Original ArticleSleep deprivation in adolescents: correlations with health complaints and health-related quality of life
Introduction
The aim of the present study was to provide an in-depth analysis of the diverse associations between sleep duration, sleep deprivation, and variability in sleep duration between weekday and weekend nights, and health and health-related quality of life.
In the present review, the most common health complaints of adolescents are addressed. A brief revision of the main sleep parameters (duration, variability, deprivation, late bedtimes and eveningness) that impact upon the health of adolescents is made, taking into account any possible geographical/cultural influences.
Health issues in adolescents are an important public health concern, with sleep habits playing an important role. In the last few decades, several studies of children and adolescents have pointed out the relations of sleep duration with: daytime sleepiness [1], [2], [3]; body mass index (BMI) [2], [4], [5], [6], [7]; type II diabetes and insulin resistance [8]; specific sleep disorders [1]; health characteristics [2]; high blood pressure [9]; pain [10], [11], [12]; race [2], [8]; cognitive tests and academic success [3], [13], [14], [15]; subjective psychological well being [16]; socioeconomic status [2], [5]; habits such as high screen- or TV-viewing time [5], [16]; low or moderate physical activity [5], [17]; poor dietary intake and quality [18]; and risk-taking behaviors [19], [20], [21], [22] namely, binge drinking [23].
In a recent meta-analysis of children and adolescents aged from 9 to 18 years, including 23 countries, sleep duration varied with gender, age, and geographical region [24]. School-day sleep differed slightly between boys and girls – girls slept for 11 min/night more than boys (p <0.003), and 29 min more on non-school days (p <0.003). Sleep time declined with age – minus 14 min/day per year of age on school days, and 7 min on non-school days. Asian adolescents sleep 40–60 min less each night than Americans, and 60–120 min less than Europeans [24]. In India, the mean sleep duration was 7.8 h, which also decreased with age [24], and in China, 34.2% of the students had complaints of poor sleep [25].
In trying to identify predictors of sleep duration and variability in a community-based cohort study of 247 adolescents (48.5% female, 54.3% ethnic minority, mean age of 13.7 years), univariate models have demonstrated that age, minority ethnicity, neighborhood distress, parent education, parent income, pubertal status, and BMI were significantly related to variability in the total sleep time. In the multivariate model, age, minority status, and BMI were significantly related to variability in total sleep time (all with p <0.05), with younger adolescents, non-minority adolescents, and those of a lower BMI obtaining more regular sleep [2].
In a Taiwanese population, the mean sleep duration on weeknights was 7.35 ± 1.23 h and 9.38 ± 1.62 h, on weekends. Weeknight sleep decreased significantly with increasing school grade; there was a trend toward increased daytime sleepiness for students in higher school grade levels. Pearson correlation showed a significant negative correlation (p = 0.0001) for increasing total sleep time on the weekend and decreasing BMI [1].
The Cleveland Children's Sleep and Health Cohort, which consisted of 471 adolescents with a mean age of 15.1 years, sleep duration, measured by actigraphy, had a quadratic ‘u-shape’ association with Homeostasis Model Assessment of insulin (HOMA). When adjusted for age, gender, race, preterm status, and activity, adolescents who slept for 7.75 h had the lowest predicted HOMA, and for adolescents who slept 5.0 h or 10.5 h, the HOMA indices were approximately 20% higher; after adjusting for adiposity, only the association with longer sleep persisted [8].
The relation between sleep duration and health goes beyond weight/obesity and insulin/insulin resistance; sleep intervenes in a significant number of clinical complaints including headache and chronic pain of different characteristics, which are either widespread, musculoskeletal, visceral, and more. In depression and multiple somatic complaints, this sleep impact or association is often multiple, with clusters of symptoms fluctuating together with bilateral influences and a comorbid profile [26], [27]. Insomnia and short sleep duration are comorbid with: obesity, metabolic syndrome, growth hormone deficiency, allergic conditions, chronic pain, neoplasms, blood malignancies, genetic and congenital disorders. Hypersomnia is comorbid with malignancies. Sleep apnea is comorbid with: obesity, metabolic syndrome, polycystic ovarian syndrome, hypothyroidism, asthma, epilepsy, ear/nose/throat (ENT) disorders, congenital malformations, and genetic conditions. Parasomnias imply a differential diagnosis with epilepsy, and some of them are more prevalent in migraine [26].
In Finland, using a very large sample of adolescents (n = 384,076) aged 14 to 20 years, it was proven that late bedtimes, especially after 23:30, increase the prevalence of depression, accidents, neck or shoulder pain, low back pain, stomachache, anxiety or nervousness, irritation or tantrums, headaches, tiredness or dizziness [28]. The high prevalence of headache, depression, and atopic conditions in adolescents not getting enough sleep the week before the study was also proven in a large epidemiological study in the USA [29].
A relationship exists between headaches and sleep, but with complex expressions, since headaches can be triggered by too much or too little sleep, and also by irregularity or changes in sleep schedules [30], [31]; the complex and bidirectional relations between sleep problems and headache have also been proven in a couple of studies performed on adolescents. Among 800 Italian adolescents, the prevalence of headaches was very high (45.6%) and was associated with irregular intake of meals (especially irregular breakfast) and sleep disturbances [32]. In a smaller sample of 69 adolescents with primary headaches, the presence of sleep disturbances was significantly high, namely insufficient total sleep (65.7%), daytime sleepiness (23.3%), difficulty falling asleep (40.6%), and night waking (38.0%) [33]. The same type of results was obtained in a larger sample (n = 1862) of adolescents in New Delhi; sleep disturbances in migraineurs were more common when compared with tension headache sufferers and controls [34]. The relationship between migraine, non-migraine headaches and sleep were also proven in a sample of 1023 youngsters aged 8–15 years: migraineurs had higher scores of daytime sleepiness and were more often evening types [35]. Furthermore, among the triggers of pediatric migraine, lack of sleep was reported in 69.6% of the individual cases, only surpassed by stress, which accounted for 75.7% [36]. A lower percentage and opposite effects were found by Bruni et al. in 2008 [35]: ‘bad sleep’ was a headache trigger in 32.32% of migraine and non-migraine adolescents, while emotional distress accounted for 27.8% of the cases; in spite of that, the objective risk factors for headache (alcohol and coffee consumption, smoking, neck pain, stress and physical inactivity) did not include sleep [37].
Sleep is also a major influent factor in adolescents with chronic pain. Insufficient sleep quantity or quality was an independent risk factor for persistence of neck and low back pain among girls [11] and for chronic pain [12]. Pain affects around 21% of adolescents [38]. The relations between chronic pain and sleep disturbances or insomnia are mutual, with insomnia being a risk for pain chronicity, while pain, poor sleep hygiene, and higher depressive symptoms are the main risks for insomnia persistence [39], [40]. The comorbidity between sleep disturbances and chronic pain was shown in a group of 1518 adolescents aged 11–19 years old, with a joint prevalence of 19.1% [41]. Furthermore, low sleep efficiency predicts next day pain, while the vice versa prediction does not hold [10], [42]. The prevalence of neck and shoulder pain is higher in girls; the risk factors are multiple, namely: family history, school furniture, long sitting time and computer use, insufficient rest time, sleep duration, transportation type, schoolbag weight, and smoking [43].
Sleep problems are common (circa 45%) in pediatric functional gastro-intestinal disorders [44]. Adolescents suffering from irritable bowel syndrome have increased percentages of ‘poor sleep’ [25], and in a clinical group of 25 adolescents with recurrent abdominal pain, 29% reported awakenings related to pain, and 75% reported poor quality of sleep [45].
Fatigue is another important associated symptom. It is often associated with chronic pain [46], depression [46], [47], and insomnia or sleep problems [27], [46], [47]. The risk factors for fatigue with poor clinical outcome are: sleep problems, somatic complaints, blurred vision, pain in the arms or legs, back pain, constipation, and memory deficits. The indicators of a good outcome are: male gender and a physically active lifestyle [48]. Fatigue is statistically associated with feeling depressed, breakfast habits, not being well in school, low physical training, no adult to talk to, having bullied someone, shoplifting and physical fighting [47]. In pediatric fibromyalgia, the dominant symptoms present in almost 90% of the children are diffuse pain and sleep disturbances [49].
In adolescents, the mutual interaction of depression and sleep also exists; it has also been demonstrated in people with chronic pain [50], [51].
Well-being and health-related quality of life (HRQoL) in children and adolescents are quite recent concepts [50]. It is important to consider these concepts within an ecological perspective through multiple levels of analysis, namely self-perceptions and family perceptions [52]. Children's perceptions of their HRQoL are influenced by several factors, such as gender, age, personal and family characteristics, psychological toughness, as well as their socio-economic status (SES) [53], [54], [55], [56].
Healthy sleep is fundamental to human health and quality of life [57], [58], and sleep deprivation increases the risk for mood and behavioral problems, such us drug and alcohol use and vulnerability to accidents [19], [20], [21], [22], [59].
Links between eveningness and poor physical, social/interpersonal relationships and mental health have also been found [60]. Adolescents with less-healthy sleeping patterns present with lower scores on emotional, social, school, psychosocial functioning, and global quality of life [61], [62], and those who are sleep deprived experience less positive and more negative effects [63]. Those with delayed sleep phase disorders have higher trends for alcohol and caffeine consumption, and lower sports participation [64].
Sleeping for 6 h or less per night is linked to symptoms of depression and lower self-esteem [65]. Sleep deprivation is associated with deficits in child and adolescent functioning, and global health [66], [67]. Children and adolescents who sleep for less than 5 h per night present with more feelings of stress, depression, and suicidal ideation [68], [69].
Section snippets
Objectives
To evaluate the interactions between sleep deprivation in adolescents and age, gender, school grade, BMI, health complaints and health-related quality of life; it was hypothesized that sleep deprivation is associated with a higher prevalence of health complaints.
Participants
The present survey is a component of the Health Behaviour in School-Aged Children (HBSC) study [70], [71], [72], [73].
The Portuguese HBSC survey included 3476 pupils; 53.8% (n = 1869) were girls, in the 8th (45.9%) and 10th grades (54.1%), with a mean age of 14.9 years (SD = 1.26, range 12.5–19.0). The children were randomly chosen from 139 schools, in a national sample that was geographically stratified by Education Regional Divisions. The school response rate was 89.9%. The overall procedure
Results
The continuous variables concerning age, BMI, SWeek, SWE, DifWE-W, Kids 10 and SD, together with gender and school grade, are presented in Table 1; for each of them, the comparison for the SD condition is shown. A total of 14.2% of the students were overweight and 2.7% were obese. The percentage of students having a difference of 2 h sleep is 27.5% and equal/more than 3 h is 18.9%. Sleep duration on weeknights was curtailed in 38.5% and increased in 5.8% of the students, taking the normative
Conclusions and discussion
The present study obtained indicators of adolescents' health complaints and health-related quality of life during the 8th and 10th grades, and correlated them with sleep deprivation. It is integrated in a multinational World Health Organization (WHO) research project [71]. Data were obtained randomly and they were nationally representative; the response rate was quite high, and the percentage of missing data per answer was small. From the questionnaire structure, one aspect must be specially
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: http://dx.doi.org/10.1016/j.sleep.2014.10.010.
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2022, Pharmacology Biochemistry and BehaviorCitation Excerpt :Epidemiologic studies worldwide indicate that the length and quality of adolescents' sleep is far from ideal (Chen et al., 2014; Hysing et al., 2013; Loessl et al., 2008; Merdad et al., 2014), leading to impairment in several aspects of this population's well-being and full functioning. Evidence shows that reduction of sleep hours and/or sleep quality at this age range leads to health consequences, including obesity, cardio-metabolic problems (Turel et al., 2016), headache, shoulder and neck pain, irritability, fatigue and dizziness (Paiva et al., 2015). A current major concern related to sleep impairment is the high incidence of emotional disorders in children and adolescents (for review see (Gregory and Sadeh, 2012; Willis and Gregory, 2015)).