The association between obstructive sleep apnea and dietary choices among obese individuals during middle to late childhood

doi:10.1016/j.sleep.2010.12.020

Sleep Medicine

Volume 12, Issue 8, September 2011, Pages 797-799

https://doi.org/10.1016/j.sleep.2010.12.020 Get rights and content

Abstract

Objective

Determine whether obstructive sleep apnea (OSA) is associated with the dietary choices of obese individuals during middle- to late-childhood. It was hypothesized that OSA would be associated with increased caloric content of a dinner order, particularly with high carbohydrate food choices. Secondarily, we examined the relationships between sleep duration and dietary choices.

Methods

42 obese subjects aged 10–16.9 years participated in a cross-sectional study that involved systematic collection of sleep duration (based on actigraphy), presence and severity of obstructive sleep apnea (obstructive apnea + hypopnea index [AHI] from inpatient polysomnography) and the macronutrient content of dinners ordered from a standardized hospital menu the evening before the polysomnogram.

Results

Primary analyses using Spearman rank-order correlations found that AHI was significantly associated with total calories, as well as grams of fat and carbohydrate, but not protein. These macronutrient variables did not correlate with sleep duration across a week, nor the night before the meal. Findings were unchanged after correcting for age- and sex-adjusted BMI.

Conclusions

More severe OSA appears to be associated with an increased preference for calorie-dense foods that are high in fat and carbohydrates in a manner that is independent of degree of obesity. Although this novel finding awaits replication, it has potential implications for the clinical care of obese youth and individuals with OSA, adds to the limited data that relate sleep to dietary choices and may have implications for OSA-related morbidity.

Introduction

Excessive body weight and obstructive sleep apnea (OSA) are well-correlated in adults, adolescents and, to a lesser degree, young children, but the underlying mechanisms remain uncertain [1], [2], [3]. The strongest evidence has suggested that excessive weight can cause OSA, but recent publications have highlighted mechanisms by which OSA might also maintain excessive weight. OSA has been linked to metabolic aberrations that can contribute to weight gain [2], [3]. OSA also disrupts sleep, and inadequate sleep can alter appetite-related leptin and ghrelin levels and result in cravings for calorie-dense sweet and “starchy” foods [4]. OSA can further cause inattention, impulsivity and negative mood, which could contribute to poor food choices [2]. Indeed, a recent report linked OSA with parent-reported diet and activity patterns of 5–9-year old children [5]. The relationship between OSA and excessive weight may be particularly important to understand during middle to late childhood, when the OSA-weight link becomes firmly established, food choices are increasingly self-determined and weight becomes highly predictive of adult obesity and its morbidity [6].

In the course of a larger study of the neurobehavioral correlates of OSA in obese 10–16 year-old children and adolescents [7] we incidentally collected information on the food chosen by participants for their dinners. In analyzing this food-choice data, we predicted that severity of OSA would be associated with increased caloric content of the orders, particularly to high carbohydrate food choices. Secondarily, because sleep duration has been linked to weight status, we examined whether the ordered food would be associated with sleep duration during a week proximal to the food order and, in a subgroup, the night before the order was placed.

Section snippets

Participants

Obese subjects were recruited from either a pediatric weight-management clinic or a sleep clinic [7]. All were 10–16.9 years old, had a body mass index (BMI) >95th percentile for their age and sex and did not have a history of neurological illness or injury, craniofacial abnormalities, neurodevelopmental disorder (e.g., Down Syndrome) or adenotonsillectomy or other treatment for OSA within the past 2 years, nor were they using any psychiatric medication. Procedures were overseen by the Cincinnati

Results

The 42 eligible participants were 71% female, 64% African-American, 31% Caucasian, 13.1 ± 1.9 years old (mean ± sd), and quite obese (BMI = 37.0 ± 7.1, zBMI = 2.44 ± 0.25). Spearman correlations were used to associate AHI with total calories and grams of protein, fat, and carbohydrates ordered. Secondary analyses substituted AHI with sleep duration. Correlations were first computed on an uncorrected basis, then as a partial correlation corrected for covariates. We a priori selected zBMI as a covariate

Discussion

To our knowledge, this is the first study of the relationship between OSA severity and the macronutrient content associated with individuals’ dietary choices. Severity of OSA correlated with calories ordered for dinner, and especially with the fat and carbohydrate content of that meal. These relationships persisted after covarying for age- and gender-corrected BMI, so they cannot be explained by a confounding relationship with obesity severity.

This novel finding has important potential

Financial support

National Institutes of Health (K23 HL075369, UL1 RR026314). The authors have no financial conflicts of interest to report.

Conflict of interest

The ICMJE Uniform Disclosure Form for Potential Conflicts of Interest associated with this article can be viewed by clicking on the following link: doi:10.1016/j.sleep.2010.12.020.

References (15)

S.L. Verhulst et al.
The prevalence, anatomical correlates and treatment of sleep-disordered breathing in obese children and adolescents
Sleep Med Rev
(2008)
M.J. Kohler et al.
Is there a clear link between overweight/obesity and sleep disordered breathing in children?
Sleep Med Rev
(2008)
W. Ramadan et al.
Effect of high-fat diet and metformin treatment on ventilation and sleep apnea in non-obese rats
Respir Physiol Neurobiol
(2006)
A.D. Goldbart et al.
High fat/refined carbohydrate diet enhances the susceptibility to spatial learning deficits in rats exposed to intermittent hypoxia
Brain Res
(2006)
C.E. Ievers-Landis et al.
Pediatric sleep apnea: implications of the epidemic of childhood overweight
Am J Respir Crit Care Med
(2007)
E. Van Cauter et al.
Sleep and the epidemic of obesity in children and adults
Eur J Endocrinol
(2008)
K. Spruyt et al.
Dietary and physical activity patterns in children with obstructive sleep apnea
J Pediatr
(2010)

There are more references available in the full text version of this article.

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The interaction between obstructive sleep apnea (OSA), obesity and sleeping position is complex. Obesity explains about 60% of the variance of the apnea hypopnea index (AHI) definition of OSA, mainly in those patients aged < 50 years and less so in the elderly. About 1 in 4 patients with OSA have respiratory events that occur exclusively in the supine sleep position. Weight loss, by either medical or surgical techniques, has a beneficial, yet unpredictable, effect upon sleep apnea, especially in those with a short jaw length. The fall in the overall AHI with weight loss, appears to be associated with a larger drop in the non-supine AHI, than supine AHI, thus converting some patients from non-positional to positional (i.e., supine only) OSA. Side sleeping can be beneficial in such patients as can other positional modifications such as a raised bed head, chin extension and closing of the mouth.
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Individuals with Down syndrome present many clinical characteristics, such as metabolic, endocrine, anatomic and neurologic dysfunctions, that contribute to the physiopathology of obstructive sleep apnea syndrome (OSAS). As a result, sleep apnea prevalence is significantly greater in population with Down syndrome, and may have critical consequences on health and quality of life, such as cardiovascular risks and obesity.
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Many patients report substantial weight gain after the onset of OSA symptoms and in the 12 months prior to diagnosis.22 In support of this hypothesis, there are some studies that indicate that patients with OSA show a preference for energy-dense foods compared with healthy control subjects.23 However, there has not been a systematic assessment of the effect of OSA on energy balance, and the hypothesis is mainly supported by extrapolating data from sleep deprivation studies.
The interaction between obesity and OSA is complex. Although it is often assumed that obesity is the major cause of OSA, and that treatment of the OSA might mitigate further weight gain, new evidence is emerging that suggests this may not be the case. Obesity explains about 60% of the variance of the apnea-hypopnea index (AHI) definition of OSA, mainly in those < 50 years and less so in the elderly. Moreover, long-term treatment of OSA with CPAP is associated with a small but significant weight gain. This weight gain effect may result from abolition of the increased work of breathing associated with OSA. Unfortunately, weight loss by either medical or surgical techniques, which often cures type 2 diabetes, has a beneficial effect on sleep apnea in only a minority of patients. A short jaw length may be predictive of a better outcome. The slight fall in the overall AHI with weight loss, however, may be associated with a larger drop in the nonsupine AHI, thus converting some patients from nonpositional to positional (ie, supine only) OSA. Importantly, patients undergoing surgical weight loss need close monitoring to prevent complications. Finally, in patients with moderate to severe obesity-related OSA, the combination of weight loss with CPAP appears more beneficial than either treatment in isolation.
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A hormonal profile that would predispose to high EI appears to exist in OSA patients, who have increased leptin [2–10], suggestive of leptin resistance, and increased ghrelin [4,5,10,11], relative to controls. Increased liking for high-fat foods [12] and preference for calorie-rich foods high in fat and carbohydrate [13] were observed in association with OSA severity. Batool-Anwar et al. investigated the effects of continuous positive airway pressure (CPAP) on food intake in OSA patients using a Food Frequency Questionnaire (FFQ), and found that CPAP treatment reduced consumption of trans-fat in women, but did not affect overall EI [14].
Obesity is among the leading risk factors for obstructive sleep apnea (OSA). A reciprocal relationship between obesity and OSA has been proposed, which may be due to excessive food intake. We conducted a pilot study to test the effects of continuous positive airway pressure (CPAP) on energy intake (EI) in OSA patients using a sham-controlled crossover design. In-laboratory total daily EI was assessed after 2 mo of active and sham CPAP. Four men were enrolled (age ± SEM: 51.8 ± 2.1 y; body mass index: 31.5 ± 1.5 kg/m²). All received active treatment first. Meals (breakfast, lunch, dinner, snack) were served in excess portions at fixed times and additional palatable snacks were freely available throughout the day. Total EI was lower after active (3744 ± 511 kcal/d) vs. sham (4030 ± 456 kcal/d) CPAP but this difference was not significant (p = 0.51) due to variability in the free snack intake. When only fixed eating occasions were considered, daily EI was significantly lower in the active (3105 ± 513 kcal/d) vs. sham (3559 ± 420 kcal/d) condition (p = 0.006). This small pilot and feasibility study is the first to utilize a sham-controlled design to investigate the effects of CPAP treatment on objective measures of EI. Findings suggest that CPAP may cause a reduction in fixed meal intake. In demonstrating feasibility of study methodology, our study also suggests a larger randomized sham-controlled trial be conducted to fully characterize the effects of CPAP treatment on EI and energy balance overall.

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Brief CommunicationThe association between obstructive sleep apnea and dietary choices among obese individuals during middle to late childhood

Abstract

Objective

Methods

Results

Conclusions

Introduction

Section snippets

Participants

Results

Discussion

Financial support

Conflict of interest

Sleep Med Rev

Sleep Med Rev

Respir Physiol Neurobiol

Brain Res

Pediatric sleep apnea: implications of the epidemic of childhood overweight

Am J Respir Crit Care Med

Sleep and the epidemic of obesity in children and adults

Eur J Endocrinol

Dietary and physical activity patterns in children with obstructive sleep apnea

J Pediatr

Brief Communication
The association between obstructive sleep apnea and dietary choices among obese individuals during middle to late childhood