The lack of sleep among upstate New York adults,...

T H E F A C T S A B O U T

The lack of sleep among upstate New York adults,2008-2009

1 of 13Fall 2010

Central New York Region

Average hours of sleep: 7.0

Percent of days having trouble sleeping: 22%

Finger Lakes Region



Western New York Region



Southern Tier Region



Utica/Rome/North Country Region



Source: New York State Department of Health, Behavioral Risk Factor Surveillance System,2008 & 2009. To request access: http://www.health.state.ny.us/nysdoh/brfss/

NOTE: Upstate New York refers to the counties highlighted in the map above.

Upstate New York



New York State



2 of 13Fall 2010

Adequate sleep, while as critical as proper nutrition, is often overlooked as a key component of good

health. An estimated 50 million to 70 million Americans – about one in five – have sleep problems.1

The health and functional importance of sleep is not well understood. Although often unrecognized

as serious, lack of sleep is associated with many physical and mental health problems, including

injury, chronic health conditions, and mortality. Insufficient rest may contribute to obesity, diabetes,

heart disease and other age-related, chronic and high-cost disorders.2

Difficulties with sleep profoundly affect daily living and have broader societal implications, such as

the risks associated with unsafe driving and resulting accidents, and the health care cost implications

of a prescription drug market flooded with sleep remedies.

This fact sheet examines the sleep patterns of upstate New Yorkers and the negative effects of

insufficient sleep, including the serious and rising chronic health problems prevalent in upstate New

York. The report concludes with a discussion of lifestyle and behavioral changes that can increase the

amount and quality of sleep and contribute to better overall health.

Sleep patterns among upstate New York adults

The New York State Department of Health’s Behavioral Risk Factor Surveillance System (BRFSS)

surveys residents about their sleep habits by asking them to gauge the average number of hours

they have slept each day in the previous 30 days and the average number of days they had trouble

sleeping over the past two weeks.

The need for sleep is governed not only by how much time people are asleep, but also by sleep

quality. Though there are individual variations, seven to eight hours of sleep per night is best for

most adults.3 Too much sleep and too little sleep is problematic. The length of time that Americans

devote to sleep per day has decreased by 1.5 to 2 hours per day over the last 50 years.4

Nontraditional work schedules, combined with extensive family and social demands, pose a chal-

lenge to regularly getting optimal sleep. “Burning the candle at both ends” has become common.

Despite expert recommendations that most adults should get seven to eight hours of sleep per day,

upstate New Yorkers on average fall on the low end of or below this standard.

3 of 13Fall 2010

Average hours of sleep per day among upstate New Yorkadults by region, 2009

Source: New York State Department of Health, Behavioral Risk Factor Surveillance System, 2009. To request access: http://www.health.state.ny.us/nysdoh/brfss/

Of upstate New York adults reporting the average number of hours they slept per day of the previous

30 days:

• Hours of sleep are barely optimal across the board: upstate (6.9 hours), New York state

(6.9 hours) and the United States (7.0 hours);

• Residents of upstate New York averaged from 6.6 hours of sleep per night in Utica/Rome/North

Country to 7.1 hours in the Southern Tier.

Central New York

FingerLakes

SouthernTier

Utica/Rome/North

Country

WesternNew York

UpstateNew York

New York State

UnitedStates

Ho

urs

0

1

2

3

4

5

6

7

8

9

7.0 6.9 7.1

6.6 6.8 6.9 6.9 7.0

Optimal sleep hours for adults is 7 to 8 hours

4 of 13Fall 2010

Percent of time upstate New York adults had trouble sleeping, 2008


When upstate New York adults were asked to report the number of days of the last two weeks in which

they had difficulty sleeping (trouble falling asleep, staying asleep or sleeping too much):

• They reported having trouble sleeping on average 24 percent of the time (3.3 days),

which is slightly higher than the average statewide (3.0 days or 21 percent of the time)

and nationally (2.8 days or 20 percent of the time).

• Finger Lakes residents reported the lowest average number of troubled days, 21 percent

of the time (2.9 days), while those in Utica/Rome/North Country reported the highest,

30 percent of the time (4.2 days).

Central New York

FingerLakes

SouthernTier

Utica/Rome/North

Country

WesternNew York

UpstateNew York

New York State

UnitedStates

Perc

ent

of

last

tw

o w

eeks

0%

5%

10%

15%

20%

25%

30%

35%

22% 21%23%

30%

24% 24%

21%20%

5 of 13Summer 2010

In upstate New York over a two-week period, women had trouble sleeping on average 26 percent of

the time (3.7 days), while men had trouble sleeping on average 21 percent of the time (2.9 days).

Source: New York State Department of Health, Behavioral Risk Factor Surveillance System, 2008, 2009. To request access: http://www.health.state.ny.us/nysdoh/brfss/

Gender differences in sleep patterns among upstate New York adults

The percentage of U.S. adults sleeping six or fewer hours in a 24-hour period increased between

1985 and 2004 across both genders and all age groups.5 In upstate New York, men and women

averaged 6.9 hours per day, slightly below the recommended number of hours. Insomnia (difficulty

falling or staying asleep or short sleep duration in spite of having an adequate opportunity for

sleep)6 affects more women than men, partly due to female hormonal changes (menstruation,

pregnancy, and menopause) and the higher likelihood that women have of suffering from anxiety

and depressive disorders.7

Percent of time upstate New York adults had trouble sleeping by gender, 2008

26% 21%

6 of 13Fall 2010

Of upstate New York adults reporting the average number of hours they slept per day in the

previous 30 days:

• The average hours of sleep for young adults (ages 18 to 29) is similar to the average for all

upstate New York adults, 6.9 hours;

• Middle-aged adults (ages 30 to 64) reported averaging the fewest number of hours per day,

6.7 hours;

• Older adults (over age 65), averaging 7.4 hours, were the only age group studied

that fell within the recommended seven to eight hours for adults;

• Young adults reported having trouble sleeping an average of 4.6 days within the past two

weeks (33 percent of the time), more than middle-aged adults (3.2 days or 23 percent of the

time) and older adults (2.3 days or 16 percent of the days). (Data not shown.)


Age differences in sleep patterns among upstate New York adults

Changes in the amount and quality of sleep have been associated with age.8 50 percent of adults

age 60 and older have sleep disturbances such as insomnia.9 It is unknown whether this is a normal

part of the aging process or due to medical conditions and/or medications that interfere with sleep.10

A study of people over age 65 found that 13 percent of men and 36 percent of women take longer

than 30 minutes to fall asleep.11

Average hours of sleep per day among upstate New York adults by age, 2009

6.9hours

18-29 year olds

6.7hours

30-64 year olds

7.4hours

65+ year olds

7 of 13Fall 2010

Among motor vehicle drivers, sleepiness manifests itself in slower reaction times, reduced awareness

of road conditions and an inability to properly interpret immediate surroundings. Crashes due to

sleep impairment are likely to be underreported and inconsistently reported across jurisdictions.12

By conservative estimates from the National Highway Traffic Safety Administration, sleep-impaired

driving in the United States is implicated in 100,000 motor vehicle accidents each year, resulting in

1,550 deaths and 40,000 injuries.13 Sleep-impaired driving stems from chronic and episodic sleep loss,

medication use, sleep disorders and alcohol consumption. New York state police report that each

year, about 2,800 people are involved in crashes reported as being caused by fatigue or falling

asleep.14

The 2009 BRFSS survey asked drivers whether they had nodded off or fallen asleep (even for a brief

moment) while driving within the previous 30 days. Altogether, 132,000 upstate New York drivers

acknowledged falling asleep or “nodding off” at the wheel.15

Sleep-related impairment among upstate New York motor vehicle drivers

Area Percent of Drivers Number of DriversCentral New York 1.9% 12,000

Finger Lakes 5.5% 34,000

Southern Tier 3.7% 11,000

Utica/Rome/North Country 5.3% 24,000

Western New York 5.7% 51,000

Upstate New York 4.5% 132,000


Upstate New York drivers who reported nodding off or falling asleep while driving in 2009

8 of 13Fall 2010

Some research supports an association between regular exercise and improved sleep quality with

varying results by age, exercise intensity and underlying health conditions. Studies have focused on

the positive effect of exercise on middle-aged to older adults16,17,18 but experts warn that exercise too

close to bedtime can inhibit sleep.19

Although there is little difference in the reported average number of hours of sleep among upstate

New York adults who participated in physical activity (6.9 hours) versus those who did not (6.8 hours),

both averages fell below the seven to eight hours of recommended sleep (data not shown).

Exercise and sleep

Did not exercise in the past 30 days and had sleep difficulty

Exercised in the past 30 days and had sleep difficulty

Impact of exercise on percent of days upstate New York adults had trouble sleeping, 2008

There was a difference in the quality of the hours of sleep between those who exercised and those

who did not:

• Those who reported no physical activity within the previous 30 days averaged 4.5 days of

sleep difficulty (32 percent of the time) within the past two weeks.

• Those who exercised within the previous month reported on average fewer days of sleep

difficulty (2.9 days or 21 percent of the time) within the past two weeks.


32%21%

9 of 13Fall 2010

The negative impact of sleep problems

Sources: Obtained from Statewide Planning andResearch Cooperative System (SPARCS), 2006-2008. To request access:http://www.health.state.ny.us/statistics/sparcs/datareq.htm

Lack of adequate and regular sleep has a negative impact on health and has been associated with

chronic conditions such as obesity, high blood pressure, heart disease, depression and diabetes.

Researchers don’t know fully whether sleep disruption leads to these clinical problems or the

problems disturb sleep.20

The prevalence of several chronic conditions associated with insufficient sleep has been increasing

among upstate New York adults. A comparison of the 2001 and 2009 BFRSS surveys shows substan-

tial increases in the prevalence of overweight/obesity (from 58.4 percent in 2001 to 67.5 percent

in 2009); high cholesterol (32 percent to 39.0 percent); and high blood pressure (28.7 percent to

32.4 percent).

According to the National Institutes of Health, chronic sleep loss or sleep disorders cost the United

States an estimated $16 billion in health care expenses and $50 billion in lost productivity.21 The

National Highway Traffic Administration estimates that $12.5 billion is spent each year for damages

resulting from sleep-impaired automobile accidents.22

Studies linking lack of sleep and weight gain show that obesity can contribute to sleep problems,

but having difficulty sleeping may also lead to obesity. Reduced sleep affects the secretion of two

hormones related to appetite: ghrelin (which triggers appetite) is increased; and leptin (which

reduces appetite) is decreased.23

People who are overweight or obese are at higher risk for numerous serious medical conditions,

particularly type 2 diabetes, hypertension, heart disease and stroke.

Difficulties falling asleep, staying asleep or early waking lead to fatigue, depression and an inability

to function at full capacity. Inadequate sleep can result from poor sleep habits or sleep disorders

that interfere with consistently sleeping seven to eight hours a night.

10 of 13Fall 2010

What can be done to improve sleep?

Sleep problems can be treated by a number of interventions ranging from adopting healthier habits

to trying more complicated medical, pharmaceutical or surgical interventions.

For many people, changing daily routines such as avoiding alcohol near bedtime, quitting smoking,

losing weight, shifting sleep positions and changing the sleep environment may relieve the

symptoms of sleep apnea (a sleep disorder with brief interruptions of breathing during sleep24) and

help insomnia.

Tips for getting a good night’s sleep

The National Heart, Lung, and Blood Institute of the National Institutes of Health suggests a range of dietary andother lifestyle changes to promote better sleep hygiene:

Stick to a sleep schedule. Go to bed and wake up the same time each day. As creatures of habit, people have ahard time adjusting to altered sleep patterns. Sleeping later on weekends won’t fully make up for the lack of sleepduring the week and will make it harder to wake up early on Monday morning.

Exercise is great but not too late in the day. Try to exercise at least 30 minutes on most days but not later than5 or 6 hours before your bedtime.

Avoid caffeine and nicotine. Coffee, colas, certain teas, and chocolate contain the stimulant caffeine, and itseffects can take as long as 8 hours to wear off fully. Therefore, a cup of coffee in the late afternoon can make ithard for you to fall asleep at night. Nicotine is also a stimulant, often causing smokers to sleep only very lightly. Inaddition, smokers often wake up too early in the morning because of nicotine withdrawal.

Avoid alcoholic drinks before bed. You may think having an alcoholic “nightcap” will help you sleep, but alcohol robs you of deep sleep and REM sleep, keeping you in the lighter stages of sleep. You also tend to wake upin the middle of the night when the effects of the alcohol have worn off.

Avoid large meals and beverages late at night. A light snack is okay, but a large meal can cause indigestionthat interferes with sleep. Drinking too many fluids at night can cause frequent awakenings to urinate.

If possible, avoid medicines that delay or disrupt your sleep. Some commonly prescribed heart, blood pressure, or asthma medications, as well as some over-the-counter and herbal remedies for coughs, colds, or aller-gies, can disrupt sleep patterns. If you have trouble sleeping, talk to your doctor or pharmacist to see if any drugsyou’re taking might be contributing to your insomnia.

Don’t take naps after 3 p.m. Naps can help make up for lost sleep, but late afternoon naps can make it harderto fall asleep at night.

Relax before bed. Don’t overschedule your day so that no time is left for unwinding. A relaxing activity, such asreading or listening to music, should be part of your bedtime ritual.

Take a hot bath before bed. The drop in body temperature after getting out of the bath may help you feel sleepy,and the bath can help you relax and slow down so you’re more ready to sleep.

Have a good sleeping environment. Get rid of anything that might distract you from sleep, such as noises,bright lights, an uncomfortable bed, or warm temperatures. You sleep better if the temperature in your bedroom iskept on the cool side. A TV or computer in the bedroom can be a distraction and deprive you of needed sleep.Having a comfortable mattress and pillow can help promote a good night’s sleep.

Source: “Your Guide to Healthy Sleep,” National Institutes of Health, National Heart, Lung, and Blood Institute, NIH Pub No. 06-5271 11-5, p. 30http://www.nhlbi.nih.gov/health/public/sleep/healthy_sleep.pdf

11 of 13Fall 2010

Additional measures to take to avoid sleep problems and their associated risks

• Talking with a primary care physician about sleep issues can shed light on what symptoms mean

and help identify appropriate treatment approaches. For more serious sleep disorders such as sleep

apnea, a primary care physician may recommend consulting a sleep specialist.

• Exploring cognitive behavioral therapy25 which offers training techniques to reduce anxiety that

can interfere with sleep. Researchers in a randomized controlled study compared cognitive

behavioral therapy with sleep medication and concluded that young and middle-aged patients

fare better with cognitive behavioral therapy alone rather than with medication and recommend-

ed that cognitive behavioral therapy be the first-line intervention.26

• Using pharmaceuticals wisely. Although sleep medications are widely promoted for sleep

disturbances, they are most effective for short-term use and to treat the symptoms of poor sleep.

They do not treat the underlying causes of sleep disruptions and can be dangerous if misused.

Americans received 56 million sleep prescriptions in 2008, a 7 percent increase from the previous

year.27 That doesn’t include the over-the-counter sleep aids, herbs, vitamins and minerals for which

little research substantiates long-term effectiveness.28

• Taking safe driving precautions by napping before a long drive, not driving alone, consuming

caffeine and avoiding alcohol and driving between midnight and 6 a.m.

• Minimizing the effect of alternative work schedules on safety and well-being. Employers can

educate workers about the dangers of driving while drowsy and ways to improve their sleep.29

Workers can structure their home environment to make it more conducive to sleep, improve their

own habits to support sleep, and work with their families to support their efforts.30

• Implementing environmental or societal actions to address drowsy driving. When the New York

State Thruway Authority installed rumble strips on roadways, run-off-road crashes decreased 34

percent, even though the overall crash rate increased 11 percent during the same time period.31

Increasing the number of safe stopping and resting areas make roads safer. Requiring long-

distance drivers to take fatigue management programs and regulating the number of hours truck

operators are on the road can help reduce the rate of crashes due to lack of sleep.32

• Targeting public education to reduce drowsy driving accidents among men ages 16 to 24,

commercial vehicle operators, shift workers and other at-risk motorists.

• Treating sleep disorders that do not improve with lifestyle changes. Sleep apnea and other sleep-

disordered breathing conditions (pauses or difficulty in breathing during sleep) can be treated

with an oral appliance, a continuous positive airway pressure device or surgery.33

12 of 13Fall 2010

Primary data sources

Prevalence (self-reported) data were obtained from the New York State Department of Health’s 2008

and 2009 Behavioral Risk Factor Surveillance System (BRFSS). This is an ongoing, state-based, random

telephone survey of the non-institutionalized civilian adult population ages 18 and older. State and

national data are compiled and reported by the Centers for Disease Control and Prevention.

The BRFSS questionnaire asks all respondents:

• On average, how many hours of sleep do you get in a 24-hour period? Think about the time

you actually spend sleeping or napping, not just the amount of sleep you think you should

get. (Number of hours of sleep is recorded in whole numbers, rounding 30 minutes or more

up to the next whole hour and dropping 29 or fewer minutes to the previous one.)

• Over the last two weeks, how many days have you had trouble falling asleep or staying

asleep or sleeping too much?

• During the past month, other than your regular job, did you participate in any physical

activities or exercises such as running, calisthenics, golf, gardening or walking for exercise?

BRFSS asks drivers:

• During the past 30 days, have you ever nodded off or fallen asleep, even just for a brief

moment, while driving?

To request access to the BRFSS data: http://www.health.state.ny.us/nysdoh/brfss/index.htm

13 of 13Fall 2010

Endnotes1 National Center on Sleep Disorders Research, “2003 National Sleep Disorders Research Plan,” Publication No. 03-5209, July 2003, p. vii,http://www.nhlbi.nih.gov/health/prof/sleep/res_plan/sleep-rplan.pdf US Census Bureau, “State & County Quick Facts,” Aug 16, 2010, http://quickfacts.census.gov/qfd/states/00000.html

2 National Center on Sleep Disorders Research, p. 49.

3 National Institute of Neurological Disorders and Stroke, “Brain Basics: Understanding Sleep,” May 21, 2007, p. 2 http://www.ninds.nih.gov/disorders/brain_basics/understanding_sleep.htm

4 Eve Van Cauter, Ph.D.., Kristen Knutson, Ph.D., Rachel Leproult, Ph.D., and Karine Spiegel, Ph.D., “The Impact of Sleep Deprivation on Hormones and Metabolism,”Medscape Neurology & Neurosurgery, Apr. 28, 2005, http://cme.medscape.com/viewarticle/502825

5 Centers for Disease Control and Prevention, MMWR, “Percentage of Adults Who Reported an Average of <6 Hours of Sleep per 24-Hour Period, by Sex and Age Group–United States, 1985 and 2004,” Sept. 23, 2005 / 54(37);933, http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5437a7.htm


7 University of Maryland Medical Center, “Insomnia – Risk Factors” Jun. 23, 2009, p. 1 http://www.umm.edu/patiented/articles/who_has_insomnia_000027_4.htm


9 National Institute on Aging, National Institutes of Health, “Sleep and Growing Older,” p. 1, http://www.sleepeducation.com/Topic.aspx?id=30

10 National Institute of Neurological Disorders and Stroke, p. 2.

11 National Institute on Aging, p. 1

12 National Highway Traffic Safety Administration, Expert Panel on Driver Fatigue and Sleepiness “Drowsy Driving and Automobile Crashes,” p. 3, http://www.nhlbi.nih.gov/health/prof/sleep/drsy_drv.pdf

13 National Highway Traffic Safety Administration, "Research on Drowsy Driving, http://www.nhtsa.gov/Driving+Safety/Distracted+Driving/Research+on+Drowsy+Driving

14 SafeNY.com, “Drowsy Driving & Fatigue, p.1, http://www.safeny.com/drow-ndx.htm#Introduction

15 StateMaster.com, “Transportation Statistics > Licensed Drivers > Total number (most recent) by state,” http://www.statemaster.com/red/graph/trn_lic_dri_tot_num-transportation-licensed-drivers-total-number&b_printable=1and the US Census Bureau, http://www.census.gov/popest/counties/asrh/files/cc-est2009-agesex-36.csv

16 Shelley S. Tworoger, Ph.D.; Yutaka Yasui, Ph.D.; et. al. “Effects of a Yearlong Moderate-Intensity Exercise and a Stretching Intervention on Sleep Quality in Postmenopausal Women,” Sleep, Volume 26 Issue 07, http://www.journalsleep.org/ViewAbstract.aspx?pid=25885

17 Abby C. King, Ph.D.; Roy F. Oman, Ph.D.; Glenn S. Brassington, MA; Donald L. Bliwise, Ph.D.; William L. Haskell, Ph.D., “Moderate-intensity exercise and self-rated quality of sleep in older adults. A randomized controlled trial,” JAMA. 1997 Jan 1;277(1):32-7, http://jama.ama-assn.org/cgi/reprint/277/1/32.pdf

18 Duane L. Sherrill, Ph.D.; Kimberly Kotchou, MPH; Stuart F. Quan, M.D., “Association of Physical Activity and Human Sleep Disorders,” Archives of Internal Medicine, Vol. 158, Sep. 28, 1998, http://archinte.ama-assn.org/cgi/reprint/158/17/1894

19 MayoClinic.com, “Exercise: 7 benefits of regular physical activity,” Jul. 25, 2009, p. 3, http://www.mayoclinic.com/health/exercise/HQ01676/NSECTIONGROUP=2

20 Harvard School of Medicine, Division of Sleep Medicine, “Sleep and Disease Risk,” Dec. 18, 2007. http://healthysleep.med.harvard.edu/healthy/matters/consequences/sleep-and-disease-risk

21 National Institute of Health National Heart, Lung, and Blood Institute, “Your Guide to Healthy Sleep,” NIH Pub No. 06-5271 November 2005, p. 2, http://www.nhlbi.nih.gov/health/public/sleep/healthy_sleep.pdf

22 Safe.NY.com, “Drowsy Driving Awareness,” http://www.safeny.com/media/DDAwarenessFactSheet.pdf

23 Qanta A. Ahmed, “Sleep Deprivation: The Metabolic Costs of Chronic Partial Sleep Loss,” M.D., FCCP, PCCSU, American College of Chest Physicians, p. 2, http://www.chestnet.org/accp/pccsu/sleep-deprivation-metabolic-costs-chronic-partial-sleep-loss?page=0,3

24 National Institute of Neurological Disorders and Stroke, National Institutes of Health, NINDS Sleep Apnea Information Page, Jul. 26, 2010, p. 1 http://www.ninds.nih.gov/disorders/sleep_apnea/sleep_apnea.htm?css=print

25 MedicineNet.com, “Definition of Cognitive therapy” Jun. 10, 2004, “A relatively short-term form of psychotherapy based on the concept that the way we think about things affects how we feel emotionally. Cognitive therapy focuses on present thinking, behavior, and communication rather than on past experiences and is oriented toward problem solving. Cognitive therapy is sometimes called cognitive behavior therapy because it aims to help people in the ways they think (the cognitive) and in the ways they act (the behavior),” http://www.medterms.com/script/main/art.asp?articlekey=31748

26 Gregg D. Jacobs, Ph.D.; Edward F. Pace-Schott, MA; Robert Stickgold, Ph.D.; Michael W. Otto, Ph.D., “Cognitive behavior therapy and pharmacotherapy for insomnia: a randomized controlled trial and direct comparison,” Archives of Internal Medicine, Vol. 164, Sep 27, 2004, p.1, http://archinte.ama-assn.org/cgi/reprint/164/17/1888

27 Lloyd, Janice, “Insomnia therapy: What works, what doesn't?,” USA Today, Jul 23, 2009, http://www.usatoday.com/news/health/2009-07-22-insomnia_N.htm

28 Clinical Practice Review Committee, “Do Drugstores Have the Cure for Your Insomnia? Taking a Closer Look at Common Treatments,” Jan. 10, 2005, American Academy of Sleep Medicine, p. 4, http://www.sleepeducation.com/Article.aspx?id=2%20

29 National Highway Traffic Safety Administration, (NHTSA), “The Road To Preventing Drowsy Driving Among Shift Workers Employer Administrator’s Guide,” http://www.nhtsa.gov/people/injury/drowsy_driving1/human/drows_driving/resource/FatigueAdmin.pdf

30 National Highway Traffic Safety Administration, (NHTSA), “Sick and tired of waking up sick and tired?,” p.2, http://www.nhtsa.gov/people/injury/drowsy_driving1/human/drows_driving/wbroch/wbrochure.pdf

31 SafeNY.com , “Drowsy Driving & Fatigue,” http://www.safeny.com/drow-ndx.htm#Introduction

32 Jane Stutts, Ronald R. Knipling et. al., “A Guide for Reducing Crashes Involving Drowsy and Distracted Drivers,” Transportation Research Board of the National Academies, Volume 14, p. I-4, http://onlinepubs.trb.org/onlinepubs/nchrp/nchrp_rpt_500v14.pdf

33 National Institutes of Health National Heart, Lung, and Blood Institute, p. 47 – 49.

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