In the fight against obesity in teens, we've considered a number of different strategies — taxing sugary drinks, rewriting food labels and encouraging young people to cut down on screen time.
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But one expert says we also need to look at how much sleep teens are getting.
Dr. Nicholas Chadi is a pediatrician and researcher specializing in adolescent medicine in Toronto, and a fellow in global journalism at the Munk School of Global Affairs.
As he told CBC Radio, he's looking at why sleep apnea is a major issue for teens, and how it connects to the obesity problem.
How are sleep apnea and obesity connected?
"It's a bit of a chicken and egg question," said Chadi.
"We could think of sleep apnea as a symptom of obesity. But we could also see it the other way around."
Sleep apnea can affect people of all ages, and can cause serious health problems. The sleep disorder is characterized by pauses in breathing at night because of a blockage in the airways.
Less air reaches the lungs and the brain and body become oxygen deprived, which disrupts sleep, in addition to causing other health issues.
And in terms of obesity, it can create a cycle, says Chadi.
"If you have sleep apnea, this will impact the quality of your sleep, and make it harder for you to control your eating or exercise. During the day you might binge on foods because you're tired and you want to stay awake. So sleep apnea really brings you in this kinds of vicious circle where if you have obesity and develop sleep apnea, it becomes difficult to lose weight and to get away from your sleep apnea."
Why is it particularly problematic for teens?
Regardless of age, sleep apnea brings a number of possible health issues, Chadi said, such as increased blood pressure and headaches during the day.
For teens, developing such symptoms at a relatively early age is especially dangerous, he said.
"If they can't get rid of that problem, the consequences really will stay. And the risks of developing all those impacts on their health — like diabetes and heart attacks and stroke — are more significant for teens," Chadi said.
"The recent research shows that there's strong effects on mental health. Teens who have sleep apnea are much more likely to be depressed, have trouble concentrating in school, and it can even impact brain development to a level that's quite significant. So really, we can't be overlooking that problem in teens who are obese."
It's estimated between three and five per cent of teens — which would be more than 180,000 people in Canada — suffer from it, Chadi said. For obese teens, that number rises to 60 to 70 per cent.
How hard is sleep apnea to diagnose in teens?
Sleep apnea can present symptoms which may be obvious, Chadi said, such as loud snoring.
But other signs to watch for are pauses in breathing that are typically 10 to 20 seconds long, morning headaches, feeling distracted and constantly tired, or feeling sad or depressed.
These are issues many parents may shrug off as typical "teen problems," according to Chadi.
"The tricky thing is so many teens complain of always being tired and not being able to sleep right, and will sleep very long hours. So that's perceived as teens just being lazy," he said.
"For parents, [sleep apnea is] not necessarily the first thing that you'll think when you have a teen who's hooked up on their smartphone all day and staying up really late at night."
And he said even medical professionals might miss the signs.
"Doctors learn about sleep apnea in medical school, so pediatricians do learn about it," he said. "But it's not kind of a gut reflex for pediatricians to think, 'Oh, this teen must have sleep apnea because he's not sleeping well.'"
Diagnosing sleep apnea requires a sleep study, Chadi says, which involves spending a night with a monitor that records breathing and the level of oxygen in the blood, and monitors how often the patient wakes up during the night. Such studies are usually done in hospitals or specialized clinics.
In some provinces, it's possible to do the testing from home with a portable monitor, but the quality of the testing is not the same as testing done in a clinic or hospital.
One of the biggest problems, Chadi says, is long wait times for sleep studies, and the challenge of finding hospitals to conduct them — especially in rural areas.
What's the best approach to dealing with it?
"The more obvious way is to lose weight. Most people, if they lose enough weight, will get better and be cured of their sleep apnea," said Chadi.
There are other solutions, but each presents its own challenges.
"The first one is continuous positive airway pressure machines, or CPAP," he said.
"So what that means is sleeping with a small machine and a face mask, with positive pressure that's pushed into your lungs all night long. Adults aren't great at complying with that, and teens for sure aren't either.
"Another one is oral devices — so palate expanders, or a way to bring the top jaw forward to create more space in the mouth. Usually, your dentist or orthodontist will make those for you, but they're quite expensive, and they're not covered by provincial health plans."
Surgery to open up airways is also an option, but not necessarily a good one, said Chadi.
"It's not something we would recommend for teens as a first option, because it can also recur once we've done the surgery and the obesity's not treated."
More research, Chadi said, could help find better ways to treat sleep disorders in teens.
"Really, the issue here is that we need to know more about sleep apnea in teens to research better ways to prevent it and treat it — and then once we've confirmed the diagnosis, really making sure that teens have access to treatment for that problem."