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The use of entertainment and communication technologies before sleep could affect sleep and weight status:… Dube, Nomathemba; Khan, Kaviul; Loehr, Sarah; Chu, Yen; Veugelers, Paul Jul 19, 2017

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RESEARCH Open AccessThe use of entertainment andcommunication technologies before sleepTV (54%), cell phone (52%), tablet (51%) and video games (51%). Odds of obesity were doubled by bedroomd obesityDube et al. International Journal of Behavioral Nutritionand Physical Activity  (2017) 14:97 DOI 10.1186/s12966-017-0547-2Terrace, 8303 112 Street, Edmonton, AB T6G 2T4, CanadaFull list of author information is available at the end of the article* Correspondence: paul.veugelers@ualberta.ca1Department of Public Health Sciences, Population Health InterventionResearch Unit, School of Public Health, University of Alberta, 3-50 Universityefficiency compared to their peers. Having access to an EECD in the bedroom was associated with increasedespite frequently reading during the hour before sleep.(Continued on next page)access to and use of a TV and computer during the hour before sleep. Children who rarely read a printedbook in the bedroom during the hour before sleep had a shorter sleep duration and poorer sleep quality and sleepcould affect sleep and weight status: apopulation-based study among childrenNomathemba Dube1, Kaviul Khan1,2, Sarah Loehr1, Yen Chu1,3 and Paul Veugelers1*AbstractBackground: Short sleep duration and poor sleep quality have been demonstrated to be associated withchildhood obesity. It has been suggested that electronic entertainment and communication devices (EECDs)including TVs, computers, tablets, video games and cell phones interfere with sleep in children and youth.The aim of this study was to assess the impact that the use of EECDs in the hour before bedtime has onsleep and weight status to inform sleep promotion interventions and programs to prevent childhood obesity.Methods: A provincially representative sample of 2334 grade 5 children and their parents in Alberta, Canadawas surveyed. Parents reported their child’s bedtime and wake-up time along with how often their child snored, feltsleepy during the day, woke-up at night and woke-up in the morning feeling unrefreshed. Sleep duration, sleep qualityand sleep efficiency were derived from these indicators. Parents also reported on the presence of EECDs in their child’sbedroom, while children reported use of EECDs during the day and frequency of using each of these devices duringthe hour before sleep. The height and weight of children were measured. Multivariable mixed effect linear and logisticregression models were used to determine how sleep duration, sleep quality, sleep efficiency and weightstatus are influenced by (i) access to EECDs in children’s bedrooms, (ii) use of EECDs during the hour beforesleep, and (iii) calming activities specifically reading during the hour before sleep.Results: Sleep duration was shorter by −10.8 min (cell phone), −10.2 min (computer) and −7.8 min (TV) forthose with bedroom access to and used these EECDs during the hour before sleep compared to no accessand no use. Good sleep quality was hindered by bedroom access to and use of all EECDs investigated duringthe hour before sleep, particularly among users of cell phones (OR = 0.64, 95% CI: 0.58–0.71) and computers(OR = 0.72, 95% CI: 0.65–0.80). Very good sleep efficiency was decreased by access to and frequent use of a© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.leendionssedsleDube et al. International Journal of Behavioral Nutrition and Physical Activity  (2017) 14:97 Page 2 of 15mains unclear whether it is merely the presence ofEECDs in the bedroom, or whether it is their use imme-diately before bedtime that is detrimental to sleep. It istherefore important to investigate how the presence anduse of EECDs in the bedroom affect sleep, and specific-ally, how sleep may be affected when these devices areused during the hour before bedtime. In the presentstudy, we have investigated the effects of independentand interdependent presence and use of EECDs by grade5 children in the bedroom during the hour before sleepon: i) sleep duration, ii) sleep quality iii) sleep efficiencySleep duration and Total time in bedParents were asked to report their child’s usual bed-time, additional time required to fall asleep after goingto bed and wakeup time for weekdays and weekenddays. Sleep duration was calculated by subtracting thechild’s bedtime and additional time required to fallasleep from wakeup time. Total time in bed (TTIB) wascalculated by subtracting the child’s bedtime fromwakeup time. For each child, sleep duration across thewhole week was calculated by multiplying the weekdaysleep duration by five and the weekend sleep durationhave been shown to shorten sleep duration [9], it re- Outcomes of interest(Continued from previous page)Conclusions: Our findings suggest that sleep duration, samong children who do not have EECDs in the bedroom aopposed to those who use EECDs during this hour. Educatoutcomes. These findings will inform health promotion meregarding EECD use.Trial registration: ClinicalTrials.gov NCT01914185. RegisterKeywords: Sleep duration, Total time in bed, Sleep qualityElectronic devicesBackgroundThe National Sleep Foundation recommends 9–11 h ofsleep per night for children aged 6–13 years [1].Obtaining the recommended amount of sleep is im-portant for mental and physical health [2, 3]. Despitethis, children nowadays are sleeping much less thanchildren 20 years ago [4]. Between 1974 and 1986alone, sleep duration in children was found to have de-creased by one hour [4]. The rising use of electronicentertainment and communication devices (EECDs) bychildren have been shown to play a role in shorter sleepduration [5] as well as poor sleep quality [6] and sleepefficiency [7]. Between 1996 and 2009, children aged 8–18 years old were reported to use EECDs (TVs, com-puters, tablets, video games and cell phones) for asmuch as 8 ½ hours daily, seven days a week [8, 9]. Thenegative effects of long periods of EECD use on sleepare well established [7, 9–11] and so are the effects ofsleep deprivation on body weight [10, 12–14], demon-strated by the activation of a hormonal response whensleep is insufficient, which increases appetite and foodconsumption leading to obesity [15–19]. In an era ofdeteriorating sleep habits and rising childhood obesityrates, understanding fully which practices affect bothsleep duration and sleep quality is essential to publichealth decision makers.While access to and use of EECDs in the bedroomand iv) weight status. Furthermore, since reading aprinted book has been recommended as a calming activ-ity to help the body wind down and shift into sleepp quality, sleep efficiency and weight status are betterfrequently read a book during the hour before sleep asof limits against EECD use by parents may improve sleepages and may give rise to national recommendations31 July 2013 Retrospectively registered.ep efficiency, Weight status, Elementary school children,mode [20], we also investigated how reading during thehour before sleep is associated with these four outcomes.Reading a printed book was of interest as opposed to aself-luminous eReader because calming effects of eRea-ders require further validation [21].MethodsStudy populationIn 2012, 181 geographically representative elementaryschools in Alberta, Canada were invited to participatein the Raising healthy Eating and Active Living Kids inAlberta (REAL Kids Alberta) survey. Of those invited,143 (77.9%) schools agreed to participate. Packets con-taining a consent form and a home-based questionnaire[22], both to be completed by parents, were sent homewith 4957 grade 5 children, who typically are either 10or 11 years old. Of the packets sent home, 2732 werereturned (55.1% return rate) with 50.1% (2483/4957) ofchildren receiving parental consent. Of the childrenwith parental consent, 94.0% (2334/2483) completedthe school-based questionnaire and had heights andweights measured by evaluation assistants while theremaining 6.0% (149/2483) of children with parentalconsent were either absent on the day of the survey ordeclined to participate. More information about studytools is available at http://www.REALKidsAlberta.ca.by two before obtaining the sum of both and dividing itby seven. The same was done for TTIB using weekdayand weekend TTIB in bed.Dube et al. International Journal of Behavioral Nutrition and Physical Activity  (2017) 14:97 Page 3 of 15Sleep quality and sleep efficiencyParents were asked four questions about their child’ssleep quality. They were asked whether their child (i)snored; (ii) woke up feeling unrefreshed; (iii) felt sleepyduring the daytime; and (iv) woke up during the nightafter falling asleep. Response options were ‘Never’,‘Sometimes’, ‘Frequently’ and ‘Almost always’. These sleepquality questions were adapted from validated questionsamong adults and were used in our population. To ob-tain sleep efficiency, sleep duration was divided by TTIB,before multiplying the result by 100. Sleep efficiency,was categorized into good (90–94%) and very good(≥95%).Weight statusBody Mass Index (BMI) of each student was calculatedusing her or his measured height and weight. Childrenwere asked to remove their shoes before the measure-ments were taken. Height was measured to the nearest0.1 cm on a portable stadiometer, and body weight wasmeasured to the nearest 0.1 kg on calibrated digitalscales. The resulting BMI was used to define weight sta-tus based on the age- and gender-specific cut-off pointsspecified by the Extended International Obesity TaskForce [23, 24].Exposures of interestAccess to EECDs in the bedroomParents were asked to indicate, which EECDs (TV, com-puter, tablet, video game or cell phone) their child hadaccess to in the bedroom. Responses included: ‘Yes’, ‘No’and ‘Sometimes’, where ‘Sometimes’ was considered as‘Yes’ in the analysis. Additionally, in the analysis, chil-dren were considered to have access to “at least one de-vice” in their bedroom if parents responded ‘Yes’ or‘Sometimes’ to having access to any one of the EECDs inthe bedroom.Bedroom use of EECDs during the hour before sleepChildren were asked how often they used each EECD intheir bedroom during the hour before sleep. Responseoptions were ‘Never’, ‘About once per month’, ‘1–2 timesa week’, ‘3–4 times a week’ and ‘5 or more times perweek’. Children whose responses were ‘Never’ or ‘Aboutonce per month’ were regarded as ‘Never’ using theEECDs during the hour before sleep, while children pro-viding alternative responses were regarded as ‘Used’EECDs during that hour.Frequency of reading a book one hour before sleepChildren were asked how often they read in their bed-room during the hour before sleep. Response optionswere categorized as ‘Rarely’ and ‘Frequently’.Other covariatesParents who completed the survey were asked about thegender of their child, their highest level of educationalattainment (secondary or less, college, university orabove) and household income levels in Canadian dollars(CA$) (≤CA$50,000; CA$50,001–CA$100,000; or≥CA$100,000). Region of elementary school (metropol-itan, city or rural) was determined using school postalcodes. Children were asked how many hours per daythey spend (i) using the computer, (ii) playing videogames and (iii) watching TV outside of school hours. Re-sponse options were ‘Less than 1 hour a day’ regarded as0.5 h; ‘1 – 2 hours a day’ regarded as 1.5 h; ‘3 – 4 hoursa day’ regarded as 3.5 h; and 5 or more hours a day’regarded as 5.5 h. The total sum of hours each studentspent on EECDs was calculated to represent total dailyexposure to EECDs.Statistical analysisSleep quality was derived by using exploratory factoranalysis with varimax rotations. The resulting factorscores were grouped into tertiles, with the first repre-senting good sleep quality and the second and third ter-tiles representing poor sleep quality [9]. For descriptivestatistics, one-way analysis of variance (ANOVA) wasused to test for differences in the means of sleep dur-ation, a normally distributed continuous variable, andexposure variables. Associations between sleep quality,sleep efficiency and weight status with the exposures ofinterest were evaluated with Rao-Scott chi-square sta-tistics [25, 26]. When one or more of the variable fre-quencies was five or less, the Fishers Exact test wasused instead. To accommodate clustering of studentobservations within schools, the effect of EECD accessand use during the hour before sleep was evaluatedusing mixed effect linear regression for sleep durationand TTIB and mixed effect logistic regression for sleepquality and sleep efficiency. For weight status, thinnessweight categories (grade 1, grade 2 and grade 3) werecombined into one category (underweight) and obeseand morbid obese were also combined to form theobese weight category. Multinomial logistic regressionwas used to evaluate the association between weightstatus categories (normal, overweight and obese) andthe exposure groups. All multivariable analyses wereadjusted for gender, household income, parental educa-tion, and area of residence as potential confounders.For all regression analyses, total daily exposure toEECDs outside of school hours was adjusted for and acombined effect of total daily exposure to EECDs andexposure during the hour before sleep was computedusing linear combinations of estimators. Statistical ana-lyses were performed in STATA version 14 (StataCorp,College Station, Texas). A p value of less than 0.05(two-sided test) was considered statistically significant.Study ethical approval was obtained from University ofAlberta Health Research Ethics Board.ResultsDemographic characteristics of the 2334 children whoparticipated in the survey are shown in Table 1. Sleepduration on weekdays ranged between 7.33 h and12.58 h, whilst it ranged between 7.00 h and 13.25 h onthe weekend. TTIB ranged between 7.50 h and 13.00 hon weekdays and 7.50 h and 14.00 h on the weekend.On average, TTIB were statistically significantly longerfor girls than boys. Compared to their peers, longer sleepduration and TTIB were observed amongst children inschools located away from metropolitan areas, whoTable 1 Sleep duration and Total time in bed of grade 5 children by gender, highest level of parental education, school region,household income, weight status, total daily exposure to devices and days of the week, Alberta, 2012Variables Frequency (%) Sleep duration (Hours) p-value Total Time in Bed (Hours) p-valueGenderGirls 1235 (53.2) 9.85 (±0.56) 0.05 10.22 (±0.56) 0.01Boys 1071 (46.8) 9.82 (±0.58) 10.16 (±0.59)Highest level of parental educationNo school/Elementary school 63 (3.0) 9.83 (±0.58) 0.65 10.19 (±0.58) 0.29Secondary/college 1391 (59.0) 9.86 (±0.54) 10.21 (±0.54)University 792 (38.0) 9.83 (±0.58) 10.17 (±0.59)Region of elementary schoolMetropolitan 612 (49.0) 9.78 (±0.59) <0.001 10.11 (±0.60) <0.001City 781 (16.3) 9.90 (±0.57) 10.21 (±0.54)Rural/town 941 (34.7) 9.88 (±0.54) 10.24 (±0.58)Household income< $50,000 (Low) 385 (19.7) 9.71 (±0.58) <0.001 10.08 (±0.57) <0.001$50,001 - $100,000 (Middle) 614 (26.6) 9.84 (±0.55) 10.21 (±0.55)> $100,000 (High) 684 (28.2) 9.90 (±0.55) 10.22 (±0.56)Don’t know/Prefer not to answer* 575 (25.5) 9.91 (±0.57) 10.22 (±0.59)Weight categoryThinness grade 3 20 (0.9) 10.06 (±0.63) ** < 0.001 10.38 (±0.63) <0.001Thinness grade 2 49 (2.1) 9.91 (±0.71) 10.27 (±0.71)Thinness grade 1 233 (10.1) 9.98 (±0.51) 10.30 (±0.51)Normal 1503 (65.0) 9.88 (±0.57) 10.21 (±0.61)Overweight 399 (17.3) 9.75 (±0.60) 10.08 (±0.57)Obese 48 (2.1) 9.69 (±0.57) 10.01 (±0.01)Morbid Obese 3 (0.1) 9.80 (±0.14) 10.20 (±0.59)Total daily exposure to devices (hours)< 2 438 (18.8) 9.97(±0.55) <0.001 10.29 (±0.56) <0.0012.0 1045 (44.1) 9.89 (±0.52) 10.22 (±0.53)0.±0±05.5 318 (13.3) 9.78 (±0±0±0Dube et al. International Journal of Behavioral Nutrition and Physical Activity  (2017) 14:97 Page 4 of 15Days of the weekWeek days 2276 (97.5) 9.78 (Weekend days 2.263 (97.0) 9.99 (3.5 48 (2.2) 9.71(±4.0 264 (12.1) 9.82 (5.0 201 (9.5) 9.72 (*Household income category “Don’t know/Prefer not to answer” excluded from p tr**p values generated using an aggregate of ‘thinness grade 1’, thinness grade 2′ anp value <0.05 was considered statistically significant54) 10.04 (±0.51).62) 10.14 (±0.61).54) 10.07 (±0.66).60) 10.12 (±0.61).64) <0.001 10.12 (±0.63) <0.001.72) 10.37 (±0.79)end calculations.d thinness grade 3′ and ‘obese and morbid obese’ categorieswere from high-income families, who were of normalweight or less and were exposed to EECDs for less thantwo hours a day, (p trend > 0.001) (Table 1).Good sleep quality was more likely to be observedamong children whose parents had a university education(p trend < 0.001) and who were from high-income families(p trend < 0.001) (Table 2). Average very good sleep effi-ciency was 97.6% ± 1.2% (range: 95.0% – 99.3%).Sleep duration and TTIB were statistically signifi-cantly shorter for those with access to a TV, com-puter, video game and cell phone in the bedroomcompared to those without (Table 3). Frequentlyreading a book in the bedroom with no access toEECDs was associated with longer sleep duration,longer TTIB (Table 3), the highest sleep quality andbetter sleep efficiency (Table 4) compared to otherreading categories.Furthermore, an increase in the proportion of childrenwith good sleep quality (additional 2.1%) was observedamongst those who both frequently read during the hourbefore sleep and had no EECDs accessible in the bedroom(Data not shown).Table 2 Sleep quality and sleep efficiency of grade 5 children by gender, highest level of parental education, school region, householdincome, weight status and total daily exposure to devices, Alberta, 2012Variables Frequency (%) Good sleep quality (%) p-value Very good sleep efficiency (%) p-valueGenderGirls 1235 (53.2) 32.5 0.08 94.2 0.96Boys 1071 (46.8) 37.1 94.2Highest level of parental educationNo school/Elementary school 63 (3.0) 30.3 <0.001 92.2 0.18Secondary/college 1391 (59.0) 32.6 94.4University 792 (38.0) 39.8 95.2Region of elementary schoolMetropolitan 612 (49.0) 36.5 0.30 94.7 0.63City 781 (16.3) 32.9 94.1Rural/town 941 (34.7) 33.7 93.5Household income< $50,000 (Low) 385 (19.7) 22.9 <0.001 94.0 0.60$50,001 - $100,000 (Middle) 614 (26.6) 32.7 94.4> $100,000 (High) 684 (28.2) 35.1 94.2Don’t know/Prefer not to answer* 575 (25.5) 38.4 94.7Weight category**Thinness grade 3 20 (0.9) 21.5 ***0.10 100.0 ***0.53Thinness grade 2 49 (2.1) 38.0 89.6Thinness grade 1 233 (10.1) 35.9 94.5Normal 1503 (65.0) 36.2 94.9Overweight 399 (17.3) 29.8 92.8p trDube et al. International Journal of Behavioral Nutrition and Physical Activity  (2017) 14:97 Page 5 of 15Obese 48 (2.1) 22.5Morbid Obese 3 (0.1) 26.6Total daily exposure to devices (hours)< 2 438 (18.8) 37.42.0 1045 (44.1) 36.83.5 48 (2.2) 33.94.0 264 (12.1) 32.75.0 201 (9.5) 28.45.5 318 (13.3) 30.4*Household income category “Don’t know/Prefer not to answer” excluded from**Missing weight category excluded***p values generated using an aggregate of ‘thinness grade 1’, thinness grade 2′ anp value <0.05 was considered statistically significant94.3100.00.07 96.4 0.0694.589.593.892.592.5end calculationsd thinness grade 3′ and ‘obese and morbid obese’ categoriesnd(HDube et al. International Journal of Behavioral Nutrition and Physical Activity  (2017) 14:97 Page 6 of 15Table 3 Sleep duration and Total time in bed of grade 5 children aaccess and use during the hour before sleep% Sleep durationTVWhen compared to normal weight children, a largerproportion of obese children had access to EECDs in thebedroom and used them during the hour before sleep, ex-cept for the tablet, which was used by a large proportionof normal weight children. However, a statistically signifi-cant difference in proportion of weight status was only ob-served with the TV (Table 5).No access and no use 53.7 9.87 (±0.56)Access but never used 14.2 9.80 (±0.59)Access and used 20.1 9.75 (±0.60)aNo access and used 12.0 9.90 (±0.54)ComputerNo access and no use 54.5 9.89 (±0.56)Access but never used 13.8 9.77 (±0.59)Access and used 12.3 9.70 (±0.63)aNo access and used 19.4 9.84 (±0.54)TabletNo access and no use 52.3 9.86 (±0.57)Access but never used 10.2 9.83 (±0.65)Access and used 16.3 9.83 (±0.56)aNo access and used 21.2 9.83 (±0.55)Video GamesNo access and no use 60.9 9.87 (±0.55)Access but never used 15.9 9.78 (±0.58)Access and used 10.3 9.78 (±0.65)aNo access and used 12.9 9.85 (±0.62)Cell PhoneNo access and no use 59.0 9.89 (±0.57)Access but never used 23.1 9.78 (±0.53)Access and used 11.8 9.73 (±0.57)aNo access and used 6.1 9.87 (±0.69)At least one deviceNo access and no use 12.2 9.93 (±0.56)Access but never used 17.8 9.82 (±0.58)Access and used 56.4 9.80 (±0.57)aNo access and used 13.6 9.96 (±0.53)ReadingNo access and frequent reading 19.9 9.97 (±0.53)Access but frequent reading 52.9 9.83 (±0.58)Access and rarely reading 21.2 9.74 (±0.56)No access and rarely reading 6.0 9.89 (±0.60)aResponse category considered illogical: No access to EECD in the bedroom and isp value <0.05 was considered statistically significantelectronic and entertainment communication device bedroomours) p-value Total Time in Bed (%) p-valueEffects of EECD access and use on sleep duration andTotal time in bedAfter adjusting for covariates, children with access toEECDs in the bedroom and reportedly used themduring the hour before sleep reported shorter sleepduration of −10.8 min for a cell phone (β = −0.18 h;95% CI = −0.26, −0.09), −10.2 min for a computer<0.001 10.19 (±0.56) <0.00110.12 (±0.61)10.09 (±0.60)10.23 (±0.54)<0.001 10.21 (±0.57) <0.00110.10 (±0.60)10.02 (±0.64)10.17 (±0.54)0.50 10.18 (±0.58) 0.5210.15 (±0.65)10.17 (±0.56)10.15 (±0.56)<0.001 10.19 (±0.56) 0.00210.11 (±0.58)10.12 (±0.65)10.19 (±0.60)<0.001 10.21 (±0.58) <0.00110.11 (±0.53)10.06 (±0.57)10.19 (±0.69)<0.001 10.27 (±0.57) <0.00110.15 (±0.60)10.13 (±0.58)10.26 (±0.54)<0.001 10.28 (±0.54) <0.00110.16 (±0.59)10.08 (±0.56)10.19 (±0.60)used in the bedroom during the hour before sleepey (Dube et al. International Journal of Behavioral Nutrition and Physical Activity  (2017) 14:97 Page 7 of 15Table 4 Sleep quality and sleep efficiency of grade 5 children andaccess and use during the hour before sleep% Good sleep qualitTV(β = −0.17 h; 95% CI = −0.26, −0.08) and −7.8 min for aTV (β = −0.13 h; 95% CI = −0.20, −0.06) compared to thereference (Table 6). These findings coincided with a re-duced TTIB of −7.8 min for a cell phone (β = −0.13 h; 95%CI = −0.22, −0.05), −9.0 min for a computer (β = −0.15 h;95% CI = −0.23, −0.06) and −4.2 min for TV (β = −0.07 h;No access and no use 53.7 36.3Access but never used 14.2 35.9Access and used 20.1 32.1aNo access and used 12.0 32.4ComputerNo access and no use 54.5 36.4Access but never used 13.8 31.5Access and used 12.3 30.1aNo access and used 19.4 36.2TabletNo access and no use 52.3 36.2Access but never used 10.2 32.7Access and used 16.3 35.0aNo access and used 21.2 33.5Video GamesNo access and no use 60.9 36.3Access but never used 15.9 31.6Access and used 10.3 34.2aNo access and used 12.9 35.0Cell PhoneNo access and no use 59.0 36.6Access but never used 23.1 33.2Access and used 11.8 28.9aNo access and used 6.1 38.8At least one deviceNo access and no use 12.2 35.5Access but never used 17.8 36.9Access and used 56.4 33.1aNo access and used 13.6 39.1ReadingNo access and frequent reading 19.9 38.4Access but frequent reading 52.9 37.5Access and rarely reading 21.2 25.9No access and rarely reading 6.0 34.1aResponse category considered illogical: No access to EECD in the bedroom and isp value <0.05 was considered statistically significantlectronic and entertainment communication device bedroom%) p-value Very good sleep efficiency (%) p-value95% CI = −0.14, −0.00) among children with access toEECDs in the bedroom and reportedly used them duringthe hour before sleep. Interestingly, when a child had accessto a cell phone in the bedroom, their sleep duration de-creased (−7.8 min) as well as their TTIB (−5.4 min) (Table6). Access to and frequent use of tablets and video games0.67 94.5 0.0196.490.894.70.17 94.5 0.7193.193.193.50.67 94.3 0.6493.792.594.30.77 95.1 0.0194.691.990.60.10 95.1 0.0393.190.694.60.29 94.9 0.0695.792.896.0<0.001 96.3 0.0194.591.092.7used in the bedroom during the hour before sleeptroNDube et al. International Journal of Behavioral Nutrition and Physical Activity  (2017) 14:97 Page 8 of 15Table 5 Weight status characteristics of grade 5 children and elecand use during the hour before sleep% aUnderweight (13.4%) %TVin the bedroom during the hour before sleep had no statis-tically significant effect on sleep duration and TTIB.Among children who frequently read during the hourbefore sleep, those with an EECD present in the bedroomhad a shorter sleep duration of −9.0 min (β = −0.15 h;95% CI = −0.23, −0.08) and a shorter TTIB of −6.6 minNo access and no use 53.7 61.7 54Access but never used 14.2 8.5 14Access and used 20.1 15.3 19cNo access and used 12.0 14.6 11ComputerNo access and no use 54.5 55.5 57Access but never used 13.8 12.3 13Access and used 12.3 10.3 10cNo access and used 19.4 21.9 18TabletNo access and no use 52.3 50.7 50Access but never used 10.2 9.3 9.Access and used 16.3 16.4 17cNo access and used 21.2 23.6 21Video GamesNo access and no use 60.9 64.1 60Access but never used 15.9 12.1 15Access and used 10.3 9.3 10cNo access and used 12.9 14.5 13Cell PhoneNo access and no use 59.0 56.7 61Access but never used 23.1 25.9 21Access and used 11.8 10.2 11cNo access and used 6.1 7.2 5.At least one deviceNo access and no use 12.2 12.8 12Access but never used 17.8 17.2 17Access and used 56.4 54.7 56cNo access and used 13.6 15.2 13ReadingNo access and frequent reading 19.9 21.6 20Access but frequent reading 52.9 49.7 53Access and rarely reading 21.2 22.3 21No access and rarely reading 6.0 6.4 5.aThinness grade 1, Thinness grade 2 and Thinness grade 3 weight categories combbObese and Morbid obese weight categories combinedcResponse category considered illogical: No access to EECD in the bedroom and isp value <0.05 was considered statistically significantnic and entertainment communication device bedroom accessormal (66.7%) % Overweight (17.7%) % bObese (2.3%) % p-value(β = −0.11 h; 95% CI = −0.18, −0.05) compared to thosewithout an EECD in the bedroom. Rarely reading with anEECD present in the bedroom shortened sleep duration(−12.6 min) and TTIB (−9.6 min) further (Table 6).Daily exposure to EECDs was associated with a de-crease in sleep duration of between −2.1 and −2.2 min.0 49.7 28.6 <0.001.2 16.5 22.5.9 24.6 38.8.9 9.2 10.2.1 57.0 43.8 0.23.8 12.7 16.7.2 12.1 22.9.9 18.2 16.7.7 54.4 50.0 0.829 8.8 8.7.7 13.6 15.2.7 23.2 26.1.3 62.6 52.1 0.17.9 16.3 27.1.4 10.3 14.6.4 10.8 6.3.1 55.6 53.1 0.39.5 26.6 24.5.9 12.3 14.36 5.5 8.2.3 12.1 6.0 0.56.9 17.7 8.0.3 57.7 72.0.5 12.7 14.0.1 16.8 14.0 0.66.1 52.2 56.0.0 23.3 24.08 7.8 6.0inedused in the bedroom during the hour before sleepevbedju%f.09.13Dube et al. International Journal of Behavioral Nutrition and Physical Activity  (2017) 14:97 Page 9 of 15Table 6 Effect of electronic entertainment and communication dduring the hour before sleep on Sleep duration and Total time inSleep durationUnadjusted coefficient(95% CI)aA(95TVNo access and no use bRef ReAccess but never used −0.07 (−0.16, 0.02) −0Access and frequently used −0.10 (−0.17, −0.03) −0for all EECDs. A similar association was observed amongchildren who used EECDs during the day and read dur-ing the hour before sleep (Data not shown).Effects of EECD access and use on sleep qualityAfter adjusting for covariates, access to a computer,tablet, video games or cell phone in the bedroom,whether used or not during the hour before sleep(compared to the reference) decreased the odds ofgood sleep quality (Table 7). Having a TV in the bed-room affected good sleep quality when it was fre-quently used during the hour before sleep (OR = 0.86,ComputerNo access and no use Ref RefAccess but never used −0.05 (−0.17, 0.06) −0.12Access and frequently used −0.14 (−0.24, −0.05) −0.17TabletNo access and no use Ref RefAccess but never used −0.03 (−0.15, 0.08) −0.08Access and frequently used −0.05 (−0.15, 0.05) −0.09Video GamesNo access and no use Ref RefAccess but never used −0.06 (−0.14, 0.02) −0.08Access and frequently used −0.07 (−0.18, 0.03) −0.08Cell PhoneNo access and no use Ref RefAccess but never used −0.12 (−0.18, −0.05) −0.13Access and frequently used −0.16 (−0.24, −0.08) −0.18At least one deviceNo access and no use Ref RefAccess but never used −0.08 (−0.20, 0.04) −0.11Access and frequently used −0.11 (−0.20, −0.02) −0.13ReadingNo access and frequent reading Ref RefAccess but frequent reading −0.12 (−0.19, −0.05) −0.15Access and rarely reading −0.19 (−0.27, −0.11) −0.21No access and rarely reading −0.04 (−0.17, 0.08) −0.07aAdjusted for gender of the child, household income, region of elementary school,entertainment and communication devicesbReference categoryice use during the day and access and use in the bedroomd in grade 5 childrenTotal time in bedsted coefficientCI)Unadjusted coefficient(95% CI)aAdjusted coefficient(95% CI)Ref Ref(−0.18, −0.01) −0.07 (−0.16, 0.02) −0.07 (−0.15, 0.02)(−0.20, −0.06) −0.08 (−0.15, −0.00) −0.07 (−0.14, −0.00)95% CI: 0.80, 0.94) (Table 7). Cell phone access and itsfrequent use during the hour before sleep had the greatestimpact on good sleep quality, decreasing it by 36%(OR = 0.64, 95% CI: 0.58, 0.71) (Table 7).Having access to any EECD and rarely reading duringthe hour before sleep (compared to no access and fre-quently reading) decrease good sleep quality by 43%(OR = 0.57, 95% CI: 0.52, 0.63) (Table 7). Among chil-dren with access to EECDs in the bedroom, those whorarely read (compared to those who frequently read)had a 34% decrease in good sleep quality (OR = 0.66,95% CI: 0.61, 0.71) (Data not shown).Ref Ref(−0.22, 0.02) −0.10 (−0.20, 0.00) −0.09 (−0.19, 0.01)(−0.26, −0.08) −0.12 (−0.22, −0.02) −0.15 (−0.23, −0.06)Ref Ref(−0.19, 0.03) −0.05 (−0.13, 0.03) −0.04 (−0.11, 0.03)(−0.18, 0.01) −0.05 (−0.15, 0.05) −0.01 (−0.11, 0.07)Ref Ref(−0.16, −0.01) −0.02 (−0.13, 0.09) −0.04 (−0.14, 0.07)(−0.17, 0.02) −0.03 (−0.13, 0.06) −0.03 (−0.13, 0.06)Ref Ref(−0.20, −0.07) −0.12 (−0.18, −0.05) −0.09 (−0.15, −0.03)(−0.26, −0.09) −0.16 (−0.24, −0.08) −0.13 (−0.22, −0.05)Ref Ref(−0.24, 0.03) −0.08 (−0.20, 0.05) −0.07 (−0.21, 0.06)(−0.23, −0.03) −0.11 (−0.20, −0.02) −0.10 (−0.20, −0.01)Ref Ref(−0.23, −0.08) −0.11 (−0.18, −0.05) −0.11 (−0.18, −0.05)(−0.30, −0.13) −0.17 (−0.25, −0.09) −0.16 (−0.24, −0.07)(−0.19, 0.06) −0.06 (−0.18, 0.06) −0.05 (−0.18, 0.07)highest level of parental education and total daily exposure to electronicevinjus(0(0Dube et al. International Journal of Behavioral Nutrition and Physical Activity  (2017) 14:97 Page 10 of 15Table 7 Effect of electronic entertainment and communication dduring the hour before sleep on sleep quality and sleep efficiencyGood sleep qualityUnadjusted OR (95% CI) aAdTVNo access and no use bRef RefAccess but never used 1.09 (1.01, 1.19) 1.01Access and frequently used 0.90 (0.84, 0.97) 0.86ComputerTotal daily exposure to EECDs was consistently associ-ated with lower good sleep quality of between 8% and9% for all EECDs investigated. Exposure to EECDs dur-ing the day also decreased good sleep quality amongchildren who frequently read during the hour beforesleep (Data not shown).Effects of EECD access and use on sleep efficiencyAlthough frequently using the TV during the hour be-fore sleep significantly decreased very good sleep effi-ciency by 54% (OR = 0.46, 95% CI: 0.39, 0.56), it wasnotable that, the odds of very good sleep efficiency wereNo access and no use Ref RefAccess but never used 0.82 (0.75, 0.90) 0.73 (0Access and frequently used 0.83 (0.75, 0.91) 0.72 (0TabletNo access and no use Ref RefAccess but never used 0.84 (0.76, 0.93) 0.79 (0Access and frequently used 0.87 (0.81, 0.95) 0.82 (0Video GamesNo access and no use Ref RefAccess but never used 0.86 (0.79, 0.93) 0.80 (0Access and frequently used 0.99 (0.90, 1.09) 0.87 (0Cell PhoneNo access and no use Ref RefAccess but never used 0.84 (0.78, 0.90) 0.73 (0Access and frequently used 0.67 (0.61, 0.74) 0.64 (0At least one deviceNo access and no use Ref RefAccess but never used 1.10 (0.99, 1.22) 0.97 (0Access and frequently used 0.96 (0.88, 1.05) 0.87 (0ReadingNo access and frequent reading Ref RefAccess but frequent reading 0.99 (0.92, 1.06) 0.87 (0Access and rarely reading 0.61 (0.56, 0.67) 0.57 (0No access and rarely reading 0.95 (0.83, 1.08) 0.86 (0aAdjusted for gender of the child, household income, region of elementary school,entertainment and communication devicesbReference categoryice use during the day and access and use in the bedroomgrade 5 childrenVery good sleep efficiency (≥95%)ted OR (95% CI) Unadjusted OR (95% CI) aAdjusted OR (95% CI)Ref Ref.93, 1.11) 1.93 (1.56, 2.39) 1.45 (1.13, 1.85).80, 0.94) 0.58 (0.50, 0.66) 0.46 (0.39, 0.56)increased by 45% among children with access to a TV inthe bedroom, though not used during the hour beforesleep (OR = 1.45, 95% CI: 1.13, 1.85) (Table 7). The effectof having access to a tablet or cell phone in the bedroom,whether used or not during the hour before sleep, affectedvery good sleep efficiency to a similar extent (Table 7).Never using a computer during the hour before sleep,although accessible in the bedroom, decreased very goodsleep efficiency by 17% (OR = 0.83, 95% CI: 0.69, 0.98)(Table 7).Compared to having no access to EECDs and frequentlyreading during the hour before sleep, access to EECDs inRef Ref.67, 0.80) 0.77 (0.65, 0.91) 0.83 (0.69, 0.98).65, 0.80) 1.19 (0.98, 1.44) 0.96 (0.79, 1.18)Ref Ref.71, 0.87) 0.97 (0.81, 1.15) 0.58 (0.48, 0.71).76, 0.89) 0.55 (0.46, 0.65) 0.49 (0.42, 0.58)Ref Ref.74, 0.87) 0.74 (0.61, 0.89) 0.91 (0.76, 1.10).79, 0.97) 0.55 (0.48, 0.64) 0.49 (0.41, 0.59)Ref Ref.69, 0.80) 0.84 (0.78, 0.90) 0.56 (0.49, 0.65).58, 0.71) 0.67 (0.61, 0.74) 0.48 (0.41, 0.57)Ref Ref.87, 1.08) 1.29 (1.01 1.65) 1.06 (0.82, 1.37).79, 0.95) 0.59 (0.48, 0.72) 0.52 (0.42, 0.63)Ref Ref.81, 0.94) 0.62 (0.52, 0.75) 0.66 (0.55, 0.80).52, 0.63) 0.36 (0.29, 0.43) 0.33 (0.27, 0.40).76, 0.99) 0.57 (0.44, 0.76) 0.77 (0.58, 1.03)highest level of parental education and total daily exposure to electronicthe bedroom, whether one frequently read during thehour before sleep (OR = 0.66, 95% CI: 0.55, 0.80) ornot (OR = 0.33, 95% CI: 0.27, 0.40), was associatedwith a 34% and 67% decrease in very good sleep effi-ciency respectively. Among children with access toEECDs in the bedroom, those who rarely read (com-pared to those who frequently read) had a 50% de-crease in very good sleep efficiency (OR = 0.50, 95%CI: 0.33, 0.57) (Data not shown). Among those whorarely read, having no access to EECDs in the bed-room doubled the odds of having very good sleep ef-ficiency (OR = 2.04, 95% CI: 1.57, 2.65) whencompared to having access (Data not shown).Effects of EECD access and use on weight statusAfter adjusting for covariates, when compared to the ref-erence, access to a TV and a computer, when frequentlyused during the hour before sleep increased the odds ofbeing overweight by more than 20% and doubled theodds of being obese (Table 8). When accessible in thebedroom, a cell phone was associated with an increasein odds of being overweight (OR = 1.44, 95% CI: 1.32,1.58) and obese (OR = 1.56, 95% CI: 1.24, 1.98), despiteit never being used during the hour before sleep. Simi-larly, access to a TV and video games in the bedroomgreatly increased the odds of obesity although reportedlynot used during the hour before sleep (Table 8). Overall,Table 8 Effect of electronic entertainment and communication device use during the day and access and use in the bedroomduring the hour before sleep on weight status in grade 5 childrenOverweight vs. Normal Obese vs. NormalUnadjusted OR (95% CI) aAdjusted OR (95% CI) Unadjusted OR (95% CI) aAdjusted OR (95% CI)TVNo access and no use bRef Ref Ref RefAccess but never used 1.20 (1.08, 1.32) 1.15 (1.04, 1.28) 2.42 (1.86, 3.14) 2.28 (1.74, 2.98)Access and frequently used 1.22 (1.11, 1.33) 1.21 (1.10, 1.33) 2.90 (2.31, 3.64) 2.56 (2.02, 3.24)ComputerNo access and no use Ref Ref Ref RefAccess but never used 1.01 (0.91, 1.13) 0.99 (0.89, 1.11) 1.08 (0.80, 1.46) 1.17 (0.86, 1.59)Access and frequently used 1.37 (1.23, 1.53) 1.34 (1.20, 1.50) 2.28 (1.77, 2.94) 2.79 (2.15, 3.63)TabletNo access and no use Ref Ref Ref RefAccess but never used 0.81 (0.71, 0.91) 0.76 (0.66, 0.86) 0.73 (0.49, 1.07) 0.84 (0.57, 1.25)Access and frequently used 0.72 (0.65, 0.80) 0.75 (0.67, 0.84) 1.12 (0.86, 1.46) 1.19 (0.91, 1.57)Video GamesNo access and no use Ref Ref Ref RefAccess but never used 1.03 (0.94, 1.14) 0.99 (0.89, 1.09) 1.77 (1.40, 2.23) 1.61 (1.27, 2.05)Access and frequently used 1.02 (0.90, 1.14) 0.80 (0.70, 0.91) 1.32 (0.98, 1.78) 1.10 (0.80, 1.50)Cell Phone(1(1(0(0(1(1(1Dube et al. International Journal of Behavioral Nutrition and Physical Activity  (2017) 14:97 Page 11 of 15No access and no use Ref RefAccess but never used 1.41 (1.29, 1.53) 1.44Access and frequently used 1.20 (1.08, 1.34) 1.28At least one deviceNo access and no use Ref RefAccess but never used 0.99 (0.86, 1.12) 0.92Access and frequently used 1.13 (1.01, 1.27) 1.06ReadingNo access and frequent reading Ref RefAccess but frequent reading 1.22 (1.22, 1.34) 1.18Access and rarely reading 1.41 (1.26, 1.58) 1.19No access and rarely reading 1.64 (1.40, 1.92) 1.42aAdjusted for gender of the child, household income, region of elementary school,entertainment and communication devicesbReference categoryRef Ref.32, 1.58) 1.45 (1.15, 1.82) 1.56 (1.24, 1.98).14, 1.43) 1.25 (0.93, 1.68) 1.31 (0.96, 1.78)Ref Ref.80, 1.05) 0.55 (0.34, 0.90) 0.54 (0.33, 0.88).94, 1.19) 2.04 (1.44, 2.89) 1.82 (1.28, 2.59)Ref Ref.07, 1.31) 1.42 (1.09, 1.86) 1.35 (1.03, 1.77).06, 1.34) 1.43 (1.05, 1.96) 1.09 (0.79, 1.51).20, 1.68) 1.38 (0.86, 2.19) 1.11 (0.69, 1.79)highest level of parental education and total daily exposure to electronicDube et al. International Journal of Behavioral Nutrition and Physical Activity  (2017) 14:97 Page 12 of 15access to at least one device in the bedroom, and fre-quently using it was associated with an 82% increase inodds of obesity (OR = 1.82, 95% CI: 1.28, 2.59) (Table 8).Amongst those with no bedroom EECD access, rarelyreading during the hour before sleep (compared to fre-quently reading) increased the odds of being overweightby 42% (OR = 1.42, 95% CI: 1.20, 1.68) (Table 8). Inaddition, frequently reading with access to EECDs in thebedroom (compared to without) increased the odds ofobesity by 35% (Table 8).Total daily exposure to EECDs was statistically signifi-cantly associated with an increase in weight status ran-ging from 4% to 7% increase in the odds of beingoverweight and 24% to 28% increase in odds of beingobese for all EECDs (Data not shown).DiscussionIn the present study, we found that for most EECDs,both their presence in the bedroom and their frequentuse during the hour before sleep was negatively associ-ated with sleep duration, good sleep quality and verygood sleep efficiency and positively associated withweight status. As expected, the magnitude at which sleepand weight status was affected depended on the EECDin question, however, the TV, computer and cell phonewere identified as common culprits. Rarely reading dur-ing the hour before sleep was associated with a decreasein sleep duration, sleep quality and sleep efficiency andan increase in the chance of being overweight. Havingaccess to EECDs in the bedroom was associated with anincrease in being obese even if children read frequentlyduring the hour before sleep. Exposure to EECDs duringthe day also contributed to their effect on sleep andweight status when they were used in the bedroom dur-ing the hour before sleep.Our findings support the American Academy ofPediatrics recommendation to remove EECDs from thebedroom to improve sleep amongst children [27]. Theobserved negative effect on sleep and weight status thatthe presence of EECDs and their use during the hourbefore sleep have, suggests that an interdependent rela-tionship exists between EECD presence and use in thebedroom during the hour before sleep. This finding begsfor restrictions to EECD use during the hour beforesleep as well as their accessibility in the bedroom. Somemay argue that the decrease in sleep duration associatedwith the use of EECDs an hour before sleep is modest.On the contrary, as little as 15 min difference in sleepduration has been shown to have clinical significance onmental, behavioral and daytime functioning [28]. Wheremultiple EECDs are used, this threshold of 15 min willbe exceeded as demonstrated in a similar study [9]. Ourfindings also show an association of sleep and weightstatus with total exposure to EECDs during the day.Parents should therefore be encouraged to implementEECD limits on use during the daytime in addition torestrictions to bedroom accessibility and use during thehour before sleep. This should begin while their childrenare young so as to develop habits that can be continuedthrough to the teenage and adult years.The negative impact of EECDs when used in the bed-room during the hour before sleep may be related to thebright light emitted from many of these devices [16].The backlight of many EECDs currently being manufac-tured emits diodes rich in blue light. Exposure to bluelight close to bedtime suppresses the release of thesleep-facilitating hormone; melatonin, thereby delayingsleep onset, shortening total sleep duration and affectinggood sleep quality [29, 30]. Exposure time needed to sig-nificantly suppress melatonin production may however,differ between products depending on their built-in abil-ity to decrease brightness as well as filter out blue light[21]. In an experimental trial involving tablets, re-searchers found that after exposure to light from self-luminous Apple iPad® tablets for one hour, the tablets’built-in lighting did not suppress melatonin productionsignificantly, and therefore, did not delay sleep onset.However, after a two-hour exposure to the same tablets,melatonin production was significantly suppressed,delaying sleep onset [21]. The effect of tablets on sleeplatency observed in this trial is consistent with the effectof tablets on sleep duration and weight status observedin our study. We suspect that the duration of exposure(1 h or less) amongst children who used tablets beforesleep was insufficient to significantly suppress melatoninproduction and to have a meaningful effect on sleepduration.A number of cross-sectional studies have shown thatEECDs affect sleep and weight status when accessiblein the bedroom even if they are reportedly not used[31–34]. Similarly, in our study, a large number ofEECDs investigated negatively affected sleep and weightstatus when accessible in the bedroom even if childrenreported these were not used during the hour beforesleep. A possible reason for this maybe that the pres-ence of EECDs in the bedroom is a mediator for use[35]. Therefore, we speculate that reporting bias regard-ing actual use of EECDs during the hour before sleepmay exist which explains why sleep (duration, quality,and efficiency) as well as weight status was negativelyaffected when EECDs were accessible in the bedroom,though reportedly never used during the hour beforesleep. These children may have used these devices butreported otherwise due to fear of their parents findingout. The positive effect that TV access in the bedroomhad on very good sleep efficiency among students whonever used it during the hour before sleep is notable.This is inconsistent with the effect that other screensDube et al. International Journal of Behavioral Nutrition and Physical Activity  (2017) 14:97 Page 13 of 15investigated here have shown. Chaput et al. (2014) re-cently found that the presence of one screen in the bed-room does not lower sleep efficiency. Although numberof screens in the bedroom was not investigated here,the presence of only the TV in the bedroom that wasnever used decreased any sleep interruptions and there-fore increased very good sleep efficiency. As opposed toa TV, having access to a computer, tablet, video gamesand a cell phone though never used an hour beforesleep negatively affected very good sleep efficiency. Cellphone access in the bedroom, even when not in use,has previously been shown to impact negatively onsleep by giving off alerts for incoming calls or messages[36]. By the same token, tablets may give off alerts evenwhen not in use while computers and video games maycontinually flicker and make sounds that disturb sleep,particularly when left in stand-by mode.The increase in weight status associated with theinterdependent presence and use of EECDs duringthe hour before sleep is consistent with our previousstudy which reported that both presence of EECDs inthe bedroom and their use at night were associatedwith lower diet quality, less physical activity and in-creased odds of being overweight or obese in a differ-ent sample of grade 5 students [9]. As expected, theuse of EECDs at night displaces sleep thereby short-ening sleep duration. Typically, short sleep durationimpacts weight status by decreasing the production ofleptin, an appetite-suppressing hormone, and increas-ing that of ghrelin, an appetite-stimulating hormonecausing those using EECDs closer to bedtime to eatmore [37, 38].The potential for negative long-term impacts of EECDuse at night, may indicate an urgency to address the use ofEECDs before sleep. Nuutinen et al. (2013) reportedthat children who watched TV and used a computerin their bedroom had significantly shorter sleep dur-ation and later bedtimes than their counterparts.Shorter sleep duration persisted 18 months later [31],suggesting long-term negative effects of EECD use inthe bedroom. In fact, the World Health Organizationhas classified exposure to bright light after dark as acarcinogen after observations of increased incidenceof cancers amongst night-shift workers [39–41]. Pro-longed exposure to bright light after dark, such aswhat occurs among chronic night-users of EECDs,causes chronic suppression of melatonin.In place of engaging in stimulating interactive activitieswith bright lights, we found that frequently reading abook during the hour before sleep without EECD accessin the bedroom, is key to a longer sleep duration, goodsleep quality, very good sleep efficiency, and normalweight status. A recent study showed that reading aprinted book under reflected light has a significantpositive impact on restorative sleep, morning alertnessand the circadian cycle compared to reading a bookfrom a light-emitting eReader [29]. Based on our resultsand other supporting literature [29, 30], we recommendthat children should not have access EECDs in theirbedroom, and should refrain from using EECDs duringthe hour before sleep. Instead, parents should encouragechildren to read a book, preferably printed and with dimlighting, during the hour before sleep. Parental rules tocontrol chronic EECD use have been found to be effect-ive [42], and may be applied in our population.Our findings need to be interpreted within confines of anumber of limitations. Firstly, as a cross sectional study,temporality, hence, causality cannot be determined. Therelationship of the exposures (EECDs access and use) andthe outcomes (sleep duration, sleep quality, sleep effi-ciency and weight status) may be bidirectional [43]. Sec-ondly, all sleep measures are self-reported and basedmainly on parental reports. Parental reports regardingsleep problems have been shown to disagree widely withreports from children, and are therefore prone to error[44]. Reports of children as young as 6 years old have beenshown to be valid and add valuable information regardingmedical history, behavior and health care [45]. Nonethe-less, a more objective measure of sleep, such as that fromactigraphy, may improve the validity of study findings.Thirdly, the sample, comprising exclusively of grade 5elementary school children, is not representative of thegeneral population limiting generalizability; however, thisdoes not discredit any associations found. Lastly, the out-comes studied may have been associated with additionalfactors such as how long the children were exposed toEECDs during the hour before sleep. Such factors not in-vestigated here could have resulted in residual confound-ing. Further experimental studies should be conducted toexplore how EECD content, type of video games or vari-ous uses of cell phones (e.g. calling versus social media) af-fects sleep and weight status. Additionally, experimentalstudies on how best to prevent EECD use during the hourbefore sleep in an era of booming technology and pro-mote reading a printed book instead are required. Despitethese limitations, our study has several strengths. Asa school-based survey, the response rate and result-ing large sample size increased our study power.This is the first study, to our knowledge, to specific-ally focus on the use of a wide range of EECDs anddistinguish between mere bedroom access and actualuse within a specified time period before sleep, andhow this impacts sleep and weight status. Finally,our study assessed the impact of reading a book onsleep duration, good sleep quality, very good sleepefficiency and weight status comparing and contrast-ing this with the use of various EECDs which addsto its novelty.13. Nielsen LS, Danielsen KV, Sorensen TI. Short sleep duration as a possibleDube et al. International Journal of Behavioral Nutrition and Physical Activity  (2017) 14:97 Page 14 of 15ConclusionsIn conclusion, we have demonstrated that there mayindeed be unappreciated effects of access to EECDsin the bedroom on sleep (duration, quality and effi-ciency) and weight status, more so, when EECDs arereportedly used during the hour before sleep. Ourfindings highlight the importance of ensuring thatparents not only remove all EECDs from their chil-dren’s bedroom but also discourage their use duringthe hour before sleep. Alternatively, children shouldbe encouraged to read a book during the hour beforesleep as this may improve sleep duration, sleep qual-ity and sleep efficiency and decrease prevalence ofoverweight and obesity.AbbreviationsBMI: Body Mass Index; CA$: Canadian dollars; EECD(s): Electronicentertainment and communication device(s); OR: Odds ratio; REALKids: Raising healthy Eating and Active Living Kids; TTIB: Total time in bed;TV(s): Television(s)AcknowledgementsWe would like to thank the reviewers who gave valuable feedback regardingthis publication. We are grateful to all grade 5 children, parents, and schoolsfor their participation in the study. We also thank the evaluation assistantsand school health facilitators for their contribution during data collection. Allinterpretations and opinions in the current study are those of the authors. Part ofthe results from this research have been presented at the 15th Annual meeting ofthe International Society of Behavioral Nutrition and Physical Activity, Cape Town,South Africa, 8 – 11 June 2016.FundingThe REAL Kids Alberta survey was funded through Alberta Health. Thepresent analysis was funded through the Collaborative Research andInnovation Opportunities (CRIO) Team program from Alberta Innovates-Health Solutions. ND received a postdoctoral stipend through this CRIO pro-gram and through the Women and Children’s Health Research Institute. PJVholds a Canada Research Chair in Population Health, an Alberta ResearchChair in Nutrition and Disease Prevention, and an Alberta Innovates HealthScholarship. All interpretations and opinions in the present study are thoseof the authors.Availability of data and materialsThe approval for the current study granted by the Health Research EthicsBoard at the University of Alberta was granted on the basis that all datawould be kept confidential and would be stored and used in adherence tothe guidelines established by the University. For these reasons, data areavailable upon request and requests can be made by contacting thePrincipal Investigator of the study, Dr. Paul Veugelers.Authors’ contributionsConceived and designed the study: ND MK PV. Analyzed the data: NM, MK.Wrote the paper: ND MK SL YC PV. All authors read and approved the finalmanuscript.Ethics approval and consent to participateThe protocol for the current survey was included in that of a larger study, theReal Kids Alberta survey approved by the Health Ethics Research Board at theUniversity of Alberta. All parents provided written consent for their children totake part in the survey.Consent for publicationNot applicable.Competing interestsThe authors declare that they have no competing interests.cause of obesity: critical analysis of the epidemiological evidence. Obes Rev.2011;12(2):78–92.14. Wolfson AR, Carskadon MA. Understanding adolescents' sleep patternsand school performance: a critical appraisal. Sleep Med Rev. 2003;7(6):491–506.15. Vgontzas AN, Bixler EO, Chrousos GP. Metabolic disturbances in obesityversus sleep apnoea: the importance of visceral obesity and insulinresistance. J Intern Med. 2003;254(1):32–44.16. Fossum IN, Nordnes LT, Storemark SS, Bjorvatn B, Pallesen S. The associationbetween use of electronic media in bed before going to sleep andinsomnia symptoms, daytime sleepiness, morningness, and chronotype.Behav Sleep Med. 2014;12(5):343–57.17. Kuehni CE, Strippoli MP, Chauliac ES, Silverman M. Snoring in preschoolchildren: prevalence, severity and risk factors. 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