Introduction

Epidemiological studies have shown that the prevalence of allergic rhinitis (AR) is quite high in Asia. A national survey in China showed that the prevalence of childhood asthma has been on the rise since the past 20 years. Studies have also linked sleep impairment to increased incidence of AR and asthma. The incidence of new-inset asthma has been associated with insufficient sleep duration and sleep-disordered breathing. The results of studies evaluating the impact of physical activity on asthma and/or AR are mixed. There is no data on combined effects of sleep quality and physical activity on the prevalence of asthma and AR in children.

Aim

To assess the combined effects of sleep quality and outdoor activities on asthma and AR in children.

Method

Study Design

Treatment Strategy

• The study analyzed 16,936 children aged between 3-12 years from 31 kindergartens and 17 primary schools in 13 administrative districts of Shanghai, China
• Of these, 11.4% and 9.2% were diagnosed with asthma and AR respectively
• The outdoor activity was assessed by a question, and the children were then classified into two groups: moderate outdoor activities <3 times/week and >3 times/week
• The children were classified into 4 groups:   
  1. Good sleep quality and high outdoor activity frequency (Good SQ & high OA)
  2. Good sleep quality and low outdoor activity frequency (Good SQ & low OA)
  3. Poor sleep quality and high outdoor activity frequency (Poor SQ & high OA)
  4. Poor sleep quality and low outdoor activity frequency (Poor SQ & low OA)
• Multivariable logistic regression models were used to analyze the correlation of sleep quality, outdoor activities and their combined effects on asthma and AR
• Covariates used in the model included age, gender, family history of allergy, education of parents, mode of delivery, breastfeeding, family income, history of sleep disorder of parents, overweight/obesity and premature birth

Endpoints

• Quality of sleep evaluated using the Children’s Sleep Habits Questionnaire (CSHQ)
• Asthma and AR were assessed using the International Study of Asthma and Allergies in Childhood (ISAAC) questionnaire 

Results

• The overall prevalence of asthma and AR was 10.2% and 17.6%, respectively
• Children with asthma were more likely to have a poor sleep quality (86.7% bs 80.1%) and low outdoor activity frequency (73.4% vs 68.8%)
• The children with AR had no significant differences in sleep quality, however they had low outdoor activity frequency (74.4% vs 68.8%)
• When the combined effect of both factors was analyzed, the proportions of children with asthma and AR was as seen in Figure 1

Figure 1. Prevalence of asthma and AR across the groups

• After adjustment of confounding factors, sleep quality correlated with a higher risk of both asthma (aOR 1.45) and AR (aOR 1.16)
• Multivariable analyses revealed that less frequent outdoor activity increased the risk of asthma (aOR 1.30) and AR (aOR 1.18)
• These associations were independent of sleep duration, but being stronger in subgroup of long sleepers (>10 hrs/day)
• Similar associations were validated after stratification by gender, premature birth and family history of allergy

Conclusion

• The synergistic effect of poor sleep quality and low outdoor activity is more pronounced on the prevalence of asthma and allergic rhinitis in children, as compared to its individual effects and is independent of sleep duration.
• The findings emphasize on the need of public health strategies targeting multiple lifestyle factors to reduce the risk of allergic disease.

J Asthma Allergy. 2025 Feb 4; 18:101–111. Doi: 10.2147/JAA.S494662.