Sleep-disordered breathing in adolescents with obesity: When does it start to affect cardiometabolic health?

Multidimensions of sleep health among in-school adolescents in rural and urban areas in southwestern Nigeria

INTRODUCTION

Previous studies have focused on sleep inequities among disadvantaged populations in high-income countries. However, little is known about the differences in sleep health among adolescents in Africa. We aimed to compare the multidimensions of sleep health in adolescents living in rural vs. urban communities in Nigeria.

METHODS

This cross-sectional study enrolled adolescents aged 13-19 in six rural and six urban schools in Osun State, Nigeria. We measured the prevalence of poor sleep quality (Pittsburgh Sleep Quality Index score >5), daytime sleepiness (Epworth Sleepiness Scale for Children and Adolescents score >10), and risk of sleep apnea (Teen STOPBANG). We compared the sleep health variables between the rural and urban populations using multivariable logistic regression.

RESULTS

Of the 900 participants (51% rural; 59% female; average age (SD)= 15.1(1.4) years), 79% had short sleep duration (<8.5 hours), 14.9% poor sleep quality, 9.6% excessive daytime sleepiness and 9.8% risk of sleep apnea. Urban adolescents had a higher prevalence of poor sleep quality (p = .004), short sleep duration (p < .001), daytime sleepiness (p = .044), and risk of sleep apnea (p = .006) compared to rural adolescents. The adjusted odds of having poor sleep quality (p = .008) and daytime sleepiness (p = .007) were about 2-fold higher among urban compared to rural adolescents. Later school end time, having single/separated parent(s), absence of parental setting of bedtime were independently associated with poorer sleep health.

CONCLUSION

Adolescents in rural communities had better sleep health than adolescents in urban communities. There is a need to develop interventions to improve the sleep quality and overall sleep health of urban-dwelling adolescents.

Food Intake and Sleep Disorders in Children and Adolescents with Obesity

Over the last few decades, numerous scientific studies have investigated the possible association between sleep duration and adiposity during childhood, since it has been reported that sleep deprivation causes a related increase in caloric intake. Even though the underlying pathogenetic mechanisms are still under study and not completely known, the effect of dietetic habits and nutrient intake on sleep quality and patterns has been reported. The aim of this study is to explore the intricate interplay between food intake/diet patterns and pediatric sleep disturbances in children and adolescents with obesity, emphasizing the importance of not underestimating this aspect in the prevention and treatment of this complex disease. Recent evidence supports a high correlation between specific diet patterns and foods with sleep disturbances in children at all ages. Diets rich in fiber, fruit, vegetables, and anti-inflammatory nutrients and low in saturated fats seem to promote better sleep quality. Sleep disturbances are, in turn, risk factors for the development of obesity. Therefore, food strategies should be applied to counteract this harmful process. Unraveling the complex links between dietary habits, sleep patterns, and obesity is essential for developing effective strategies to combat this critical public health issue.

Metabolic disturbances in children with narcolepsy: a retrospective study

STUDY OBJECTIVES

To determine the prevalence of metabolic syndrome (MS) in children with narcolepsy and to evaluate their clinical and sleep characteristics according to the different components of MS.

METHODS

This retrospective study consisted of 58 de novo children with narcolepsy (median age: 12.7 years, 48.3% of boys). The recently published MS criteria in a French population of children were used. Clinical and sleep characteristics were compared between groups with different components of MS.

RESULTS

MS was present in 17.2% of children with narcolepsy, among whom 79.3% presented with high homeostasis model assessment for insulin resistance (HOMA-IR), 25.9% with high body mass index, 24.1% with low high-density lipoprotein cholesterol (HDL-C), and 12.1% with high triglycerides. Patients with at least two MS components had more night eating behaviors and tended to have lower percentage of slow-wave sleep and more fragmented sleep. On multiple sleep latency test, they had shorter mean sleep latencies to rapid eye movement (REM), non-REM sleep and tended to have more sleep onset REM periods (SOREMPs) than those with less than two MS components.

CONCLUSIONS

Insulin resistance was found to be the core metabolic disturbance in obese as well as in nonobese children with narcolepsy. Children with narcolepsy with at least two MS components presented a more severe daytime sleepiness and a higher prevalence of night-eating behaviors than those with less than two MS components. Such children might benefit from early evaluation and management in order to prevent future complications.

Apnoea-hypopnoea index of 5 events·h-1 as a metabolomic threshold in patients with sleep complaints

Background

The apnoea-hypopnoea index (AHI) forms the basis for severity of obstructive sleep apnoea (OSA), a condition expected to reprogramme metabolic pathways in humans. We aimed to identify the AHI breakpoint from which the majority of significant changes in the systemic metabolome of patients with sleep complaints occur.

Methods

In a prospective observational study on symptomatic individuals, who underwent polysomnography for the diagnosis of OSA, profiles of 187 metabolites including amino acids, biogenic amines, acylcarnitines, lysophosphatidylcholines, phosphatidylcholines and sphingomyelins were analysed with liquid chromatography mass spectrometry in peripheral blood drawn at three different time points overnight. Comparisons of rank-transformed data using a general linear model for repeated measures after dichotomising the study group at different AHI levels were applied to define the best cut-off based on Cohen's f.

Results

65 subjects were recruited with a median AHI of 15.6 events·h^-1. The mean Cohen's f over the metabolites was highest (0.161) at an AHI level of 5 events·h^-1 representing the metabolomic threshold. Of the particular between-group differences, eight phosphatidylcholines, nine acylcarnitines and one amino acid (threonine) had significantly lower concentrations in the individuals with an AHI level equal to or above the metabolomic threshold. The metabolomic changes at AHI levels defining moderate and severe OSA were smaller than at an AHI of 5 events·h^-1.

Conclusions

The metabolomic threshold for patients with sleep complaints described in this report for the first time coincides with the AHI threshold required to confirm the diagnosis of OSA.

Sleep-related breathing disorders and cardiometabolic risk factors in pediatric kidney transplant recipients

BACKGROUND

SRBDs have been shown to increase the risk of cardiovascular disease, which is a significant cause of mortality in kidney transplant recipients. Few studies have investigated the association between SRBDs and cardiometabolic risk factors in pediatric kidney transplant recipients.

METHODS

This was a cross-sectional study of pediatric kidney transplant recipients using baseline cardiometabolic data from a previous clinical trial (NCT01007994). Parents/guardians of pediatric kidney transplant recipients filled out 22-item PSQ. A score greater than 33% was defined as a diagnosis of a SRBD. Fisher's exact test, Mann-Whitney U test, and regressions were used to determine associations.

RESULTS

Among the 58 transplant recipients enrolled, 14.80% (n = 8) of participants identified as Black and 40.7% (n = 22) were male. The median age was 13 (IQR 8.25, 17) years and median number of years post-transplant for participants was 2 (IQR 1, 4). The prevalence of SRBDs was 26% (n = 14). The presence of a SRBD was associated with abnormalities in multiple cardiometabolic risk factors including total cholesterol level (β = 23.63; 95% CI 3.58-43.67), LDL level (β = 24.94; 95% CI 6.37-43.50), triglyceride level (β = 54.62; 95% CI 8.74-100.50), and LVH (OR = 5.12; 95% CI 1.12-23.45) when adjusted for age, sex, and race.

CONCLUSIONS

Similar to associations reported in the general pediatric and general CKD populations, SRBD is associated with increased cardiometabolic risk in pediatric kidney transplant recipients.

Characterization of rapid weight gain phenotype in children with narcolepsy

Objectives

To characterize the rapid weight gain (RWG) phenotype associated with the onset of childhood narcolepsy and to determine whether it could constitute a marker of severity of the disease.

Methods

RWG was defined using the BMI z‐score slope reported to one year (>0.67 SD) from symptom onset to disease diagnosis. We compared the clinical, metabolic, and sleep characteristics between patients with or without RWG at diagnosis. Pharmacological management, anthropometric, and clinical progression were also evaluated during the follow‐up.

Results

A total of 84 de novo narcoleptic pediatric patients were included; their median age at diagnosis was 12.0 years; 59.5% boys, 90.5% cataplexy, and 98.7% HLA‐DQB1*06:02, 57% had RWG profile. RWG patients were younger at diagnosis than non‐RWG patients, despite a shorter diagnostic delay. They had a higher BMI z‐score and a higher prevalence of obesity at diagnosis, but not at symptom onset, and higher adapted Epworth Sleepiness Scale and Insomnia Severity Index scores than non‐RWG patients. No differences on nocturnal polysomnography and multiple sleep latency tests were found between groups at disease diagnosis. After a median follow‐up of 5 years, RWG patients still had a higher BMI z‐score and a higher prevalence of obesity despite benefiting from the same therapeutic management and displaying improvement in sleepiness and school difficulties.

Conclusions

Narcoleptic RWG patients were younger, sleepier, and the prevalence of obesity was higher at diagnosis despite a shorter diagnostic delay than that of non‐RWG patients. These patients had also a higher risk of developing a long‐term obesity, despite a positive progression of their narcoleptic symptoms. RGW could then represent a maker of a more severe phenotype of childhood narcolepsy, which should inspire a prompt and more offensive management to prevent obesity and its complications.

Weight reduction added to CPAP decreases blood pressure and triglyceride level in OSA: systematic review and meta-analysis

Obstructive sleep apnea (OSA) is associated with treatment‐resistant hypertension and high cardiovascular risk. Continuous positive airway pressure (CPAP) fails to reduce cardiovascular risks consistently. Obesity and OSA show reciprocal association and they synergistically increase hypertension via different pathways. Our meta‐analysis aimed to assess the cardiovascular benefits of combining weight loss (WL) with CPAP (vs. WL or CPAP alone) in OSA. Outcomes included systolic and diastolic blood pressure (BP) and blood lipid parameters. We explored Medline, Embase, Cochrane, and Scopus. Eight randomized controlled studies (2627 patients) were included. The combined therapy decreased systolic BP more than CPAP alone. Weighted mean difference (WMD) for CPAP + WL versus CPAP was −8.89 mmHg, 95% confidence interval (95% CI; −13.67 to −4.10, p < 0.001) for systolic BP. For diastolic BP, this decrease was not significant. In case of blood lipids, the combined treatment decreased triglyceride levels more than CPAP alone (WMD = −0.31, 95% CI −0.58 to −0.04, p = 0.027). On the other hand, addition of CPAP to WL failed to suppress BP further. The certainty of evidence according to GRADE was very low to moderate. In conclusion, our results showed that the addition of WL to CPAP significantly improved BP and blood lipid values in OSA. On the other hand, the addition of CPAP to WL could not significantly improve BP or blood lipid values. Review protocol: PROSPERO CRD42019138998.

Sleep-Disordered Breathing and Cardiovascular Disease in Children and Adolescents: A Scientific Statement From the American Heart Association

Obstructive sleep apnea (OSA) is a known risk factor for cardiovascular disease in adults. It is associated with incident systemic hypertension, arrhythmia, stroke, coronary artery disease, and heart failure. OSA is common in children and adolescents, but there has been less focus on OSA as a primary risk factor for cardiovascular disease in children and adolescents. This scientific statement summarizes what is known regarding the impact of sleep‐disordered breathing and, in particular, OSA on the cardiovascular health of children and adolescents. This statement highlights what is known regarding the impact of OSA on the risk for hypertension, arrhythmia, abnormal ventricular morphology, impaired ventricular contractility, and elevated right heart pressure among children and adolescents. This scientific statement also summarizes current best practices for the diagnosis and evaluation of cardiovascular disease–related complications of OSA in children and adolescents with sleep apnea and highlights potential future research in the area of sleep‐disordered breathing and cardiovascular health during childhood and adolescence.

Impact of obstructive sleep apnea on cardiometabolic health in a random sample of older adults in rural South Africa: building the case for the treatment of sleep disorders in underresourced settings

STUDY OBJECTIVES

The association between obstructive sleep apnea (OSA) and increased cardiometabolic risk (CMR) has been well documented in higher-income countries. However, OSA and its association with CMR have not yet been investigated, based on objective measures, in southern Africa. We measured polysomnography-derived sleep characteristics, OSA prevalence, and its association with cardiometabolic diseases in a rural, low-income, African-ancestry sample of older adult participants in South Africa.

METHODS

Seventy-five participants completed the study. Body mass index, hypertension, diabetes, dyslipidemia, and HIV status were determined. A continuous CMR score was calculated using waist circumference, random glucose, high-density-lipoprotein cholesterol, triglycerides, and mean arterial blood pressure. Sleep architecture, arousal index, and apnea-hypopnea index for detection of the OSA (apnea-hypopnea index ≥ 15 events/h) were assessed by home-based polysomnography. Associations between CMR score and age, sex, socioeconomic status, apnea-hypopnea index, and total sleep time were investigated by multivariable analysis.

RESULTS

In our sample (53 women, age 66.1 ± 10.7 years, 12 HIV+), 60.7% of participants were overweight/obese, 61.3% were hypertensive, and 29.3% had undiagnosed OSA. Being older (P = .02) and having a higher body mass index (P = .02) and higher waist circumference (P < .01) were associated with OSA. Apnea-hypopnea index severity (β = 0.011; P = .01) and being a woman (β = 0.369; P = .01) were independently associated with a higher CMR score in socioeconomic status- and age-adjusted analyses.

CONCLUSIONS

In this South African community with older adults with obesity and hypertension, OSA prevalence is alarming and associated with CMR. We show the feasibility of detecting OSA in a rural setting using polysomnography. Our results highlight the necessity for actively promoting health education and systematic screening and treatment of OSA in this population to prevent future cardiovascular morbidity, especially among women.

Complete sleep evaluation of top professional cross-country mountain bikers athletes

BACKGROUND

Despite growing interest in athletes' sleep, few studies have focused on professional athletes, especially in individual sports. Moreover, limited investigations included female athletes. This study aims to evaluate sleep chronotype, as well as objective and subjective sleep characteristics in male and female professional cross-country mountain bikers.

METHODS

Thirteen athletes (7 males and 6 females) of the French national team took part in this study. The Chronotype was assessed by the Horne and Östberg Morningness-Eveningness Questionnaire and sleep by actigraphy for one month, by ambulatory polysomnography (PSG) for one night and by the Pittsburgh Sleep Quality Index.

RESULTS

Most athletes (77 %) are classified as moderately morning type and a minority of athletes (23 %) are intermediate type. Athletes sleep on average 8 hours per night and during the night recorded by PSG, N3 and REM sleep stages represented 21.2 ± 3.4 % and 20.9 ± 3.1 % of the total sleep time, respectively. These good sleep parameters were confirmed by subjective data with 77 % good sleepers. Except the poorer subjective sleep quality in female athletes (5.7 ± 1.6) compared to male athletes (2.6 ± 1.7, p < 0.05), no significant sex difference was found for all characteristics evaluated.

CONCLUSIONS

The professional status of these athletes and the organization of mountain bike calendar may explain their good sleep characteristics.

A multidisciplinary weight loss intervention in obese adolescents with and without sleep-disordered breathing improves cardiometabolic health, whether SDB was normalized or not

OBJECTIVES

Pediatric obesity and sleep-disordered breathing (SDB) are strongly associated, and both promote metabolic impairments. However, the effects of a lifestyle intervention on the overall metabolic syndrome (MetS) are unknown. The objectives were i) to evaluate the effects of a lifestyle intervention on cardiometabolic risk (CMR), assessed with a dichotomous (MetS) and a continuous (MetScore_FM) instrument, in obese adolescents with and without SDB and ii) to compare the post-intervention cardiometabolic responses between adolescents with persistent (apnea-hypopnea index; AHI≥2) or normalized-SDB (AHI<2).

METHODS

Seventy-six adolescents with obesity recruited from two specialized institutions underwent a 9-12month diet and exercise intervention. Sleep and SDB (AHI≥2) were studied by polysomnography. Anthropometric parameters, fat mass (FM), glucose, insulin, lipid and leptin profiles, blood pressure (BP), MetScore_FM and MetS were assessed pre- and post-intervention. We performed comparisons between Non-SDB and SDB groups and between Normalized-SDB and Persistent-SDB subgroups.

RESULTS

Fifty participants completed the study. Pre-intervention, twenty youth had SDB (40%) with higher insulin concentrations and systolic BP than Non-SDB participants (p < 0.01), for a similar degree of obesity. Post-intervention, MetScore_FM (p < 0.001) and MetS prevalence (p < 0.05) were decreased in both groups. Eleven participants (55%) normalized SDB along with a decrease in insulin concentrations and BP (p < 0.05). Triglycerides, total cholesterol and LDL-cholesterol concentrations (p < 0.01) improved equally in the Normalized and Persistent-SDB subgroups.

CONCLUSION

SDB was associated with lower insulin sensitivity and higher BP but did not affect the lipid profile. A diet and exercise lifestyle intervention is effective in decreasing the CMR whether or not SDB was normalized in obese adolescents.

Are obstructive sleep apnea and sleep improved in response to multidisciplinary weight loss interventions in youth with obesity? A systematic review and meta-analysis

BACKGROUND

Pediatric obesity is closely associated with obstructive sleep apnea (OSA) and short sleep duration. While multidisciplinary weight loss interventions are recommended for pediatric obesity management, the evidence for their effects on OSA severity and overall sleep in youth have not been systematically examined.

OBJECTIVES

To conduct a systematic review and meta-analysis investigating the effects of multidisciplinary weight loss interventions on OSA severity and prevalence, and on overall sleep health in youth with obesity.

METHODS

A systematic search of interventional studies (participants age range: 10-19 yrs) was performed using PubMed, CENTRAL and Embase, from inception to May 2019. The quality of the evidence was assessed using the Cochrane risk of bias tool.

RESULTS

Ten studies were included by the end of the screening process. Ninety percent of the included studies reported a decrease in OSA prevalence post-intervention, and OSA was normalized for 46.2-79.7% of the youth. The meta-analysis comprising seven longitudinal studies revealed significant reductions in apnea-hypopnea index (effect size: -0.51, 95%CI -0.94 to -0.08, p = 0.019), and oxygen desaturation index (effect size: -0.28, 95%CI = -0.50 to -0.05, p = 0.016). Seventy-five percent of the studies reported improved sleep duration in youth with OSA.

CONCLUSIONS

Evidence suggests that multidisciplinary weight loss interventions result in improvements in OSA severity and sleep duration in youth with obesity. Future randomized controlled trials are warranted to better assess and understand the independent implications of weight loss, fat mass decrease and chronic exercise on OSA and sleep health in this population.