Sleep Medicine xxx (2013) xxx–xxx

Contents lists available at ScienceDirect

Sleep Medicine
journal homepage: www.elsevier.com/locate/sleep

Original Article

Sleep and eating in childhood: a potential behavioral mechanism

underlying the relationship between poor sleep and obesity
Julia Burt a,b, Laurette Dube a, Louise Thibault a, Reut Gruber a,b,⇑
a
McGill University, Montreal, Quebec, Canada
b
Attention, Behavior and Sleep Lab, Douglas Mental Health University Institute, Quebec, Canada

a r t i c l e i n f o a b s t r a c t

Article history: Objective: The goal of our study was to examine the associations between sleep and eating behaviors.
Received 7 May 2013 Specifically, we examined associations between sleep duration and continuity with behaviors that pro-
Received in revised form 8 July 2013 mote eating regardless of true physiologic hunger state including emotional (food intake in response
Accepted 14 July 2013
to emotional distress) external (eating in response to the sight or smell of food), and restrained eating
Available online xxxx
(a paradoxical behavior; food intake is initially reduced to lose or maintain body weight, but followed
by increased consumption and binge eating).
Keywords:
Participants: Fifty-six children (29 boys; 27 girls) ages 5 to 12 years participated in the study. Mean age
Sleep
Eating behaviors
was 7.7 ± 1.9 years, and average body mass index (BMI) was within the healthy range (17.8 ± 4.3 kg/m2).
Children Methods: Sleep duration, continuity and schedule were assessed using actigraphy and self-reports. The
Emotional eating Child Dutch Eating Behavior Questionnaire-modified version (DEBQ-M) was used to examine levels of
External eating emotional, external and restrained eating in the children.
Restrained eating Results: Associations between the sleep and eating behaviors were examined using partial correlations
and multiple regression analyses. External eating score was negatively associated with sleep duration;
emotional eating score was associated with lower levels of sleep continuity; and restrained eating score
were associated with a later sleep start and later bedtime.
Conclusions: Short sleep duration and poor sleep continuity were associated with higher levels of eating
behaviors shown to be associated with increased food intake. Therefore, sleep loss may be associated
with diminished self-regulation of appetite in children, increasing the risk for overeating and obesity.
Ó 2013 Elsevier B.V. All rights reserved.

1. Background
The prevalence of childhood overweight and obesity has signif-
icantly increased in the past three decades, creating a major public
health concern [1–3]. There is a substantial amount of evidence
supporting the causal relationship between sleep deprivation,
overeating, and obesity. Sleep plays a significant role in restorative
processes in the body and energy metabolism; for example, it is a
mediating factor in glucose metabolism [4] and controls the activ-
ity of the appetite-regulating hormones [5]. Sleep loss, in effect, has
been linked to disturbances in metabolic function, such as in-
creases in ghrelin (an appetite-stimulating hormone) and de-
creases in leptin (an appetite-suppressing hormone) that
promote food intake [6]. Although the physiologic mechanisms
⇑ Corresponding author. Address: Department of Psychiatry, McGill University,
Douglas Mental Health University Institute, 6875 LaSalle Blvd., Verdun, Quebec
H4H 1R3, Canada. Tel.: +1 (514) 761 6131x3476; fax: +1 (514) 762 3858.
E-mail addresses: julia.burt@mail.mcgill.ca (J. Burt), laurette.dube@mcgill.ca
(L. Dube), louise.thibault@mcgill.ca (L. Thibault), reut.gruber@douglas.mcgill.ca
(R. Gruber).
that mediate the relationship between sleep deprivation, food in-
take, and obesity have been characterized, the psychologic and
behavioral aspects of this relationship have not been investigated.
Investigating this relationship is critical, as it will result in a better
understanding of factors that are associated with increased eating,
and therefore can help identify targets for the prevention of child-
hood obesity.
Psychologic aspects of eating behavior, such as eating in
response to emotional states (for example, anxiety) or external
cues of food (such as sight or smell) play a significant role in over-
eating and the development of excess body weight [7–11]. Higher
levels of eating behaviors that promote food intake as a response to
internal or external cues unrelated to the physiologic need to eat
have been associated with increased body mass index (BMI) and
waist circumference in individuals of all ages [7]. Specifically,
behaviors that suggest diminished self-control in the presence of
food, such as emotional (food intake in response to emotional dis-
tress), external (eating in response to the sight or smell of food),
and restrained eating (a paradoxical behavior; food intake is ini-
tially reduced to lose or maintain body weight, but followed by in-
creased consumption and binge eating) have all been associated

1389-9457/$ - see front matter Ó 2013 Elsevier B.V. All rights reserved.
http://dx.doi.org/10.1016/j.sleep.2013.07.015

Please cite this article in press as: Burt J et al. Sleep and eating in childhood: a potential behavioral mechanism underlying the relationship between poor
sleep and obesity. Sleep Med (2013), http://dx.doi.org/10.1016/j.sleep.2013.07.015
2 J. Burt et al. / Sleep Medicine xxx (2013) xxx–xxx
with increased BMI and waist circumference in individuals of all
ages [7–11]. For instance, Webber et al. [7] examined eating behav-
ior and weight in children ages 7 to 9 years, and determined that
obese subjects had increased scores for a variety of eating behav-
iors shown to promote food intake, such as emotional overeating
[7]. This type of relationship has been observed throughout studies
when controlling for confounding factors known to be associated
with food intake and weight gain, including age, sex, ethnicity,
parental education, television watching and physical activity.
Although a strong relationship between sleep deprivation, in-
creased food intake, and obesity has been documented, only a
small number of studies have examined how aspects of eating
behavior may be related to sleep quantity and quality. In healthy
adults, it has been demonstrated that reduced subjective sleep
quality scores are associated with increased behaviors that are
shown to promote overeating, including cognitive restraint (the
conscious restriction of food), binge eating (periods of uncon-
trolled, excessive food intake), and emotional eating (food intake
in response to emotional distress) [10].
The objective of our study was to examine the relationship be-
tween sleep and emotional (food intake in response to emotional
distress) external (eating in response to the sight or smell of food),
and restrained eating (a paradoxical behavior; food intake is ini-
tially reduced to lose or maintain body weight, but followed by in-
creased consumption and binge eating behaviors, all of which
represent a disrupted self-control in the presence of food, causing
an individual to eat regardless of true physiologic hunger state. We
hypothesized that short sleep duration and decreased sleep conti-
nuity would be associated with increased levels of emotional,
external and restrained eating in children.
2. Methods
2.1. Participants
This study comprised 56 medically healthy children aged 5 to
12 years. Children were recruited using newspaper advertise-
ments. Exclusion criteria were as follows: (1) any medical condi-
tion that would interfere with study protocol and testing,
including breathing problems such as asthma, diabetes mellitus,
and epilepsy; and (2) food allergy or intolerance.
2.2. Procedure
To assess sleeping patterns, participant’s sleep was evaluated
for seven consecutive nights using actigraphy in the child’s home
environment. Children were asked to maintain normal sleep–wake
patterns, and actiwatches were worn each night shortly before bed
until shortly after waking. A daily sleep log was used along with
actigraphy in which participants answered questions regarding
sleep and wake times, sleepiness, overall mood, and medication in-
take. To evaluate eating behavior, parents filled out the child Dutch
eating questionnaire (DEBQ-M) [12], which assessed levels of emo-
tional, external, and restrained eating.
2.3. Measures
2.3.1. Eating behavior measure
2.3.1.1. Child Dutch Eating Behavior Questionnaire. The DEBQ-M,
modified from the Dutch Eating Behavior Questionnaire for use
in children [12] was used to examine the children’s eating behav-
ior. The DEBQ-M focuses on the three types of eating behavior,
including emotional (food intake in response to emotional distress.
For example: ‘‘Does feeling unhappy or upset ever make you want
to eat?’’) external (eating in response to the sight or smell of food.
Please cite this article in press as: Burt J et al. Sleep and eating in childhood: a potential behavioral mechanism underlying the relationship between poor
sleep and obesity. Sleep Med (2013), http://dx.doi.org/10.1016/j.sleep.2013.07.015
For example: ‘‘If food smells and looks yummy, do you eat a lot of
it?’’) and restrained eating (a paradoxical behavior; food intake is
initially reduced to lose or maintain body weight, but followed
by increased consumption and binge eating. For example: ‘‘Do
you try to eat only a little when you want to eat a lot?’’). All three
eating behaviors induce increased food intake regardless of true
physiologic hunger state. The scale includes 33 questions with
three possible answers: yes (1 point), sometimes (2 points), and
no (3 points) answered by participant’s parents. The numbers were
reversed when entered into the database so that a higher score
would indicate higher levels of disordered eating. The modified
DEBQ is deemed an appropriate measure to assess eating behavior
in boys and girls, and both obese and normal weight children ages
7 to 12 years [12,13]. The DEBQ-M also shows good internal reli-
ability and consistency between subscales, with Chronbach a val-
ues of 0.80, 0.82, and 0.68 for emotional, restrained, and external
eating, respectively [12].
2.3.2. Sleep measures
2.3.2.1. Actigraphy. Actigraphs (AW64 series) were used to assess
participants’ sleep patterns in their natural home environment.
These computerized wristwatch-like devices collect data gener-
ated by movements. They are minimally invasive and allow sleep
to be recorded reliably without interfering with the family’s rou-
tine. Actigraphy has been widely used to assess sleep and has been
validated against polysomnography with agreement rates for min-
ute-by-minute sleep–wake identification >90% [14,15]. One-min-
ute epochs were used to analyze actigraphic sleep data. The
reported bedtime and wake time (provided by the sleep logs) were
used as the start and end times for the analyses. For each 1-min
epoch, the total sum of activity counts was computed. If they ex-
ceeded a threshold (threshold sensitivity value = mean score in ac-
tive period/45), then the epoch was considered waking. If it fell
below that threshold, then it was considered sleep.
Actigraphic data were analyzed using sleep software (Actiware
Sleep 3.4, Mini-Mitter) and included the following parameters: (a)
bedtime – the time the child got in bed; (b) sleep start – the begin-
ning of sleep; (c) sleep end – the end of sleep; (d) get up time – the
time the child got out of bed; (e) actual sleep time – the amount of
time (in minutes) between sleep start and sleep end, scored as
sleep according to the Actiware-sleep algorithm; (f) assumed sleep
– the difference in time between the sleep end and the sleep start
times; (g) sleep efficiency – the percent time in bed that is actually
spent sleeping and was calculated by dividing the actual sleep time
by the time in bed and multiplying by 100; (h) sleep latency – the
amount of time (in minutes) taken from bedtime until the subject
falls asleep; (i) sleep bouts – the number of continuous blocks of
sleep, one or more epochs in length, scored as asleep between sleep
start and sleep end; (j) wake bouts – the number of continuous
blocks of wakefulness, one or more epochs in length, scored as
awake between sleep start and sleep end; (k) mean length of sleep
bouts (mean sleep bout time) – the average length of blocks of con-
tinuous sleep, calculated by dividing the actual sleep time by the
number of sleep bouts; and (l) mean length of awake bouts (mean
awake bout time) – the average length of the blocks of continuous
wakefulness, calculated by dividing the actual awake time by the
number of wake bouts.
Bedtime, sleep start, sleep end, and get up time were used as
measures of sleep schedule, actual sleep time was used as a mea-
sure of average sleep duration, and sleep efficiency, sleep latency,
sleep bouts, and wake bouts were used as measures of sleep
continuity.
Actual sleep time was chosen because we regarded the associa-
tion between sleep and cognitive and physiologic processes as
determined by the actual time spent asleep, rather than the overall
time spent in bed.
 J. Burt et al. / Sleep Medicine xxx (2013) xxx–xxx 3

2.3.2.2. Daily sleep logs. Daily sleep logs were completed by parents similar to the time spent in bed but differed from the average dura-
and included information regarding children’s bedtimes and wak- tion of actual sleep time, as expected.
ing times.
3.2. Relationship between sleep and eating measures

2.4. Statistical analysis

3.2.1. Correlation analyses
3.2.1.1. Association between restrained eating and sleep. Positive
Descriptive statistics were computed for all variables. To
associations were observed between restrained eating score and
examine the relationship between sleep and eating behavior, par-
both bedtime and sleep start (P < .05), indicating that both a later
tial Pearson product moment correlation coefficients were calcu-
bedtime and sleep start were associated with higher restrained
lated between sleep duration, schedule and continuity and DEBQ
eating scores. No other significant associations were observed be-
scores, with age, BMI, and waist circumference as covariates. To
tween restrained eating and any other sleep variables (Table 2).
determine the proportion of variance in eating behavior scores
explained by each sleep variable, relationships between sleep
3.2.1.2. Association between emotional eating and sleep. Emotional
duration, schedule and continuity, and eating behaviors (emo-
eating was negatively correlated with mean sleep bout time
tional, external and restrained eating) were tested using multiple
(P < .05) and positively correlated with number of wake bouts
linear regression analyses, adjusted for potential confounders of
(P < .01), indicating that a higher emotional eating score was asso-
age and BMI.
ciated with a lower average sleep bout time and a higher average
All analyses were conducted using PASW Statistics Version 18.0,
number of wake bouts throughout the night. (Table 2).
and a P value of <.05 was used to indicate statistical significance.
3.2.1.3. Association between external eating and sleep. Sleep duration
3. Results was negatively correlated with external eating score (P < .05), indi-
cating that higher external eating scores were associated with
3.1. Descriptive statistics shorter average sleep duration (Table 2).

Means and standard deviations (SD) for age, anthropometric 3.2.2. Multiple regression analyses
characteristics and measures of sleep, and eating behavior are pre- Multiple linear regression analyses were performed to deter-
sented in Table 1. Mean BMI was within a healthy range for sex and mine possible associations between sleep and emotional, external,
age (17.8 ± 4.3 kg/m2), and average actual sleep time was and restrained eating scores on the DEBQ-M.
7.89 ± 0.53 h per night. Average duration of time spent in bed
was 9.34 ± 0.6 h per night. Based on parental reports on the sleep 3.2.2.1. Regression analysis of the association between restrained
log, the average times children went to bed and awoke were eating and sleep. Sleep start and bedtime were negatively associ-
21.11 and 07.07, respectively, for an average reported sleep dura- ated with restrained eating score (b = 0.41, P < .05; b = 0.40,
tion of 9.93 ± 0.87 h per night. Parents’ reports were therefore P < .05, respectively) and the full models explained 13.5% and
14% of the variance, respectively. This finding indicated that later
sleep start and bedtime were associated with higher restrained
Table 1 eating scores in a manner independent of age or BMI.
Means and standard deviations for age, anthropometric characteristics, sleep, and
eating measures (N = 56).
3.2.2.2. Regression analysis of the association between emotional
Measure Mean SD eating and sleep. Emotional eating score was positively associated
Age 7.7 1.9 with the number of wake bouts (b = 0.40, P < .005), and negatively
Anthropometric characteristics
Weight (kg) 32.4 13.2
BMI (kg/m2) 17.8 4.3 Table 2
Waist circumference (cm) 65 12.8 Results of partial correlation analyses studying associations between sleep factors and
eating behaviors controlling for age, body mass index, and waist circumference.
Sleep log
Reported bedtime 21:11 0:58 DEBQ-M
Reported wake time 7:07 0:35
Emotional External Restrained
Reported sleep duration 595.9 52.2
Sleep schedule
Actigraphy
Bedtime .092 .215 .395*
Bed time 20:53 1:00
Sleep start .061 .225 .401*
Get up time 7:09 0:40
Get up time .019 .162 .167
Schedule Sleep start 21:17 0:58
Sleep end .061 .225 .166
Sleep end 6:50 0:42
Sleep latency (min) 25.7 17.6 Sleep continuity
Duration Assumed sleep time (min) 561.6 35.9 Efficiency .088 .097 .209
Actual sleep time (min) 473.4 31.6 Mean sleep bout time .476* .014 .150
Sleep latency (min) 25.7 17.6 Number of sleep bouts .206 .021 .249
Continuity Sleep efficiency 76.2 11.1 Mean wake bout time .206 .202 .173
Sleep bouts (No.) 35.5 6 Number of wake bouts .485** .085 .044
Wake bouts (No.) 34.6 7.9 Latency .187 .057 .151
Mean sleep bout time (min) 14.52 5.013
Sleep duration
Mean wake bout time (min) 2.96 2.12
Actiwatch average actual sleep .138 .354* .101
DEBQ-M duration
Emotional score 34.2 7.1
External score 20.3 4.5 Abbreviations: DEBQ, the Child Dutch Eating Behavior Questionnaire-modified
Restrained score 26.2 4.5 version.
All variables from actigraphy data excluding CSHQ sleep duration.
*
Abbreviations: SD, standard deviation; BMI, body mass index; min, minutes; No., P < .05.
**
number; DEBQ-M, the Child Dutch Eating Behavior Questionnaire-modified version. P < .01.

Please cite this article in press as: Burt J et al. Sleep and eating in childhood: a potential behavioral mechanism underlying the relationship between poor
sleep and obesity. Sleep Med (2013), http://dx.doi.org/10.1016/j.sleep.2013.07.015
4 J. Burt et al. / Sleep Medicine xxx (2013) xxx–xxx
associated with mean sleep bout time (b = 0.44, P < .05). The full
models explained 13.5% and 14% of the variance, respectively, indi-
cating that sleep continuity contributed to emotional eating scores
in a manner independent of age or BMI.
3.2.2.3. Regression analysis of the association between external eating
and sleep. A significant negative association was observed between
sleep duration and external eating scores (b = 0.35, P < .05) and
the full model explained 11% of the variance. This finding suggests
that lower sleep duration contributes to the observed variance in
external eating scores in a manner independent of age or BMI.
4. Discussion
The main goal of our study was to examine the relationship be-
tween sleep duration and continuity and emotional, external and
restrained eating in a sample of healthy children ages 5 to 12 years.
The study extended previous research by examining, the psycho-
logic and behavioral aspects of the interplay between sleep and
eating for the first time.
In addition, the use of objective methodology to assess sleep in
the participants’ natural home environment for several consecu-
tive nights allowed to accurately and objectively determine habit-
ual sleep duration. Our main findings were: (1) decreased sleep
duration was associated with higher levels of external eating; (2)
decreased sleep continuity was associated with increased emo-
tional eating; and (3) later bedtime and sleep start were correlated
with increased restrained eating. These findings are consistent
with the only study to date that has examined the interplay among
these variables in adults [10]. That study showed that poor sleep
quality was associated with higher levels of hunger, cognitive re-
straint, and emotional eating.
4.1. Each eating behavior was associated with a different aspect of
sleep
Sleep duration was negatively associated with external eating,
suggesting that children who habitually sleep less are more likely
to consume food due to external sensory influences such as sight
or smell.
Four brain circuits are thought to be involved in overeating: re-
ward–saliency, motivation–drive, learning–conditioning, and
inhibitory control–emotional regulation–executive function [16].
Because short sleep duration impairs children’s executive function-
ing [15], it can reduce the activity of the circuits related to control
and inhibition leading to a poor ability to resist temptation and to
exert self-control in the presence of food [17], i.e., to increased lev-
els of external eating. Future studies should investigate the moder-
ating role of sleep deprivation on intermediate neurocognitive
phenotypes related to executive dysfunction associated with
excessive eating. Differences between individuals in these areas
are likely to contribute to the differences in vulnerability to over-
weight and obesity.
Dietary restraint has been demonstrated in children as young as
five years of age [18] and is shown to be correlated with psycho-
logic factors such as weight concern and body image [19]. Because
cognitive suppression of hunger is paradoxically a risk factor for
overeating, it has been suggested that it is a risk factor for obesity
in children [20]. Our results indicate that this behavior may be
associated with a later bedtime and sleep start.
These findings are consistent with results suggesting an associ-
ation between eating behavior and circadian sleep mechanisms.
There is evidence that circadian processes are related to eating
behavior, in particular to food availability or restriction. Circuitry
that governs sleep and wakefulness is intimately related to feeding
Please cite this article in press as: Burt J et al. Sleep and eating in childhood: a potential behavioral mechanism underlying the relationship between poor
sleep and obesity. Sleep Med (2013), http://dx.doi.org/10.1016/j.sleep.2013.07.015
circuitry [33], and it has been suggested that just as staying awake
is intrinsic to the regulation of feeding, the availability of food is
critical for shaping wake–sleep cycles [33]. Animal studies strongly
support an association between the timing of food availability or
deprivation and circadian sleep–wake rhythms. For example, labo-
ratory rats, which typically are nocturnal, can be changed into
diurnal animals by restricting food intake to a time window during
daylight hours [24–27]. Food availability is most likely one of a
range of variables that can affect the circadian patterning by allow-
ing it to adjust to a wide range of environmental exigencies, result-
ing in patterns of circadian activity of wakefulness, feeding, and
body temperatures that are most adaptive for survival [28–33].
In our study, restricted eating was associated with delayed circa-
dian tendencies, manifested in later bedtime and sleep start. In
light of the work described above, we suggest that restricted eating
may have affected the patterning of circadian rhythms and may
have contributed to delayed circadian tendencies. Because our
study was correlational, we could not determine if this was the
case, but the association observed and the results of animal studies
linking restricted eating to changes in circadian mechanisms sug-
gest that additional studies are needed to assess the interplay be-
tween circadian mechanisms and food availability in humans,
particularly in children.
4.2. Clinical implications
Our findings suggest that insufficient and poor sleep are associ-
ated with eating behaviors shown to promote overeating and in-
crease obesity risk in children, and this relationship can be used
to determine behavioral targets for the prevention of childhood
obesity. We suggest that an assessment of a child’s risk factors
for obesity should include an assessment of sleep habits, dietary
intake, as well as specific eating patterns and behaviors which
may promote weight gain and obesity, including emotional, exter-
nal, and restrained eating. Using a log to assess sleep duration,
quality, and eating patterns would be beneficial to help identify
this association and permit the family or child to observe how
these factors may be interrelated, so that they can monitor and
modify them if necessary.
4.3. Limitations and future directions
Limitations of our study should be noted. First, it is important to
recognize that the findings were correlational in nature, meaning
that no causation or directionality between sleep loss and eating
behaviors can be inferred. Second, both eating behaviors and sleep
are affected by a variety of biologic, social, and cultural factors,
such as education level, household income, and other familial fac-
tors. For example, parental control is a significant variable to con-
sider when examining eating behavior. High parental control may
diminish the child’s own self-regulating mechanism of food con-
sumption and they may consequently focus on external cues or
emotions to govern their intake [21,22]. Therefore, future studies
examining parental influence and other potential confounding fac-
tors on eating behaviors are needed. Third, the study-population
are only non-overweight children. According to the continuum
hypothesis, eating behavior in individuals with different levels of
pathology may share certain neurobiologic correlates and neural/
central nervous system circuitry pathways related to food reward
systems but vary in the frequency or severity of these traits
[34,35]. Hence, while our results apply only to typically developing
non-overweight children, the inclusion of overweight or obese
children would likely increase the range of variation in weight;
thus the identified associations may be even stronger than those
obtained here.
 J. Burt et al. / Sleep Medicine xxx (2013) xxx–xxx
Future research should further examine how a decrease in sleep
quantity and continuity in children is associated with behaviors
that may result in overeating. Sleep is an important factor in brain
development during childhood, and it has been established that as-
pects of executive cognitive functioning, including inhibitory con-
trol, emotional control, and planning, are linked to self-control
pertaining to food intake [23] such that less cognitive control over
negative emotions increases food consumption. Therefore, examin-
ing how sleep loss is associated with changes in neural functioning
related to behavioral control over appetite in children would con-
tribute to our current knowledge regarding the relationship be-
tween sleep and obesity. Additionally, each eating behavior was
associated with different aspects of sleep, suggesting that sleep
duration, continuity and schedule may relate to specific behaviors
shown to increase food intake. For example, although sleep dura-
tion was negatively associated with external eating, sleep continu-
ity was significantly associated with emotional eating scores.
Future studies should attempt to clarify the nature of these associ-
ations through comprehensive and objective measures of sleep.
5. Conclusion
To our knowledge, our study is the first study to examine quan-
tity and continuity of sleep and its association with eating behav-
iors in children. We found that less sleep or poor sleep continuity
were associated with an increase in eating behaviors that are asso-
ciated with overeating and increase obesity risk. This association
was present in healthy non-overweight children, suggesting that
the relationship between sleep loss and specific eating behaviors
is present in all individuals, regardless of their weight, and hence
may be a risk factor for obesity later in life. Earlier studies did
not assess the associations between eating behaviors associated
with overeating and homeostatic or circadian sleep processes. A
key developing area of research concerns predictors of individual
differences in susceptibility to overeating [36]. Our findings sug-
gest that multiple mechanisms associated with different eating
behaviors may be involved in the observed associations between
sleep deprivation and obesity.
Conflict of interest
The ICMJE Uniform Disclosure Form for Potential Conflicts of
Interest associated with this article can be viewed by clicking on
the following link: http://dx.doi.org/10.1016/j.sleep.2013.07.015.
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