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Sleep Disorders&Obesity in Your Teen

Online Health Chat with Sally Ibrahim, MD and Daniela G. Isakov, MD

October 1, 2012

Introduction

Cleveland_Clinic_Host: Teenagers need an average of 9.5 hours of sleep at night, but average only 7.5 hours of sleep. Did you know that teenagers who sleep less than eight to nine hours per night may have an increased chance of gaining weight than those who do get adequate sleep? In fact, many teens suffer from treatable sleep disorders, such as narcolepsy, insomnia, restless leg syndrome or sleep apnea, without even knowing about it. Not getting the proper amount or quality of sleep leads to more than just feeling tired. Sleepiness interferes with cognitive function, which can lead to learning disabilities, memory impairment, personality changes and depression. Sleep deprivation may result in many consequences that affect your teen, including daytime sleepiness, mood swings, drowsy driving, lower grades and weight gain. If your teen has difficulty falling asleep or staying asleep, he or she may have a sleep disorder. Among the many issues that result from less sleep, obesity may be the most threatening to your teen’s health.

According to the American Obesity Association, about 30.4 percent of teenagers are overweight, and 15.5 percent of teens are obese, which puts them at risk for developing numerous health problems due to their weight. The effects that teen obesity has on health can begin during adolescence and extend throughout a lifetime if not addressed.

Teenage obesity may lead to other problems, such as type 2 diabetes, asthma, sleep problems, orthopaedic problems, hypertension and heart disease. Together these conditions create an unhealthy cycle—not getting enough sleep may cause your teen to eat too much or eat unhealthy foods that may lead to weight gain, while obesity can lead to your teen having a lesser quality of sleep.

For More Information

On Cleveland Clinic
Established in 1978, Cleveland Clinic's Sleep Disorders Center was among the first in the nation dedicated to the diagnosis and treatment of sleep disorders in people of all ages. Accredited by the American Academy of Sleep Medicine, Cleveland Clinic's Sleep Disorders Center is staffed by physicians from a variety of disciplines, including adult and child neurology, pulmonary and critical care medicine, psychology, psychiatry and otolaryngology. More than 8,000 sleep studies are performed in our laboratories each year.

Cleveland Clinic Children's Hospital has a staff of more than 300 pediatric primary care and subspecialty physicians who serve newborns, infants, children and adolescents at convenient locations throughout northern Ohio. Our pediatric physicians offer comprehensive general and preventive care, as well as care for children with complex or chronic health issues. With access to leading-edge diagnostic and treatment resources, as well as a total commitment to family-centered care, our pediatric professionals are well-equipped to diagnose and treat common, everyday illnesses, as well as serious childhood diseases and conditions like cancer and diabetes.

On Your Health
MyChart®: Your Personal Health Connection, is a secure, online health management tool that connects Cleveland Clinic patients with their personalized health information. All you need is access to a computer. For more information about MyChart®, call toll-free at 866.915.3383 or send an email to: mychartsupport@ccf.org

A remote second opinion may also be requested from Cleveland Clinic through the secure Cleveland Clinic MyConsult® website. To request a remote second opinion, visit eclevelandclinic.org/myConsult


For Appointments

To make an appointment with Sally Ibrahim, MD, or any of the other specialists in our Neurological Institute at Cleveland Clinic, please call 216.636.5860 or call toll-free at 866.588.2264. You can also visit us online at clevelandclinic.org/sleep.

To make an appointment with Daniela G. Isakov, MD or any of the other pediatricians in our Cleveland Clinic Children’s Hospital, please call 216.444.KIDS (5437) or call toll-free at 800.801.2273. You can also visit us online at clevelandclinicchildrens.org.


About the Speakers

Sally Ibrahim, MD, is a sleep specialist who treats adults, children and adolescents in the Sleep Disorders Center at Cleveland Clinic’s main campus and Richard E. Jacobs Health Center in Avon. Dr. Ibrahim is board certified in sleep medicine, internal medicine and pediatrics. She completed her sleep medicine fellowship at Cleveland Clinic following her residency in internal medicine-pediatrics at MetroHealth Medical Center in Cleveland. She received her medical degree at the University of Texas Medical Branch at Galveston, Galveston, Tex. She has many specialty interests, including sleep disorders in children and adults, sleep apnea, insomnia, parasomnias, adolescent obesity, restless legs syndrome, narcolepsy, daytime sleepiness and circadian rhythm disorders.

Daniela G. Isakov, MD, practices general pediatrics with Cleveland Clinic Children’s Hospital at Cleveland Clinic Twinsburg Family Health & Surgery Center. She is board-certified in pediatrics and completed her internship and residency in pediatrics at Cleveland Clinic. She received her medical degree from The Ohio State University College of Medicine. Dr. Isakov’s specialty interests include preventative medicine, healthy lifestyle, perinatal research, parasitology and immunology.


Let’s Chat About Sleep Disorders and Obesity in Your Teen

Cleveland_Clinic_Host: Welcome to our Online Health Chat with Cleveland Clinic specialists Dr. Sally Ibrahim and Dr. Daniela Isakov. We are thrilled to have them here today for this chat on Sleep Disorders and Obesity in Your Teen.


Excess Weight and Obesity

nutzy: From my previous knowledge, obesity could have a big influence on a quiet profound sleep. What you recommend to do along with diet and sport activity?
Dr__Isakov: Reduce sedentary time. For example limit the amount of TV and video games.

dolphi: My child is alert and doing well in school but her BMI is 26. Is that considered overweight?
Dr__Isakov: In children we look at percentiles. Overweight is defined as a BMI at or above the 85th percentile and lower then the 95th percentile. Obesity is defined as BMI at or above the 95th percentile.

got_funds: Does being overweight also cause sleep problems?
Dr__Ibrahim: Overweight children and teens are at higher risk for obstructive sleep apnea. We perform sleep studies on suspected cases.

MamaKath: I've read that obesity can lead to an increase in emotional problems. Do you think that's possible? I feel like my 15 year-old daughter is just in that ‘phase,’ but am wondering if it would improve if she became more active and ate better. Do you think that's possible?
Dr__Isakov: Yes this is true. We often see that children and teens have low self esteem related to their obesity. There are a lot of changes and challenges that teen face, so it may be a combination of several factors. Exercising is a great mood lifter, so it is an effective way to minimize depression and help keep fit. I would suggest that you talk to her physician about the concerns that you have and they may be able to give you some suggestions.

 

Association with Diabetes Mellitus

squeakers: Does an adequate amount of sleep in my teen help protect against diabetes?
Dr__Ibrahim: There is some research showing that adults who do not sleep enough tend to have higher rates of many types of medical illnesses such as diabetes. Adequate and healthy sleep likely plays a role in keeping people healthy. Teenagers who get adequate sleep are less likely to be overweight and more likely to have increased activity level, which indirectly affects the risks of disease such as diabetes.

pattieB: My son has been battling weight issues since he was 10 years old. I am concerned that his weight could lead to early onset diabetes or hypertension. At what point should I begin having him screened for these types of diseases?
Dr__Isakov: I would suggest talking to his physician. We do start screening as early as nine years of age for diabetes.

can_too: What are the symptoms or warning signs of diabetes in teens?
Dr__Isakov: In Type 1 diabetes mellitus, we often see weight loss, increased thirst and increased appetite. In Type 2 diabetes mellitus, you can see changes in activity level, fatigue, headaches and, at times, see some discoloration of the skin.

leah: Is it dangerous for a teen with Type 1 diabetes to rely on her insulin pump to regulate blood sugar levels and eats whatever she wants?
Dr__Isakov: This can be a problem. There are potentially a lot of factors to consider in this situation. I would make sure that you talk to the endocrinologist who is caring for you child. It may be worthwhile sitting down with the dietician if you have not done that in a while.

 

Adolescent Sleep Disorders

good_b: I know that there are different types of sleep disorders. What are the common ones in teens?
Dr__Ibrahim: Circadian rhythm disorders (delayed phase tendency for later bedtime and rise time), insomnia, poor sleep hygiene and sleep apnea especially in the obese group. We see other disorders in Cleveland Clinic’s sleep clinic, such as restless leg syndrome and parasomnias (e.g., sleep walking, etc.). Less common disorders are narcolepsy and sleep related epilepsy, but we see these in pediatric sleep clinic as well.

frederic: What does a sleep study involve with an adolescent? Also, if necessary, how would we going about getting one?
Dr__Ibrahim: A sleep study involves a comprehensive evaluation of an EEG (or electroencephalogram, to study brain waves) to detect your teen’s sleep stages (awake, REM [rapid eye movement] sleep and deep sleep), as well as evaluation of leg movement and breathing during sleep, by means of belts and oxygen sensors. There is also video monitoring for position and any unusual sleep-related movements or activities in sleep.

A sleep study can be ordered either by your pediatrician or by a sleep physician such as myself after a full sleep evaluation. Sometimes the latter may help to guide the sleep study further, in terms of the details involved in each study.

 

Sleep Apnea

duo3: How can I determine if my child has breathing problems during sleep?
Dr__Ibrahim: Breathing disturbances during sleep can affect sleep quality and potentially cause disease. Snoring, breathing pauses and heavy breathing may be signs of a breathing disorder during sleep such as sleep apnea. Other symptoms also can be present, such as mouth breathing, stuffy nose, night sweats, night awakenings, unrefreshing sleep and daytime fatigue. Some teens will have poor school performance, decreased concentration and memory, and other effects. If you have concerns about breathing problems during sleep, a sleep study may be indicated.

Oversleeping

hadden: My teen sleeps in past noon on weekends to make up for lost time during the week. Is that normal behavior, or should I help establish a healthier weekend routine?
Dr__Ibrahim: This is a common, but not normal, pattern. In adolescence, there is a tendency to stay up, then have insufficient sleep on weekdays, and then sleep in on weekends to ‘make up’ for being so sleep deprived. The problem is many fold:

  1. Teens that have a later bedtime and rise time on weekends tend to be those who are more likely to be overweight with less exercise and activity.
  2. Insufficient sleep during the weekdays affects learning, memory and scholastic achievements.  (Those who sleep more, on average, get better grades.)
  3. Insufficient sleep during the weekdays also affects mood and other behaviors.
  4. Those who sleep in on the weekends, do not fully achieve the lost sleep from the week.

Thus, overall, it is an unhealthy pattern and regular routines are in order. Concentrating on regular bedtime on the weekdays and wake time on the weekends is important.

jump_up: What about kids that oversleep? Does this have any effect?
Dr__Ibrahim: Oversleeping on weekends is likely a sign of insufficient sleep on the weekdays or due to delayed bedtimes. It is best to have more regular sleep periods and sleep times with sufficient sleep nightly where possible.

winters_coming: All my 17-year-old daughter wants to do is sleep. I know she is not depressed. What else could be the reason for this?
Dr__Ibrahim: It would be unusual for teens to be too sleepy all the time. There may be a disorder of too much sleepiness or hypersomnia requiring further evaluation. We evaluate these disorders in Cleveland Clinic’s pediatric sleep clinics.

great: How can I, as a parent, tell if my daughter is having sleep problems? According to her, of course, she's fine.
Dr__Ibrahim: If she does not have complaints—great. But many times, parents may note some patterns that may not be healthy. As a parent, try to enforce a regular bedtime, and be sure she is getting sufficient sleep. Those teens with a parental set bedtime are more likely to have sufficient sleep, earlier bedtimes and less tendency for being overweight.

 

Evening and Bedtime Routines

dawgs: What should the routine be prior to bed to ensure a good night’s sleep, and how long before bedtime?
Dr__Ibrahim: Bedtime routines are variable, but need to be tailored to the individual. Mostly, the theme should be to promote sleep—so dark, quiet and relaxing. It is clear what not to do, such as having electronics and communication devices in the bedroom or during the bedtime routine, as this has been shown to affect sleep amount and increase the tendency for being overweight. Light from these electronics as well as the ‘action’ stimulates the brain to be more awake, instead of helping with sleep transitioning.

Getting into the habit of a regular bedtime and routine is also very important. Some bedtime routines include hygiene (bathe and brush teeth and get into pajamas), listening to light music, meditation or prayer, and reading a book (non-school work) that is light and not too engaging in a dim light, etc.

nonono: What do you do to make the bedroom best for sleeping?
Dr__Ibrahim: The bedroom should be the most relaxing, less stressful, and least stimulating environment to promote sleep. Avoidance of electronics and communication devices, even telephones, in the bedroom can promote sleep. Some parents take the telephone out of the teen’s room until the next morning, due to the disturbance of text messages and other email pop-ups. The TV should be either out of the room (preferably) or off during the bedtime routine and while the teen is going to sleep.

The environment should be cool, comfortable, dark and quiet.

 

School and Daytime Routines

angels: My child is having a hard time adjusting to this year’s school schedule. The bus time is very early and it’s a struggle to get him out of bed every morning. Any tips on how to get him used to this new routine?
Dr__Ibrahim: It's difficult when you cannot change the school start time. In fact in Australia versus the U.S., school start time is one factor why the kids sleep a bit more! What you can do, however, is help create a routine sleep time on weekends similar to weekdays. If an adolescent has a hard time waking up, you should try to have the wake time on weekends very similar to what your aim is on the weekdays—even if it feels too early. This creates a better circadian rhythm that helps the weekdays. Another benefit is light therapy, which in some teens may help to promote being awake when used in the morning. This, however, should be discussed with your pediatrician or sleep physician to do this appropriately.

 

Nutritional Choices

jacko329: What are healthy bedtime snacks for my teen to indulge in?
Dr__Isakov: Overall, I would try to limit the amount of food that is eaten after dinner. Try to offer lots of fruits and vegetables. Hummus is a great addition to vegetables. Try a variety of nuts and trail mix—just make sure you limit the quantity and portion sizes. Apples or bananas with peanut butter or other nut butters. Celery with low-fat cream cheese. You can also check out fruitsandveggiesmatter.gov. You can also find some healthy snacks at kidseatright.org and myplate.gov.

It is important to avoid a large meal before bedtime. If needed, a light, sleep-promoting food may be a banana, milk or light cheese.

rufus: My son arrives home late from football practice during the week which means dinner, homework and bedtime are all delayed. He is extremely tired and irritable in the morning. What are some tips for helping him balance his time more wisely?
Dr__Isakov: You may want to try to pack some healthy snacks or dinner on those late nights, so that he is not arriving home hungry. I would also focus on eating a healthy breakfast, which will help him throughout the day. I like to have children eat eggs, oatmeal, low-fat yogurt with granola, or fruits as some options. If he has any time in between school and sports, he can start working on some of his homework.

hazel: My teen hides snacks in his room and then eats before bedtime. I have tried to explain that his bedroom is for homework and sleep only, not for eating. But, I continue to find snack wrappers. How I can curb this behavior?
Dr__Isakov: You can try to offer healthier snacks with more fruits and vegetables, so that he is not as hungry. If they are unhealthy snacks then I would limit the amount that you buy, so they are not a temptation for him.

cleo: My daughter does not like to eat breakfast, picks at her lunch and then eats a big dinner. She is overweight. She doesn't necessarily 'overeat' calorie wise per day. Why does this cause her to be overweight?
Dr__Isakov: As you are implying, breakfast is the most important meal of the day. It sets the stage for the rest of the day. You can tell her that she will do better in school if she can find something that she likes to eat in the morning. If you eat late at night, then normally you are going to bed and you are not using up the calories at the end of the day. I suggest three well-balanced meals and two healthy snacks during the day, so that you are eating every two to three hours. This helps you curb your appetite, and then you are less likely to overeat at the next meal.

jojo: What are your thoughts on energy drinks, like Monster Energy Drink® or Red Bull®, and sleep or weight problems?
Dr__Ibrahim: There are two problems with these energy drinks. They have high calories and are non-nutritional. They produce highs and lows. These drinks largely have loads of caffeine that give ‘energy.’  

However, for adolescents that drink these, they are more likely to be sleep deprived, and use these drinks to keep them awake, which is not healthy. Energy drinks and caffeine are sometimes used for safety reasons, such as if one is driving and cannot stay awake. But these do not replace sleep. Eventually the body will sleep or even ‘crash.’ These drinks can have multiple caffeine related side effects, such as nervousness, agitation, elevated heart rate, etc. Once off these drinks, rebound effects can occur.

It is wise to get sufficient sleep, avoid too much caffeine especially late in the day, and have a more even course for the day.

gero: Since my teen drinks diet soda pop (and we all do in the family), is that OK or does it still contribute to a problem with weight issues?
Dr__Isakov: Artificial sweeteners can also be a problem. I would try to have everyone cut back in the family. I know it can be difficult, but water is really the best choice! I would also limit the amount of juice in the house.

B_Jolly: I am guilty of providing too much sugar to my children in the form of soda pop, juice, Gatorade®, etc. However, I'm hesitant to switch over to diet versions of these drinks as a way to wean them off of the sugar because I've heard artificial sweeteners are especially bad for children. Is that true? If so, what are the repercussions?
Dr__Isakov: Why don't you try to eliminate one thing at a time? Changes usually work best if they are gradual. I would first eliminate the soda pop, then the juice followed by the Gatorade®. I encourage families to drink water and skim milk. You can give Gatorade® if your children will be exercising for an hour or more.

The artificial sweeteners can often act like other sweeteners and make you crave more sweets. I have seen fatigue, headaches and abdominal pain that will resolve when this is eliminated from the diet.

tell_me: How good are the sports drinks? How about the 'special' waters they sell (i.e., vitamin water, Propel®, etc.)? Are they good for the body? Do they help in weight loss?
Dr__Isakov: They do not help in weight loss. If you find that it is hard to eliminate soda pop and juice from your diet this can be a better choice. The overall goal should be to drink water and skim milk.

hardymums: I have twin 15-year-old girls who like to drink coffee before bedtime, especially during this time of year when there is a chill in the air. Is decaffeinated coffee OK or should I encourage them to drink tea or hot chocolate instead?
Dr__Ibrahim: Glad you are paying attention to caffeine! At least three hours before bedtime, one should avoid caffeine. Avoidance of caffeine as early as noon for some adolescents who are sensitive, is important to help with sleep promotion at night. Even decaffeinated coffee has a bit of caffeine. (Although they extract the caffeine from coffee beans for decaffeinated coffee, they try not to get every bit of it to maintain the taste.) Chocolate also has caffeine. Thus, some teas (chamomile) without caffeine are best, followed by decaffeinated alternatives. Hot milk, if tolerated, is a viable option as well.

 

Weight Management

Help_Me: My son's doctor just put him on a weight management program. He and we are having difficulty getting my son to stick to the program. Do you have any suggestions on how we can better implement this plan to ensure its success?
Dr__Isakov: I usually suggest that as you make changes, you implement it as a family. For example you can set time aside to exercise all together. I would make healthy choices at the grocery store, like no juice or soda pop at home and limiting the snacks or junk food that you bring into the house. Let your child help you make the choices. Get him involved; bring him to the grocery store or let him pick out new recipes.

yeah_yeah: My daughter who is 17 years old is overweight. She has tried dieting and exercising and only seems to lose a few pounds. She is very discouraged. Is there a medical reason why she may not be losing weight, or is she more likely 'cheating' and not admitting it?
Dr__Isakov: There is a small risk that there is an underlying medical condition like a thyroid problem. This is usually not the case though. I would really look at the foods, quantity and amount of exercising that she is going. This is something that I would have you talk to her physician about. They may be able to help determine if any testing is appropriate.

 

Sleep-aid Medications

chicago: My teenager complains about not being able to sleep through the night. This has been a long-time struggle of hers. Should I offer her a non-habit forming sleep aid?
Dr__Ibrahim: One should try to explore reasons for not being able to sleep through the night. One possibility is insomnia, which can respond to a sleep aid. However, I would strongly encourage you to first discuss this with a pediatrician or sleep physician. There are other causes of sleep disruption, for example, sleep apnea, reflux, etc. Thus, exploring these with your doctor would be helpful, especially given the long-time struggle.

you_and_me: My 16-year-old son has told me that if he has trouble sleeping he may take a Benadryl® or night-time cold medicine to help him sleep. I've told him to no longer do this. Is this dangerous, and what is safe for him to take?
Dr__Ibrahim: Benadryl® and many over-the-counter ‘p.m.’ medications contain diphenhydramine, which can causes sleepiness. Some people have used this for help with going to sleep. I would discuss this with your pediatrician, as it appears he is using this often. There may be a sleep disorder that warrants more attention.

For sleep initiation, there are generally two ways we go to sleep. The circadian rhythm is aligned with when we need to sleep, and we have enough sleep pressure built up during the day to help us fall asleep. Behaviors such as caffeine intake and exposure to light late at night can affect these processes. Make sure that these processes are maximized.

Ask your son or observe your son’s sleep patterns. If it is on the weekends, he has not used a sleep aid, and goes to sleep without a problem at a more delayed bedtime, he may have a mal-alignment of his sleep circadian cycle. Fixing this would be the best option rather than the use of sleep aids. Additionally, it is important to form better sleep habits during adolescence, as these will affect future sleep.

 

Weight Gain and Medications

LadyJ: My son is very active, but is on steroids for asthma. I believe that this has contributed to some weight gain. Is that possible? Is it possible to prevent weight gain from steroids or is that inevitable?
Dr__Isakov: If he is on inhaled steroids, this usually does not cause significant weight gain. However, oral steroids can cause weight gain. Usually oral steroids are only used for a short duration to treat asthma flares. Obesity can contribute to asthma; so if you are able to maintain a healthy weight that can often alleviate some of the asthma symptoms.

 

Sleep Aids in the Elderly

LJK: I have taken zolpidem 5 mg for about five years because I wake up in the middle of the night. Will this do me harm? I am 76 years old.
Dr__Ibrahim: Although this is a pediatric forum, I will briefly discuss this. It is largely unclear what long term effects there are for zolpidem in each individual. With aging, some may be at risk for falls, so I try to limit the use of sleep aids. However, waking in the middle of the night may be another disorder that is masked by a sleep aid, such as sleep apnea. Thus, further evaluation may be needed.


Closing

Cleveland_Clinic_Host: I'm sorry to say that our time with Cleveland Clinic specialists Sally Ibrahim, MD, and Daniela G. Isakov, MD is now over. Thank you Dr. Ibrahim and Dr. Isakov for taking the time to answer our questions today about Sleep Disorders and Obesity in Your Teen.
Dr__Ibrahim: Thank you for your attention to sleep in your adolescents! Our sleep center offers pediatric sleep consultations and full sleep evaluation for children and adolescents.
Dr__Isakov: Thank you for all you your questions. The first step in making changes is asking questions! Good luck.


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