp on sleep.

The largest performance drop-offs can be seen among endurance athletes, and sports requiring quick reaction times and reflexes.

Non-athletes will also optimize their health and longevity by paying attention to the quality of their sleep. In fact, getting enough sleep appears to be key for aging well, and maintaining healthy brain and body into old age.

Competitive Athletes Get a Leg Up with More Sleep

To determine whether an athlete might gain a competitive edge simply by sleeping more, Stanford researcher Cheri D. Mah reached out to The Cardinal’s men’s basketball team.

For two weeks, the players’ athletic performance was assessed after getting their normal amount of sleep. They were fitted with motion-sensing wristbands to determine the actual length of their sleep, which averaged in at a mere 6.5 hours per night.

Next, the players were asked to extend their sleep time as much as possible for five to seven weeks. The players increased their average sleep time by about two hours—to 8.5 hours nightly. As reported in the featured article:

“The results were startling. By the end of the extra-sleep period, players had improved their free throw shooting by 11.4 percent and their three-point shooting by 13.7 percent. There was an improvement of 0.7 seconds on the 282-foot sprint drill—every single player on the team was quicker than before the study had started.

A 13-percent performance enhancement is the sort of gain that one associates with drugs or years of training—not simply making sure to get tons of sleep. Mah’s research strongly suggests that most athletes would perform much better with more sleep...”

Unfortunately, extensive and hectic travel schedules usually make sleep hard to come by when you’re a competitive athlete. While not an ideal alternative to getting a solid night’s sleep, taking naps whenever possible can help.

For the majority of you though, who are not professional athletes, research like this shows just how important it is to get enough sleep. If athletes can improve their professional performance by sleeping more, the same will apply to “regular folks” as well.

The Importance of Staying in Sync with Nature

Maintaining a natural rhythm of exposure to sunlight during the day and darkness at night is one crucial foundational component of sleeping well. This was addressed in a previous interview with Dan Pardi, a researcher who works with the Behavioral Sciences Department at Stanford University and the Departments of Neurology and Endocrinology at Leiden University in the Netherlands.

Exposure to bright daylight synchronizes your master clock—a group of cells in your brain called the suprachiasmatic nuclei (SCN). These nuclei synchronize to the light-dark cycle of your environment when light enters your eye. You also have other biological clocks throughout your body, and those clocks subsequently synchronize to your master clock.

One reason why so many people get so little sleep, and/or such poor sleep, can be traced back to a master clock disruption. One lifestyle factor that can significantly hamper your sleep is spending the entire day indoors in an area with few or no windows.

That, combined with spending your evenings in too-bright artificial light, is a surefire way to get out of sync with the natural rhythm of daylight and nighttime darkness. The end result is difficulty falling or staying asleep when it’s time for bed, and persistent daytime sleepiness.

Improve Your Sleep Hygiene with a Fitness Tracker

Getting enough sleep is really crucial to overall good health; I strongly recommend taking the matter seriously. While overuse of light-emitting technology is part of the problem, some gadgets can actually help you improve your sleep hygiene.

We’re about to see an explosion of fitness trackers hitting the market, and I believe this can be a really good thing, provided you make good use of it.

There are already a few good ones available, but even better versions are sure to follow. The Apple Watch being launched next year is one example. Currently, one of the best is Jawbone’s Up32—it’s definitely among the most advanced fitness tracker to date.

This lightweight wristband keeps track of a wide variety of data, including exercise, hydration levels, and REM sleep. The data collected can even tell you what activities led to your best sleep, and what factors resulted in poor sleep.

With this kind of data at hand, you can start making some really healthy choices. The Smart Coach will also remind you when it’s time to hit the sack. Besides tracking your sleep patterns, a fitness tracker can also inspire you to get enough movement into your day-to-day life.

A Fitness Tracker Can Help You Lead a More Active Lifestyle

Overwhelming evidence shows that prolonged sitting is an independent risk factor for chronic health problems and a shorter lifespan, so regularly getting off your chair is just as important as having a regular workout schedule.

While some experts in this field recommend standing up at least 10 minutes out of every hour of sitting, I believe this may not be enough for optimal health. Personally, I now try to sit as little as possible. I strive to sit less than one hour per day, which is an achievable goal unless I’m travelling and am forced to sit in a plane or car.

Simply standing up has had the remarkable effect of “curing” my chronic back pain, which I’ve struggled with for many years. It would normally start after I’d walk or stand for more than 30 minutes, but since I reduced my sitting, the pain has essentially disappeared. 

Prior to this simple intervention, I’d tried four different chiropractors, posture exercises, Foundation Training, ab work, inversion tables, standing up every 15 minutes to stretch, and strength training. Yet the improvements were minimal. I’m still surprised I missed this important health principle for so long! Another recent epiphany I had is that most of us need to walk much more than we do. This is where a fitness tracker can be very helpful, as it allows you to objectively record how much you walk.

Most of us need about 7,000-10,000 steps a day, which is about four to five miles (6-9 km). Keep in mind that this is walking is in addition to, not in place of, your normal exercise program. If you can, consider walking barefoot, as this will help you get grounded—it’s even better if you can walk on the beach by the ocean. I believe the combination of high intensity training, non-exercise activities like walking 10,000 steps a day, along with avoiding sitting whenever possible is the key to being really fit and enjoying a pain free and joyful life. If you don't have a fitness tracker that records your steps and your sleep, I would encourage you to get one.

Beware of Sleeping Pills...

While most would not knowingly put their life on the line, you may be doing just that if you take sleeping pills. They’re simply NOT a viable alternative to synchronizing your sleep rhythm to the natural cycle of light and darkness... According to the statistics3 from the Centers for Disease Control and Prevention (CDC), between 50 and 70 million Americans suffer from sleep deprivation, and nearly nine million Americans take prescription sleeping pills in pursuit of good night’s rest.

Unfortunately, the price you may end up paying for taking this “shortcut” could be higher than expected. A study4 by the Substance Abuse and Mental Health Services Administration (SAMHSA) reveals that emergency room visits involving the sleep aid zolpidem nearly doubled between 2005 and 2010, reaching 42,274 visits in the year 2009-2010. Zolpidem is the active ingredient in sleep aids sold under brand names like Ambien, Ambien CR, Edluar, and Zolpimist. Polypharmacy—the use of multiple drugs—is part of the problem. In 57 percent of these overmedication cases, there were additional drugs involved:

• In 26 percent of cases, zolpidem was combined with benzodiazepines (Valium, Xanax, Ativan, etc.)
• 25 percent involved a combination with narcotic pain relievers
• Alcohol was also used in 14 percent of these emergency room visits

Sleeping Pill Use and Driving Can Be a Dangerous Mix

Recent research also shows that prescription drugs are involved in fatal car crashes at three times the rate of marijuana, and sleeping pills are among the drugs that could turn you into a danger on the road. Studies submitted to the FDA have revealed that blood levels of zolpidem above 50 ng/mL may impair your driving to a degree that increases the risk of an accident, especially among women. As a result, FDA recommended manufacturers cut the dosage of zolpidem from 10mg to 5mg for immediate-release products (Ambien, Edluar, and Zolpimist) and from 12.5 mg to 6.25 mg for extended-release products (Ambien CR).5

A 2013 CDC report6 also estimated that up to one-third of all fatal car crashes involve a drowsy driver, and daytime drowsiness is a very common side effect of sleeping pills. Other side effects associated with zolpidem include dizziness, hallucinations, agitation, and sleep-walking. It’s also important to realize that narcotic pain relievers and anti-anxiety drugs or sedatives can cause a dangerous enhancement of sleeping pills’ sedative effects.7 Sleeping pills have also been linked to a 35 percent increased cancer risk, along with a greatly increased risk of death from any cause.

Helpful Tips to Improve Your Sleep

My advice is to skip the medication and focus your attention on lifestyle changes that will allow you to get the best sleep possible. Remember, to sleep well, you need to have properly aligned circadian rhythms, and to achieve that, you need to get daylight exposure, ideally around solar noon, for a minimum of 30-60 minutes each day. In the evening, once the sun has set, dim all artificial light sources. In particular, you want to avoid the blue light wavelength.

Research shows that exposure to bright room light before bedtime suppresses melatonin production in 99 percent of individuals, which can rob you of sleep by preventing sleepiness. For night-time lighting, use blue-blocking light bulbs, dim your lights with dimmer switches and turn off unneeded lights, and if using a computer, install blue light-blocking software like f.lux.8 Also keep in mind that digital alarm clocks with blue light displays could have a detrimental effect. The following infographic, created by BigBrandBeds.co.uk, illustrates how your electronic gadgets wreak havoc on your sleep when used before bedtime.9

How Technology Affects Sleep - An infographic by the team at Big Brand Beds

Is Snoring a Sign of a Disorder?

Notes from Dr. Norman Blumenstock

Snoring is not the only sign of a Disorder. Please read about STOP BANG below:

POSTED 8:54 AM, NOVEMBER 11, 2014, BY HIGH POINT REGIONAL - SPONSORED CONTENT, UPDATED AT 09:01AM, NOVEMBER 11, 2014

Sleep apnea is a common sleep disorder affecting up to 20 percent of the population. It is a condition where the throat, above the voice box/Adam’s Apple, closes off during sleep. The patient is frequently tired during the day, sleeping at inappropriate times.

During sleep, a person with sleep apnea usually snores loudly along with gasping and choking spells. One of the best tests may be a complaint by your bed partner that you snore loudly or that you stop breathing repeatedly while you are asleep.

Other risk factors for sleep apnea include hypertension, being male, older than 50, moderately to severely overweight and having a neck size greater than 16 inches in women and 17 inches in men.

STOP BANG is an easy way to remember the symptoms of sleep apnea.

Snoring

Tired, Fatigued, or Sleepy during the daytime (such as falling asleep during driving)

Observed Breathing Stoppage or Choking/Gasping during your sleep

Pressure – being treated for High Blood Pressure?


Body Mass Index more than 35 kg/m2

Age older than 50

Neck size large

Gender = Male

If you believe you or a loved one has these symptoms, or is concerned you might have sleep apnea, it is important to get tested and subsequent treatment. The complications of sleep apnea include increased risk of motor vehicle accidents, hypertension, heart disease and stroke. Start by talking with your physician who can send you for a sleep study from a Sleep Center certified by the American Academy of Sleep Medicine like the UNC Regional Physicians Sleep Center.

Not so interested in sleeping overnight in a sleep lab? Now you have the Home Sleep Study option. Home sleep testing is intended for patients who believe they have apnea, but who are otherwise healthy and have no major medical problems like diabetes and heart disease. Once ordered by the physicians, the patient would go into a certified Sleep Center where a specially trained sleep technician will prepare the device and instruct the patient on its use. It takes only a few minutes. Not more involved than a simple finger probe, chest belt and nose piece. The patient then goes home to bed. After sleeping, the device is removed and returned to the Sleep Center. The results are scored and reviewed by a board certified sleep specialist who then shares the results with the ordering physician. The cost is significantly less than an in-lab study and is covered by most insurance.

Sleep apnea is treatable, but often goes unrecognized and untreated. Learning how to identify the warning signs, how to distinguish it from normal snoring, is the first step to overcoming sleep apnea and getting a good night’s sleep.

Gregory Mieden, MD, PhD is the Sleep Center Medical Director and a practicing neurologist at UNC Regional Physicians Neuroscience Center. Dr. Mieden received his medical degree from the University of Maryland, and served his residency training at Johns Hopkins University, and University of Maryland. He also holds a PhD in anatomy from the University of Wisconsin. Dr. Mieden is certified by the American board of Psychiatry and Neurology and is a diplomat with the American board of Sleep Medicine. He has been working at High Point Regional and UNC Regional Physicians for more than 23 years. To make an appointment with Dr. Mieden or for an in-lab or home sleep study, call (336) 887-3091.

Notes from Dr. Norman Blumenstock

A five year study is a wake-up call to a child snoring problem

Obese boys are more prone to habitual snoring than other children and they sleep less hours.

This would have been a better study if they all had sleep studies to see how many children had undiagnosed sleep apnea.

Elizabeth Cheung elizabeth.cheung@scmp.comPUBLISHED : Tuesday, 11 November, 2014, 4:49am        UPDATED : Tuesday, 11 November, 2014, 4:49am

Obese boys are more prone to habitual snoring than other children, a five-year study reveals. Photo: Reuters

Obese boys are more prone to habitual snoring than other children, a five-year study reveals.

The paediatric department of Kwong Wah Hospital in Yau Ma Tei conducted a phone survey with parents of 3,047 children in 2002 to understand the prevalence of sleep symptoms among local primary school pupils.

A similar follow-up survey was conducted five years later when the students had reached puberty. In 2007, researchers managed to interview 2,005 of the students involved in the first survey.

They found that 12.7 per cent of respondents, or 254 teenagers, were habitual snorers, meaning they snored on at least six nights a week.

About 40.6 per cent of pupils suffered from habitual snoring in both studies, while 7.1 per cent of children became habitual snorers when they moved to secondary school.

Dr Daniel Ng Kwok-keung, head of paediatrics at Kwong Wah Hospital, said male gender and a body mass index over 30 were factors leading to persistent and incidental habitual snoring.

Allergic rhinitis, inflammation of the nasal airways, is associated with persistent habitual snoring, while asthma is linked with incidental habitual snoring, meaning non-snorers started to snore in the second stage of study.

Habitual snoring affected the quality of teenagers' sleep. Pupils who showed excessive daytime tiredness slept for 7.1 hours on average every day, which is half an hour less than those who did not show any tiredness during the day, the study found.

The study pointed out that as many as 90 per cent of respondents did not reach the international recommended sleeping range of at least 91/2 hours a day. Hong Kong teenagers sleep for an average of 7.6 hours a day.

To prevent habitual snoring, Ng suggests that children exercise for one hour every day to prevent obesity, treat allergic rhinitis with nasal wash or topical steroid, and avoid sleep deprivation.

He also advised children to maintain proper sleep hygiene, such as avoiding exposure to a computer monitor two hours before bedtime and by exercising in the afternoon.

The result of the research was published in the Journal of Paediatrics and Child Health in June.