Obese Teens With Sleep Apnea Show Impaired Neurobehavioral Functioning

Navigating the tumultuous teenage years can be exhausting, and new research shows that they can be particularly challenging for overweight adolescents with obstructive sleep apnea syndrome (OSAS), a sleep disorder that affects an estimated 2 percent of youths. Obesity and OSAS often exist simultaneously, and both conditions have been associated with neurobehavioral changes such as problems with regulating emotions, school performance, attention, and alertness.

As child obesity rates have tripled among school-aged children and adolescents over the past 30 years, it appears that teens are on the fast track for increasing their risk of developing OSAS. It is a trend that Melissa Xanthopoulos, PhD, sees firsthand as a child and adolescent psychologist at The Children’s Hospital of Philadelphia and as an investigator for its Sleep Center and Healthy Weight Program.

At the clinical level, Dr. Xanthopoulos and colleagues observed a pattern among some young patients with obesity who were struggling to follow their treatment recommendations and also reporting difficulties in school. The research team wondered if an interaction between obesity and sleep could somehow be impeding their success.

“It is an important research question because during this critical period of adolescence, the brain’s frontal lobe, which is in charge of executive functioning, is making a lot of changes,” Dr. Xanthopoulos said. “Executive functioning involves higher order cognitive processing such as planning, monitoring, and initiating tasks.”

If a teen’s brain is busy reorganizing during this sensitive time, what happens when it is repeatedly disrupted by the many pauses in breathing during sleep — called apneas and hypopneas — and ensuing abrupt dips in blood oxygen saturation that are the hallmarks of nightly episodes of OSAS?

Research performed with adults who have OSAS suggests that they experience cognitive changes, Dr. Xanthopoulos said, but she found that the obesity and sleep research literature involving teens was lacking in this area. In order to build evidence for the adolescent period, the study team looked at three groups of teens ages 12 to 16 years old: obese teens with OSAS, obese teens without OSAS, and lean teens without OSAS. The investigators hypothesized that obese teens with OSAS would exhibit more neurobehavioral functioning deficits.

They analyzed self-reports from the teens and their parents that focused on several dimensions of neurobehavioral abnormalities that have been associated with sleep disorders including executive function, attention, sleepiness, and behavior and mood. The results showed that executive function, in particular, was impacted in this age group of participants who had obesity and OSAS.

The study team also used sophisticated statistical methods to examine how participants’ BMI z-scores, which is a measure of relative weight adjusted for a child’s age and sex, related to their obstructive apnea hypopnea index (AHI), which is an average that represents the combined number of apneas and hypopneas that occur per hour of sleep. Their analysis revealed that the AHI level had a significant influence on the relationship between BMI-z scores and executive functioning, attention, and behavior.

Dr. Xanthopoulos and her co-investigators want to spread the word about this study’s outcomes with their colleagues and raise patients’ awareness about the potential risks of OSAS and obesity. When a teen with obesity is exhibiting attention problems, difficulty in school, and signs of depression, she encourages healthcare providers to ask, “Does this patient snore?” and then to consider recommending a sleep study.

The next step, Dr. Xanthopoulos said, is figuring out which treatment method these patients need in order to be healthy physically, mentally, and emotionally. Typically, the treatment for adults and teens with OSAS is continuous positive airway pressure (CPAP), which delivers a steady stream of pressurized air through a mask that patients wear during sleep to keep their airways open and restore normal oxygen levels.

“CPAP is not something a teenager usually wants to hear about, but it might help them feel better and be better able to engage in weight loss behaviors such as making healthy choices and increasing physical activity,” Dr. Xanthopoulos said. “If you treat obesity, oftentimes sleep apnea is reduced or goes away. But, losing weight is very hard, especially for a teenager who is super sleepy and potentially has these neurobehavioral deficits.”

Dr. Xanthopoulos suggested that more research is needed to determine if OSAS treatment could potentially reverse neurobehavioral concerns for teens with obesity and OSAS, and also to see if the therapy could help them engage in weight loss interventions more effectively.

The study appeared online ahead of print in the journal SLEEP. It is a sub-study of a larger research project led by Sleep Center Director Carole L. Marcus, MBBCh, that is focused on the pathophysiology of childhood OSAS and is funded by the National Heart, Lung, and Blood Institute. The sub-study also involved Paul R. Gallagher, MA, of the Clinical and Translational Research Center coordinated by CHOP and the Perelman School of Medicine at the University of Pennsylvania; Robert I. Berkowitz, MD, a CHOP psychiatrist who is director of the Weight and Eating Disorders Research Program and also an associate professor of psychiatry at UPenn; Jerilynn Radcliffe, PhD, a CHOP psychologist and professor of clinical psychology at UPenn; and Ruth Bradford, research coordinator for CHOP’s Sleep Center.

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