Sleep Problems and Health Outcomes Among Urban American Indian and Alaska Native Adolescents

Importance

Adolescent sleep problems are prevalent, particularly among racial and ethnic minority groups, and can increase morbidity. Despite the numerous strengths of their racial and ethnic group, urban American Indian and Alaska Native adolescents face significant health disparities but are rarely included in health research. Understanding how sleep problems are associated with health outcomes among American Indian and Alaska Native adolescents may elucidate novel targets for interventions to promote health equity.

Objective

To assess whether baseline sleep problems are associated with changes in behavioral and cardiometabolic health outcomes among urban American Indian and Alaska Native adolescents 2 years later.

Design, Setting, and Participants

American Indian and Alaska Native adolescents were recruited via flyers and community events for an observational cohort study in California. Baseline assessments were conducted among 142 adolescents from March 1, 2018, to March 31, 2020, and follow-ups were conducted among 114 adolescents from December 1, 2020, to June 30, 2022.

Exposures

Baseline actigraphy-assessed sleep duration and efficiency and self-reported sleep disturbances and social jet lag (absolute value of the difference in sleep midpoint on weekends vs weekdays; indicator of circadian misalignment).

Main Outcomes and Measures

Main outcome measures included self-reported depression (measured using the Patient Health Questionnaire), anxiety (measured using the Generalized Anxiety Disorder 7-item scale), past year alcohol and cannabis use, body mass index, systolic blood pressure (SBP) and diastolic blood pressure (DBP), waist circumference, and glycosylated hemoglobin (HbA1c). Analyses examined whether baseline sleep was associated with health outcomes at follow-up, controlling for age, sex, and baseline outcome measures.

Results

The baseline sample included 142 urban American Indian and Alaska Native adolescents (mean [SD] age, 14.0 [1.4] years; 84 girls [59%]), 80% of whom (n = 114; mean [SD] age, 14.1 [1.3] years; 71 girls [62%]) completed follow-ups. Linear or logistic regressions showed significant negative associations between shorter sleep duration and depression (β = -1.21 [95% CI, -2.19 to -0.24]), anxiety (β = -0.89 [95% CI, -1.76 to -0.03]), DBP (β = -2.03 [95% CI, -3.79 to -0.28]), and HbA1c level (β = -0.15 [95% CI, -0.26 to -0.04]) and likelihood of alcohol (odds ratio [OR], 0.57 [95% CI, 0.36-0.91]) and cannabis use (full week: OR, 0.59 [95% CI, 0.35-0.99]) at follow-up. Greater social jet lag was associated with significantly higher SBP (β = 0.06 [95% CI, 0.01-0.11]) at follow-up.

Conclusions and Relevance

This cohort study found significant associations between poor sleep and adverse changes in health outcomes. Findings highlight the importance of developing culturally responsive interventions that target sleep as a key modifiable risk factor to improve the health of American Indian and Alaska Native adolescents.

Characteristic Sleep Patterns and Associated Obesity in Adolescents

Poor sleep adversely affects health and may cause obesity. Poor sleep includes short sleep duration, low quality of sleep, and sleep discrepancy. Although most studies have focused on the association between sleep duration and obesity, poor sleep is a significant risk factor for obesity. Adolescents have characteristic sleep patterns which correspond to poor sleep. Adolescents sleep late due to various biological and psychosocial factors; also, they wake up early to be on time for school. This causes them to sleep less. To make up for this sleep debt, adolescents sleep more on non-school days, which causes sleep discrepancies. Therefore, since adolescents have characteristic sleep patterns, an in-depth investigation is needed to identify whether poor sleep is a risk for obesity. This article presents an overview of the characteristic sleep patterns of adolescents, and reviews studies on the association of each sleep pattern with obesity.

Examination of Sleep and Obesity in Children and Adolescents in the United States

PURPOSE

This study contributes to the growing literature on the association between sleep and obesity by examining the associations between hours of sleep, consistency of bedtime, and obesity among children in the US.

DESIGN

Analysis of a nationally representative sample of non-institutionalized children from the 2016-17 National Survey of Children's Health.

SETTING

US, national.

SUBJECTS

Children ages 10-17 years (n = 34,640).

MEASURES

Parent reported weeknight average hours of sleep and consistency of bedtime. Body mass index classified as underweight, normal, overweight or obesity using parent-reported child height and weight information, classified using CDC BMI-for-Age Growth Charts.

ANALYSIS

Multivariate logistic regression models were used to estimate associations between measures of sleep and body mass index weight category adjusting for individual, household and neighborhood characteristics.

RESULTS

An additional hour of sleep was associated with 10.8% lower odds of obesity, net of consistency in bedtime. After controlling for sleep duration, children who usually went to bed at the same time on weeknights had lower odds of obesity (24.8%) relative to children who always went to bed at the same time.

CONCLUSION

Sleep duration is predictive of lower odds of obesity in US children and adolescents. Some variability in weeknight bedtime is associated with lower odds of obesity, though there were no additional benefits to extensive variability in bedtime.

Children's Body Mass Index Depending on Dietary Patterns, the Use of Technological Devices, the Internet and Sleep on BMI in Children

Due to the increase in overweight as well as obesity in children, the researchers undertook the studies to determine the occurrence of these irregularities and identify the factors leading to them. The study aimed to assess the body mass index of the children subcategorized and compared depending on the dietary patterns, the use of technical devices, the Internet, and sleeping habits. The study group consisted of 376 children (189 girls and 187 boys) aged 6 to 15. The body composition estimates were obtained with the use of a foot-to-foot bioelectrical impedance analysis, the body height was measured by means of a stadiometer, and blood pressure was monitored. The research questionnaire was distributed among the surveyed and included the question concerning the children's lifestyle, eating and sleeping habits, the use of electronic devices, the Internet, and socio-demographic data. As indicated, the number of sleeping hours per day significantly negatively correlated with body mass index (BMI), whereas the frequency of using the smartphone had a positive correlation with BMI. The children who sleep less and spend more time using the smartphone had higher BMI values. Bearing in mind the conditions that may have an influence on the BMI of early-school age children, the emphasis must be placed on healthy lifestyle education among children and parents alike.

Is late bedtime an overlooked sleep behaviour? Investigating associations between sleep timing, sleep duration and eating behaviours in adolescence and adulthood

OBJECTIVE

To examine whether bedtime is associated with usual sleep duration and eating behaviour among adolescents, emerging adults and young adults.

DESIGN

Cross-sectional multivariable regression models, stratified by developmental stage, to examine: (1) association between bedtime and sleep duration and (2) associations between bedtime and specific eating behaviours at each developmental period, controlling for sleep duration. All models adjusted for sociodemographic characteristics, depressive symptoms and screen time behaviours.

SETTING

National Longitudinal Study of Adolescent to Adult Health, waves I-IV, USA.

PARTICIPANTS

A national probability sample surveyed in adolescence (aged 12-18 years, wave I: 1994-1995, n 13 048 and wave II: 1996, n 9438), emerging adulthood (aged 18-24 years, wave III: 2001-2002, n 9424) and young adulthood (aged 24-34 years, wave IV: 2008, n 10 410).

RESULTS

Later bedtime was associated with shorter sleep duration in all developmental stages, such that a 1-h delay in bedtime was associated with 14-33 fewer minutes of sleep per night (Ps < 0·001). Later bedtime was also associated with lower odds of consuming healthier foods (i.e. fruits, vegetables; range of adjusted OR (AOR), 0·82-0·93, Ps < 0·05) and higher odds of consuming less healthy foods and beverages (i.e. soda, pizza, desserts and sweets; range of AOR, 1·07-1·09, Ps < 0·05). Later bedtime was also associated with more frequent fast-food consumption and higher sugar-sweetened beverage consumption (Ps < 0·05).

CONCLUSIONS

Later bedtime was associated with shorter sleep duration and less healthy eating behaviours. Bedtime may be a novel behaviour to address in interventions aiming to improve sleep duration and dietary intake.

The mediating role of sleep in the relationship between Indigenous status and body mass index in Australian school-aged children

AIM

Associations between sleep duration and obesity and between obesity and chronic illness are established. Current rates of obesity for all Australian people are rising. Recent reports indicate that high body mass index (BMI) is a leading contributor to overall burden of disease for Indigenous Australians. Understanding the factors that contribute to higher rates of obesity in Indigenous people is critical to developing effective interventions for reducing morbidity and premature mortality in this population. To explore the effect of sleep duration on the relationship between Indigenous status and BMI in Australian children.

METHODS

716 non-Indigenous and 186 Indigenous children aged 5-12 years in the Australian Health Survey 2011-2013. Primary carers were interviewed regarding children's sleep times; BMI was derived from measurement.

RESULTS

Analysis of covariance revealed that regardless of a number of demographic and socio-economic status markers, sleep duration and Indigenous status were independent predictors of BMI. However when both predictors were considered together, only sleep duration remained predictive of BMI.

CONCLUSIONS

Sleep duration plays an important mediating role in the relationship between Indigenous status and BMI in this Australian sample. Modification of sleep duration for Indigenous children may lead to longer-term positive health outcomes.

Experimental sleep restriction effect on adult body weight: a meta-analysis

BACKGROUND

Sleep is increasingly recognized as a potential risk for overweight and obesity. Observational studies have shown links between short sleep duration with weight gain. However, the findings from longitudinal studies in adults are conflicting. This review aimed to examine the effectiveness of experimental sleep restriction on adult body weight.

METHOD

A systematic search was undertaken in MEDLINE, EMBASE, PsycINFO, and CENTRAL (Cochrane center register of controlled trials) to identify experimental studies examining the effectiveness of sleep restriction on body weight, and search period was from January 2005 to June 2018. Meta-analysis was applied by using the random model.

RESULTS

A total of 275 adults from six experimental studies were included. The pooled standard mean difference in body weight and body fat was 0.44 (95% CI - 0.13 to 1.02) (Z = 1.51, p > 0.05) and 0.35 kg (95% CI - 0.19 to 0.88) (Z = 1.27, p > 0.05), respectively. The experimental sleep restriction did not result in significant differences in adult body weight or body fat. Subgroup analysis showed that there were differences in weight gain between genders and races.

CONCLUSION

The finding from this review cannot support the hypothesis from observational studies that short sleep leads to weight gain.

A Customized Intervention Program Aiming to Improve Healthy Eating and Physical Activity Among Preschool Children: Protocol for a Randomized Controlled Trial (Iran Healthy Start Study)

Background

Prevention of childhood obesity is a key approach to the primary prevention of noncommunicable diseases. Several models, based on the population health approach and aligned with ecological models, are used to design childhood obesity prevention programs around the world.

Objective

This study aims to introduce the design and evaluation plan of “Iran Healthy Start (IHS)/Aghazi Salem, Koodake Irani”—the customized Iranian version of Canadian Healthy Start/Départ Santé health promotion program—which is now being developed in Mashhad University of Medical Sciences (Mashhad, Iran) and focuses on improving physical activity and healthy eating among preschool children.

Methods

We will evaluate the intervention using a pilot randomized controlled design. The components of intervention include customized Decoda Web-based resources for children, an implementation guide for educators and managers, training and monitoring, communication and knowledge exchange, building partnership, and parent engagement. Outcomes include changes in anthropometry, physical activity level, nutritional risk status and dietary intake, and quality of life.

Results

The project is funded by Mashhad University of Medical Sciences. The intervention was completed by the end of March 2018, and the analysis is currently under way. The first results of the IHS intervention program are expected to be submitted for publication in December 2018.

Conclusions

The double burden of malnutrition in early years children is a major health concern in developing countries. This justifies the need for health promotion programs that are specifically designed to target both overnutrition and undernutrition prevention. If the efficacy approved, the IHS could potentially be a comprehensive health promotion program for young children whose lifestyle behaviors can be improved toward a healthy future life in a nutrition transition setting.

Trial Registration

International Clinical Trials Registry Platform IRCT2016041927475N1; https://en.irct.ir/trial/22497

International Registered Report Identifier (IRRID)

RR1-10.2196/11329

Association between short sleep duration and body mass index in Australian Indigenous children

AIM

Associations between short sleep duration and obesity and the relationship between obesity and chronic illness are well documented. Obese children are likely to become obese adults. To date, there is a paucity of information regarding sleep duration and quality for Indigenous Australian people. It may be that poor-quality, short sleep is contributing to the gap in health outcomes for Indigenous people compared with non-Indigenous adults and children. This study sought to investigate the possibility that poor sleep quality may be contributing to health outcomes for Indigenous children by exploring associations between sleep duration and body mass index (BMI).

METHODS

Participants included 1253 children aged 7-12 years in Wave 7 of the national Longitudinal Study of Indigenous Children survey. Interviewers asked primary carers about children's sleep times. BMI was derived from measurements of children made by researchers.

RESULTS

Regardless of age, relative socio-economic disadvantage and level of remoteness, unhealthy weight was associated with less sleep duration than healthy weight for Indigenous children.

CONCLUSION

The relationship between short sleep duration and BMI in Indigenous children has important implications for their future health outcomes. Both overweight conditions and short sleep are established modifiable risk factors for metabolic dysfunction and other chronic illnesses prominent in the Indigenous population. It is important to consider strategies to optimise both for Indigenous children in an attempt to help 'close the gap' in health outcomes and life expectancy between Indigenous and non-Indigenous people.

Past, present, and future: trends in sleep duration and implications for public health

Sleep is important for the physical, social and mental well-being of both children and adults. Over the years, there has been a general presumption that sleep will inevitably decline with the increase in technology and a busy 24-hour modern lifestyle. This narrative review discusses the empirical evidence for secular trends in sleep duration and the implications of these trends.

Time2bHealthy - An online childhood obesity prevention program for preschool-aged children: A randomised controlled trial protocol

BACKGROUND

The use of parent-focused internet-based programs for the prevention and treatment of childhood obesity has shown promise but there is an acknowledged gap in parent-focused interventions which target the early childhood stage.

METHODS

The aim of this study is to determine the efficacy of Time2bHealthy - an online healthy lifestyle program for parents of preschool-aged children. The program will be evaluated using a two-arm, parallel, randomised controlled design. The 11-week program is underpinned by Social Cognitive Theory and consists of interactive modules on healthy eating, physical activity, screen-time and sleep. The intervention also involves elements of social media, where participants share discuss ideas and experiences and they can interact and obtain information with experts. Time2bHealthy is being compared to a comparison condition. Outcomes include change in BMI (primary outcome), dietary intake, physical activity, sleep, child feeding, parental role-modelling and parent self-efficacy. Process evaluation data, such as adherence and engagement with the online forums, will also be collected.

DISCUSSION

Time2bHealthy is the first randomised controlled trial to our knowledge to assess the efficacy of an online parent-focussed healthy lifestyle program for preschool-aged children in changing body mass index. Early childhood is a crucial time for establishing healthy lifestyle behaviours and parents play an important role. This study therefore fills an important gap in the literature. If found to be efficacious, Time2bHealthy has potential for broad-reach access and translation into primary health care services.

TRIAL REGISTRATION

The study is registered with the Australian and New Zealand Clinical Trials Registry (12616000119493).

Association between sleep duration and cardiac structure in youths at risk for metabolic syndrome

The evidence for a link between sleep duration and cardiovascular risk is accumulating in youths, but no study has yet investigated the relationship between sleep duration and change of cardiac structure. In this study, we recruited 559 youths aged 14–28 years from the cohort of Beijing Child and Adolescent Metabolic Syndrome Study. Questionnaire, color Doppler echocardiography, oral glucose tolerance test and blood biomarkers analyses were performed. We found that sleep duration was negatively correlated with body mass index, waist circumstance, and HbA1c (all P < 0.05), but not with adiponectin and leptin. Meanwhile, participants with shorter sleep duration (≤7 h) had larger interventricular septal diastolic thickness, left ventricular (LV) end-diastolic diameter, LV posterior wall thickness, LV mass (LVM), and LV mass index (LVMI), compared to participants in 7–9 h/night or >9 h/night group. Findings remained significant after adjustment for the major confounding factors (P < 0.05). Multivariate regression modeling revealed that each additional hour of sleep was associated with smaller LVM (β: −3.483, P < 0.0001) and LVMI (β: −0.815, P < 0.0001). Our findings suggest that short sleep has a possible direct effect on cardiac remodeling, occurring already at young ages.

Sleep Duration and Media Time Have a Major Impact on Insulin Resistance and Metabolic Risk Factors in Obese Children and Adolescents

BACKGROUND

Lifestyle factors sleep duration and media time during childhood differ between countries. This study examined whether sleep duration and media time affect metabolic risk factors insulin resistance (IR), blood lipid profile, and liver enzymes, and whether there is a relationship between sleep time and media time in Turkish obese children and adolescents.

METHODS

Subjects included 108 obese children and adolescents (aged 10-15 years) whose lifestyle factors were assessed using a survey containing questions about sleep durations, television viewing, media use, and demographic factors. Metabolic risk factors were compared among groups categorized according to sleep and media duration.

RESULTS

Aspartate aminotransferase (AST), alanine aminotransferase (ALT), and triglyceride (TG) levels and homeostasis model assessment of insulin resistance (HOMA-IR) values were higher in subjects who spent >5 hours/day on media. Children 10-13 years old who slept <9 hours/day were more likely to have higher insulin and HOMA-IR (p < 0.05) levels and lower high-density lipoprotein cholesterol (HDL-C) levels compared with subjects who slept 9-10 hours/day and >10 hours/day. Correlation analysis revealed a negative relationship between sleep time and media time (r = -0.471, p = 0.000).

CONCLUSIONS

Short sleep duration was associated with IR and an elevated plasma lipoprotein profile in children and adolescents. Our results suggest that insufficient sleep and excessive media exposure may contribute to metabolic risk in the context of obesity, and therefore, working to improve sleep duration and limit media time could help reduce metabolic risk in obese children and adolescents.

Habitual Sleep Duration and Risk of Childhood Obesity: Systematic Review and Dose-response Meta-analysis of Prospective Cohort Studies

A meta-analysis of cross-sectional studies found that shorter-time sleep was correlated with increased risk of obesity in children. However, findings from prospective cohort studies were inconsistent. PubMed and other data resources were searched through May 2015. Twenty-five eligible studies were identified including 56,584 children and adolescents with an average 3.4-year follow-up. Compared with children having the longest sleep duration (~12.2 hours), kids with the shortest sleep duration (~10.0 hours) were 76% more likely to be overweight/obese (pooled odds ratio [OR]: 1.76; 95% confidence interval [CI]: 1.39, 2.23); and had relatively larger annual BMI gain (pooled β coefficient: 0.13; 95% CI: 0.01, 0.25 kg/m²). With every 1 hour/day increment in sleep duration, the risk of overweight/obesity was reduced by 21% (OR: 0.79; 95% CI: 0.70, 0.89); and the annual BMI gain declined by 0.05 kg/m² (β = −0.05; 95% CI: −0.09, −0.01). The observed associations were not appreciably modified by region, baseline age or the length of follow-up. Accumulated literature indicates a modest inverse association between sleep duration and the risk of childhood overweight/obesity. Further research is needed to determine the age and gender specified optimal hours of sleep and ideal sleep pattern with respect to obesity prevention in children.