Associations of short sleep duration with childhood obesity and weight gain: summary of a presentation to the National Academy of Science's Roundtable on Obesity Solutions

Activities and social contact as antecedents to sleep onset time in U.S. adolescents

This study evaluated adolescents' evening patterns in activities, social contact, and location to better understand antecedents to adolescents' sleep onset time (SOT). The SOT is important for sleep duration and related health outcomes. Using a nationally representative sample of 15- to 18-year-old adolescents from the American Time Use Survey (N = 10,341; 47% female; 57% white), structural equation modeling demonstrated that late SOTs mediated links between evening activities, social contact, locations, and shorter sleep durations. Passive leisure, time in public locations, and time with friends late in the evenings were associated with later SOTs, whereas homework and active leisure did not. Parents and practitioners can use this information to carefully evaluate evening activities, social contact, and location to support healthy SOTs for adolescents across time.

Longitudinal associations between sleep and weight status in infants and toddlers

BACKGROUND

The limited research assessing relationships between sleep duration and weight status in infants and toddlers relies primarily on parent-reported sleep and cross-sectional studies.

OBJECTIVES

Examine whether average sleep duration and changes in sleep duration among 6-24-month-old children were associated with weight-for-length z-scores, and whether these associations varied by race/ethnicity, socioeconomic status and sex.

METHODS

Data were collected when children were approximately 6, 12, 18 and 24 months old (N = 116). Sleep duration was measured using actigraphy. Weight-for-length z-scores were calculated using children's height and weight. Physical activity was assessed using accelerometry. Diet was assessed using a feeding frequency questionnaire. Demographic characteristics included sex, race/ethnicity and socioeconomic status. Separate associations of between- and within-person changes in sleep duration were estimated with weight-for-length z-score treated as the outcome variable in linear mixed model analyses. Additional models were assessed that included interactions between sleep and demographic characteristics.

RESULTS

At time points where children slept longer at night compared to their own average, their weight-for-length z-score was lower. This relationship was attenuated by physical activity levels.

CONCLUSIONS

Increasing sleep duration can improve weight status outcomes in very young children who have low physical activity levels.

The timing and quality of sleep was associated with dietary quality and anthropometry in toddlers born preterm

AIM

The aim of the study was to examine prospective associations of sleep characteristics (duration, timing, quality) with dietary and anthropometric measures among toddlers born preterm (<35 weeks).

METHODS

Children participated in the Omega Tots trial at 10-17 months' corrected age (Ohio, USA; 26 April 2012 to 6 April 2017). Caregivers reported toddlers' sleep at baseline using the Brief Infant Sleep Questionnaire. After 180 days, caregivers reported toddlers' past month diet in a food frequency questionnaire, and anthropometry was measured using standardised protocols. The toddler diet quality index (TDQI: higher scores indicating better quality), and weight-for-length, triceps skinfold and subscapular skinfold z-scores were calculated. Linear and logistic regression assessed adjusted associations with dietary and anthropometric outcomes at 180-day follow-up (n = 284), and linear mixed models assessed changes in anthropometry.

RESULTS

Daytime sleep was associated with lower TDQI (β_adj per hour = -1.62 (95% CI: -2.71, -0.52)) whereas night-time sleep was associated with higher TDQI (β_adj  = 1.01 (95% CI: 0.16, 1.85)). Night-time awakenings and caregiver-reported sleep problems were also associated with lower TDQI. Night awakening duration and sleep-onset latency were associated with higher triceps skinfold z-score.

CONCLUSION

Daytime and night-time caregiver-reported sleep showed opposite associations with diet quality, suggesting that sleep timing may be important.

ISPAD Clinical Practice Consensus Guidelines 2022: Type 2 diabetes in children and adolescents

Since the 2018 ISPAD guidelines on this topic, follow-up of large cohorts from around the globe have continued informing the current incidence and prevalence of co-morbidities and complications in young adults with youth-onset type 2 diabetes (T2D). This chapter focuses on the risk factors, diagnosis and presentation of youth-onset T2D, the initial and subsequent management of youth-onset T2D, and management of co-morbidities and complications. We include key updates from the observational phase of the multi-center Treatment Options for Type 2 Diabetes in Adolescents and Youth (TODAY) clinical trial, the SEARCH for Diabetes in Youth (SEARCH) study and new data from the Restoring Insulin Secretion (RISE) study, a head-to-head comparison of youth onset vs adult-onset T2D. We also include an expanded section on risk factors associated with T2D, algorithms and tables for treatment, management, and assessment of co-morbidities and complications, and sections on recently approved pharmacologic therapies for the treatment of youth-onset T2D, social determinants of health, and settings of care given COVID-19 pandemic.

The Mediating Effect of Sleep Duration on the Association between Food Insecurity and Childhood Obesity

Background: Childhood obesity has increased globally during the past four decades. Food insecurity could heighten the risk of obesity. However, little is known about the underlying mechanism. This study aims to investigate the mediating role of sleep duration in the association between food insecurity and childhood obesity and whether there are differences by age, sex, and race/ethnicity. Method: Data from the National Survey of Children's Health for the years 2016-2020 were used, including children 10-17 years of age. We employed causal mediation analysis within a counterfactual framework to decompose the total effect of food insecurity into natural direct and indirect effects and estimate the proportion mediated. Result: The prevalence of obesity was 15.8% in our study sample. Children with food insecurity had 78% higher odds [odds ratio (OR) = 1.78, 95% confidence interval (CI): 1.70-1.86] of having obesity compared with children who were food secure. Overall, only 6.13% of this association was mediated by sleep duration. The association between food insecurity and obesity was stronger in females (OR = 1.96, 95% CI: 1.84-2.10) than males (OR = 1.66, 95% CI: 1.56-1.75), but the proportion mediated by sleep duration was larger in males (7.13%) than females (5.22%). Evidence of mediation was more pronounced in children 10-11 years of age and non-Hispanic Asian children (proportion mediated = 14.85% and 11.21%, respectively). Conclusion: Food insecurity is associated with an increased prevalence of obesity among children. Although a small proportion of this association is mediated by sleep duration, these results suggest that sleep should be considered when assessing the link between food insecurity and childhood obesity.

Sleep onset, duration, or regularity: which matters most for child adiposity outcomes?

BACKGROUND/OBJECTIVES

Sleep measures, such as duration and onset timing, are associated with adiposity outcomes among children. Recent research among adults has considered variability in sleep and wake onset times, with the Sleep Regularity Index (SRI) as a comprehensive metric to measure shifts in sleep and wake onset times between days. However, little research has examined regularity and adiposity outcomes among children. This study examined the associations of three sleep measures (i.e., sleep duration, sleep onset time, and SRI) with three measures of adiposity (i.e., body mass index [BMI], waist circumference, and waist-to-height ratio [WHtR]) in a pediatric sample.

SUBJECTS/METHODS

Children (ages 4-13 years) who were part of the U.S. Newborn Epigenetic STudy (NEST) participated. Children (N = 144) wore an ActiGraph for 1 week. Sleep measures were estimated from actigraphy data. Weight, height, and waist circumference were measured by trained researchers. BMI and WHtR was calculated with the objectively measured waist and height values. Multiple linear regression models examined associations between child sleep and adiposity outcomes, controlling for race/ethnicity, child sex, age, mothers' BMI and sleep duration.

RESULTS

When considering sleep onset timing and duration, along with demographic covariates, sleep onset timing was not significantly associated with any of the three adiposity measures, but a longer duration was significantly associated with a lower BMI Z-score (β = -0.29, p < 0.001), waist circumference (β = -0.31, p < 0.001), and WHtR (β = -0.38, p < 0.001). When considering SRI and duration, duration remained significantly associated with the adiposity measures. The SRI and adiposity associations were in the expected direction, but were non-significant, except the SRI and WHtR association (β = -0.16, p = 0.077) was marginally non-significant.

CONCLUSIONS

Sleep duration was consistently associated with adiposity measures in children 4-13 years of age. Pediatric sleep interventions should focus first on elongating nighttime sleep duration, and examine if this improves child adiposity outcomes.

A scoping review of outcomes commonly reported in obesity prevention interventions aiming to improve obesity-related health behaviors in children to age 5 years

This scoping review was undertaken as the first stage of development of the Core Outcome Sets for Early Prevention of Obesity in CHildhood (COS-EPOCH). The aim of this review is to identify the outcomes collected and reported in randomized controlled trials of early childhood obesity prevention interventions. A systematic scoping review was undertaken following published guidelines. Trial registries and Medline were searched, and records retrieved were screened by two reviewers. Included trials aimed to prevent childhood obesity in the first 5 years of life and were randomized. Data were extracted using a standardized form. Outcomes were assigned to outcome domains, and similar definitions within each domain were merged, based on key literature and expert consensus. Outcome and domain frequencies were estimated and presented in outcome matrices. Eighteen outcome domains were identified from 161 included studies: "anthropometry," "dietary intake," "physical activity," "sedentary behaviour," "emotional functioning/wellbeing," "feeding," "cognitive/executive functioning," "sleep," "other," "study-related," "parenting practices," "motor skill development," "environmental," "blood and lymphatic system," "perceptions and preferences," "quality of life," and "economic," "oral health." The most frequently reported outcome domain was anthropometry (92% of studies), followed by dietary intake (77%) and physical activity (60%). 221 unique outcomes were identified, indicating a high degree of heterogeneity. Body mass index was the only outcome reported in >50% of studies. The considerable heterogeneity in outcomes supports the need for the development of COS-EPOCH.

Associations between Child and Family Level Correlates and Behavioural Patterns in School-Aged Children

Identifying correlates of behavioural patterns are important to target population sub-groups at increased health risk. The aim was to investigate correlates of behavioural patterns comprising four behavioural domains in children. Data were from the HAPPY study when children were 6–8 years (n = 335) and 9–11 years (n = 339). Parents reported correlate and behavioural data (dietary intake, physical activity, sedentary behaviour, and sleep). Behavioural data were additionally captured using accelerometers. Latent profile analysis was used to derive patterns. Patterns were identified as healthy, unhealthy, and mixed at both time points. Multinomial logistic regression tested for associations. Girls were more likely to display healthy patterns at 6–8 years and display unhealthy and mixed patterns at 9–11 years than boys, compared to other patterns at the corresponding ages. Increased risk of displaying the unhealthy pattern with higher age was observed at both timepoints. At 9–11 years, higher parental working hours were associated with lower risk of displaying mixed patterns compared to the healthy pattern. Associations observed revealed girls and older children to be at risk for unhealthy patterns, warranting customisation of health efforts to these groups. The number of behaviours included when deriving patterns and the individual behaviours that dominate each pattern appear to be drivers of the associations for child level, but not for family level, correlates.

Cultural Influences on Healthy Weight Care in Karen Children

PURPOSE

Although the rates of childhood obesity are disproportionately higher in children of racial and ethnic minorities, research rarely addresses possible cultural factors. The purpose of this study was to discover cultural influences that contribute to or prevent childhood obesity from the perspectives of Burmese-American children and adolescents of Karen ethnicity in the southeast U.S.

DESIGN AND METHODS

The ethnonursing research method was used to seek perspectives of healthy weight care from Karen children between 8 and 15 years-of-age (n = 10). Karen parents (n = 5) and non-Karen community members (n = 13) were also interviewed. Data sources - interviews, fieldnotes, and observation notes - were analyzed using the four phases of the ethnonursing method.

RESULTS

Four themes important to healthy weight care in Karen children were discovered: views of a healthy child, food and food preparation, physical activity, and mutual support among family and community. These themes revealed both Karen and non-Karen influences.

CONCLUSIONS

Most Karen cultural influences promote healthy weight care in Karen children and adolescents which may protect them from childhood obesity. Lack of after-school transportation, limited space to play/exercise, and the sedentary tendencies of girls could limit healthy weight care.

PRACTICE IMPLICATIONS

Pediatric nurses may use knowledge gained from this study for promotion of healthy weight care in Karen families and to advocate for community changes which could benefit all children.

Nighttime sleep duration trajectories were associated with body mass index trajectories in early childhood

BACKGROUND

The respective contribution of total, daytime and nighttime sleep duration in childhood obesity remains unclear.

OBJECTIVES

To assess the longitudinal association between developmental trajectories of sleep duration and BMI z-score in early childhood.

METHODS

Data were from the Melbourne INFANT program, a prospective cohort with 4-month-old infants being followed-up until age 60 months (n = 528). Sleep duration (total, daytime, nighttime) and BMI z-score were measured using questionnaire at ages 4, 9, 18, 43 and 60 months. Group-based trajectory modelling was used to describe longitudinal trajectories from ages 4 to 60 months. Multivariable logistic regression was conducted to assess the association between sleep duration and BMI z-score trajectories.

RESULTS

Three nighttime sleep duration trajectory groups were identified: "Long stable" (10.5 to 11.0 hours, 61%), "catchup long" (8.0 to 11.5 hours, 23%) and "short stable" (8.7 to 9.8 hours, 16%) nighttime sleepers. BMI z-score trajectory groups were classified as "low-BMIz" (-1.5 to -0.5 unit, 21%), "mid-BMIz" (-0.5 to 0.5 unit, 58%) and "high-BMIz" (0.8 to 1.4 unit, 21%). With adjustment for child and maternal covariates, both "catchup long" (OR 3.69 95%CI 1.74, 7.92) and "long stable" nighttime sleepers (OR 4.27 95%CI 2.21, 8.25) revealed higher odds of being in the "mid-BMIz" than the "high-BMIz" group. By contrast, total or daytime sleep duration trajectories were not associated with BMI z-score trajectories.

CONCLUSIONS

Longer nighttime, but not total or daytime, sleep duration was associated with lower BMI z-score trajectories in early childhood. Our findings reinforce the importance of nighttime sleep for healthy body-weight development in early childhood.

A Look Back at Healthy Lifestyle Behavioral Patterns among School-Age Children: Are We Neglecting Healthy Weight for Overweight Kids?

Objective: To describe prevalence of healthy lifestyle behaviors (HLBs) between two school-age cohorts of racial-ethnically diverse children. Methods: Using two Early Childhood Longitudinal Study cohorts (ECLS-K 1999 and 2010), we compared percentage change in HLBs (sleep, physical activity, screen time, and family meals) by child weight groups and within racial-ethnic groups. Weight groups of interest included healthy weight (HW; BMI 5th-84th percentile), overweight (OW; ≥ 85th-94th), obese (OB; ≥ 95th-99th percentile), and severely obese (SO; ≥ 99th percentile). Results: OW children within the 2010 cohort reported greater percentage change (range: 2.0%-15.1% increase) in HLBs, whereas HW children demonstrated lower percentage change (range: -6.2% to 8.7% increase). OB and SO children showed significant lower percentage change in reducing screen time (range: -11.0% and -12.7%, respectively). HW Latino children demonstrated the least favorable trends with overall declines noted for 4/5 HLBs. Screen time was noted to have the greatest degree of favorable change (2%-14%) across weight groups, whereas adequate sleep duration demonstrated the lowest favorable percentage change (2%-2.8%). Conclusion: Fewer HW and OB children were participating in recommended HLBs compared with OW children in 2010. Recent health campaigns may have helped providers prioritize the identification and counseling of OW children, yet our data suggest that we may be neglecting the role of HLB counseling in OB and HW children. Continued analysis on the social determinants that impact HLBs in school-age and HW/OB minority children should inform how we can best tailor counseling and messages in the coming decades.

Bedtime, body mass index and obesity risk in preschool-aged children

BACKGROUND

Although sleep duration is a risk factor for obesity in young children, less is known about other aspects of sleep health, including bedtime, on obesity risk.

OBJECTIVE

To determine whether bedtime is associated with body mass index (BMI) z-score or obesity risk in children ages 2 to 5 years, and to determine if associations are independent of sleep duration.

METHODS

Cohort analyses were undertaken using three early life obesity prevention trials (POI, INSIGHT, Healthy Beginnings) and a longitudinal cohort study (HOME). Bedtime was assessed by questionnaire and BMI through clinical measurement between 2 and 5 years in 1642 children. Adjusted regression models examined whether BMI z-score and obesity (BMI z-score ≥ 2) were associated with bedtime, nocturnal sleep time and 24-hour sleep time. A discrete mixture model categorized children into bedtime trajectory groups across time points.

RESULTS

Bedtime was inconsistently associated with BMI z-score. Although each hour later of bedtime was associated with greater odds of obesity at ages 3 (OR; 95% CI: 1.05; 1.003, 1.10) and 5 (1.35; 1.08, 1.69) years, odds were attenuated after adjustment for nocturnal or 24-hour sleep time. Longer nocturnal sleep duration at 2 years was associated with lower odds of obesity (OR 0.90; 0.86, 0.94), as was longer 24-hour sleep duration at 3 years in girls (0.70; 0.62, 0.78). BMI z-score and odds of obesity were not significantly different between 'early to bed' and 'late to bed' trajectory groups.

CONCLUSIONS

Timing of bedtime appears inconsistently related to obesity in young children, possibly via influencing overall sleep duration.

A systematic review of lifestyle patterns and their association with adiposity in children aged 5-12 years

Diet, physical activity, sedentary behaviour and sleep are typically examined independently with childhood adiposity; however, their combined influence remains uncertain. This review aims to systematically summarize evidence on the clustering of these behaviours through lifestyle patterns and evaluate associations with adiposity in children aged 5-12 years. Search strategies were run in six databases. Twenty-eight papers met the inclusion criteria, six of which included all four behaviours. A range of lifestyle patterns were identified (healthy, unhealthy and mixed). Mixed patterns were most frequently reported. Unhealthy patterns comprising low physical activity and high sedentary behaviour were also frequently observed. Mixed patterns comprising healthy diets, low physical activity and high sedentary behaviour were more commonly seen in girls, whereas boys were more physically active, similarly sedentary and had unhealthier diets. Children from lower socio-economic backgrounds tended to more frequently display unhealthy patterns. Unhealthy lifestyle patterns were more often associated with adiposity risk than healthy and mixed patterns. With few studies including all four behaviours, it is difficult to establish a clear picture of their interplay and associations with adiposity. Nonetheless, reliance on lifestyle patterns is likely more beneficial than individual behaviours in targeting adiposity and improving understanding of how these behaviours influence health.

Prevalence and lifestyle-related risk factors of obesity and unrecognized hypertension among bus drivers in Ghana

Obesity and hypertension are public health problems associated with cardiovascular events worldwide. Bus drivers, whose lifestyle is primarily sedentary and characterized by poor eating habits are at increased risk. This study determined the prevalence and lifestyle-related risk factors of obesity and hypertension among Inter-Regional Metromass Bus Drivers (IRMBDs) in Ghana. This cross-sectional study recruited 527 professional drivers from Metromass Bus stations in Accra and Kumasi Metropolis, Ghana. Structured questionnaires were administered to obtain socio-demographic and lifestyle characteristics from all participants. Anthropometric measurements including body mass index (BMI), waist circumference (WC), waist-to-hip ratio (WHR) and blood pressure (BP) were determined. The prevalence of unrecognized hypertension was 38.7%. The prevalence of obesity using BMI, WC, and WHR as obesity indices were 19.0%, 19.9%, and 19.4%, respectively. Use of sleep inhibitors, long-duration sitting and eating late at night were independent risk factors for obesity, regardless of the obesity index used (p < 0.05). Physical inactivity, high caloric intake and eating at stressful periods were independent risk factors for obesity based on WC and WHR measurements (p < 0.05). Ageing, smoking history, alcoholic beverage intake, sleep inhibitor drug use, high calorie intake, long-duration sitting, eating late and under stressful conditions were independent risk factors for hypertension (p < 0.05). There is a high prevalence of unrecognized hypertension and obesity among IRMBDs which were associated with individual lifestyle and behaviours. Increased awareness through educational and screening programs will trigger lifestyle modifications that will reduce cardio-metabolic disease onset and offer clues for better disease predictive, preventive and personalized medicine.

Sleeping Time, BMI, and Body Fat in Chinese Freshmen and Their Interrelation

INTRODUCTION

In the past two decades, urbanization in many Asian countries has led to sedentary lifestyle and overnutrition, which has set the stage for the epidemic of obesity. Those who have obesity during adolescence usually have obesity into adulthood, which causes many medical and psychological issues that can result in premature death. Recent data suggest that short sleep duration may contribute to the risk of obesity, opening a new avenue for potential intervention. The aim of this study was to describe the prevalence of sleeping time, body mass index (BMI), and fat mass in Chinese freshmen and to indicate the relationship among them.

METHODS

We conducted a cross-sectional study consisting of 1,938 freshmen aged from 18 to 24 years, including 684 (35.3%) men and 1,254 (64.7%) women. BMI, sleeping time, and other potential related variables were collected by questionnaire. Obesity and overweight were defined as BMI ≥28.0 and ≥24.0, respectively. All students were divided into three groups according to the tertiles of body fat percentage (Fat%), which were measured by bioelectrical impedance analysis. Sleeping time was divided into 3 categories based on the duration, <6, 6-8, and >8 h per day.

RESULTS

Participants who slept longer had lower BMI and Fat%. Sex, diet control, and maternal obesity were all significantly associated with BMI or Fat% after adjustment. There were significant differences between sleeping time <6 and >8 h in both overweight group and Fat% tertiles independent of adjustment used. The significant difference between sleeping time 6-8 and >8 h only existed in overweight group, while irrelevant relation was observed in both models of obesity group.

CONCLUSION

Longer sleeping time was associated with a lower BMI in Chinese freshmen, even after adjustment for multiple confounders. The overweight stage is a critical period of weight management intervention by changing sleeping time. If adolescents have entered the obesity stage, the effect size of lifestyle intervention might be significantly limited.

Impact of Sleep Duration and Weekend Oversleep on Body Weight and Blood Pressure in Adolescents

Introduction

Weekend oversleep or catchup sleep is a frequent occurrence in children, but there are relatively little data concerning its impact on weight and blood pressure. The aim of this study was to assess the association between sleep duration and oversleep, and weight and blood pressure in adolescents.

Methods

Sleep duration, weight and blood pressure of 327 children (51.4% boys, mean age 13.3 ± 1.7 years) who had polysomnograms performed during both exam cycles of the Tucson Children's Assessment of Sleep Apnea study (TuCASA) were analyzed. Sleep duration on school nights and non-school nights was used to compute a weighted average of child and parent reported overall sleep duration respectively. Oversleep was defined as the difference between self and parent reported weekend sleep and weekday sleep separately. Simple correlations between overall sleep duration, sleep on school and non-school nights and oversleep, and blood pressure, standardized body mass index (BMI), snoring, respiratory disturbance index (RDI) and age were calculated. Significant bivariate associations then were used to develop multivariate partial correlation models.

Results

Unadjusted negative correlations with BMI were noted for parent reported total sleep duration at the 1^st exam cycle, parent and child reported total sleep and school night sleep duration, and parent reported non-school night sleep duration at the 2^nd exam cycle. Additionally, for BMI, positive correlations were observed for log RDI at both exam cycles and snoring at the 2^nd exam cycle. For blood pressure, there were positive associations with age, parent reported oversleep, caffeine consumption and snoring. Additionally, for blood pressure, negative relationships were observed with parent reported total sleep duration at the 1^st exam cycle, and parent and child reported total sleep and school night sleep durations at the 2^nd exam cycle. Partial correlations found that BMI was negatively correlated with parent reported total sleep duration at the 1^st exam cycle and parent reported total sleep duration at the 2^nd exam cycle, and positively correlated with snoring and log RDI at both exam cycles. Systolic blood pressure was only associated with age and snoring. Diastolic blood pressure was positively correlated with age and caffeine consumption, and negatively correlated with parent reported total and school night sleep duration. Oversleep and child reported sleep duration were not represented in any of these models.

Conclusion

Lower amounts of sleep especially on school nights is associated with higher body weight and blood pressure. Oversleep was not associated with either body weight or blood pressure.