The association with obstructive sleep apnea and cardiovascular disease is not just a logical assumption; it has been well documented in the landmark Sleep Heart Health Study published in the New England Journal of Medicine.
The question now facing the health community is whether these associations also apply to teenagers. More importantly, is the association ameliorated if the sleep apnea is treated with CPAP. After all, it takes years to develop cardiovascular disease caused by hardening of the arteries. On the other hand, obesity is now prevalent in American society starting in childhood and teenager years.
This question was addressed in a study published in the Journal of Clinical Sleep Medicine. A multi-center study was conducted in youth ages 8 to 16 years of age who were diagnosed with obesity and also with severe obstructive sleep apnea (OSA). The researchers wanted to explore if there was any benefit in treating this age group with CPAP therapy for reversibility of markers suggestive of cardio metabolic disease. Specifically, they looked at several health markers including insulin resistance, which is the first clinical stage in the development of diabetes, hypertension, and inflammatory markers such as C reactive protein. All these are the main measures of cardio-metabolic disease.
The results of the study were quite surprising. Unlike adults who show improvement in blood pressure and diabetes control when treated with CPAP therapy, there was no improvement in teenagers who were adherent in CPAP therapy. It should be noted that not all of the subjects were compliant with the CPAP therapy. This is not surprising in teenagers (or frankly in many adults). CPAP therapy requires motivation, because you have to wear a mask and listen to noises generated from the machine. Many of these youngsters did not appreciate that they had a serious medical problem. The measures of hypertension, insulin resistance and inflammatory markers were the same for both the compliant and non- compliant groups.
What is of greater concern is that the relationship of obesity with obstructive sleep apnea in children and early diabetes as manifested by insulin resistance has been shown in other studies.
In this study, those young people who had severe obstructive sleep apnea had a higher correlation with insulin resistance than those with mild or moderate sleep apnea.
This data, when taken in connection with the earlier study showing that these markers are not reversible with CPAP treatment, are quite important, given the high rates of obesity in teenagers. In this young population there is the additional element that severe disease is largely unrecognized. The first signs of sleep apnea are usually recognition of loud snoring alternating with pauses in breathing by a bed partner. This is not likely to be the case in teenagers unless they happen to share a bedroom with a sibling. The other noticeable symptom that motivates people to seek treatment is excessive daytime somnolence. This behavior is really common in most teenagers, as they tend to stay up late at night and are required to get up early for school.
In other words, “life as usual” in teenagers can be full of signals of developing cardio-metabolic disease that require rapid diagnosis and recognition if they are to be reversed in early stages of presentation. This is alarming, because it’s so unlikely considering that this population largely lacks the element of concern and motivation to change behaviors and to be compliant with treatment. Obesity and sleep apnea are hard-to-treat diseases.
There are further differences among gender and ethnic groups, with males overall and African Americans and Hispanics doing worse. More long-term studies are needed to examine the reasons for these differences. The importance of this research is to raise concern regarding issues developing sub-clinically in young individuals, so they’re identified and intercepted before the problem continues into adulthood, when treatment becomes more difficult.
The prevailing theory in young teenagers who develop sleep apnea is that enlarged tonsils are the main culprit and easy to manage with a surgical procedure (tonsillectomy). Now we have the added cultural element of the rise in rates of obesity. With obesity being more prevalent in teenagers and in some cases considered “the new norm,” some societies may be less concerned take action quickly. That attitude needs to change.
From the clinical perspective, more effort should be taken to identify OSA if present in young teens and to intervene earlier in adolescents who have this dangerous health condition in order to prevent serious health consequences. This must be done with the understanding of the greater challenge posed by this group, i.e., resistance to standard treatment.
From a research perspective, more studies are necessary to identify possible new mechanisms of disease that are different from what we know. I would strongly urge pediatricians and adolescent medicine doctors, as well as general practitioners, to identify at-risk individuals in the young population that they routinely see. Parents can also be on alert for signs of early diabetes and OSA in teens diagnosed as obese.
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Eli Hendel, M.D., is a board-certified internist/pulmonary specialist with board certification in Sleep Medicine. An Assistant Clinical Professor of Medicine at Keck-University of Southern California School of Medicine, and Qualified Medical Examiner for the State of California Department of Industrial Relations, his areas include asthma, COPD, sleep disorders, obstructive sleep apnea, and occupational lung diseases. Favorite hobby? Playing jazz music. Find him on Twitter @Lung_doctor.