In summary, although actigraphy is not as accurate as PSG for determining some sleep measurements, studies are in general agreement that actigraphy, with its ability to record continuously for long time periods, is more reliable than sleep logs which rely on the patients' recall of how many times they woke up or how long they slept during the night and is more reliable than observations which only capture short time periods Actigraphy can provide information obtainable in no other practical way It can also have a role in the medical care of patients with sleep disorders However, it should not be held to the same expectations as polysomnography Actigraphy is one-dimensional, whereas polysomnography comprises at least 3 distinct types of data (EEG, EOG, EMG), which jointly determine whether a person is asleep or awake It is therefore doubtful whether actigraphic data will ever be informationally equivalent to the PSG, although progress on hardware and data processing software is continuously being made Although the 1995 practice parameters paper determined that actigraphy was not appropriate for the diagnosis of sleep disorders, more recent studies suggest that for some disorders, actigraphy may be more practical than PSG While actigraphy is still not appropriate for the diagnosis of sleep disordered breathing or of periodic limb movements in sleep, it is highly appropriate for examining the sleep variability (ie, night-to-night variability) in patients with insomnia Actigraphy is also appropriate for the assessment of and stability of treatment effects of anything from hypnotic drugs to light treatment to CPAP, particularly if assessments are done before and after the start of treatment A recent independent review of the actigraphy literature by Sadeh and Acebo reached many of these same conclusions Some of the research studies failed to find relationships between sleep measures and health-related symptoms The interpretation of these data is also not clear-cut Is it that the actigraph is not reliable enough to the access the relationship between sleep changes and quality of life measures, or, is it that, in fact, there is no relationship between sleep in that population and quality of life measures? Other studies of sleep disordered breathing, where actigraphy was not used and was not an outcome measure also failed to find any relationship with quality of life Is it then the actigraph that is not reliable or that the associations just do not exist? The one area where actigraphy can be used for clinical diagnosis is in the evaluation of circadian rhythm disorders Actigraphy has been shown to be very good for identifying rhythms Results of actigraphic recordings correlate well with measurements of melatonin and of core body temperature rhythms Activity records also show sleep disturbance when sleep is attempted at an unfavorable phase of the circadian cycle Actigraphy therefore would be particularly good for aiding in the diagnosis of delayed or advanced sleep phase syndrome, non-24-hour-sleep syndrome and in the evaluation of sleep disturbances in shift workers It must be remembered, however, that overt rest-activity rhythms are susceptible to various masking effects, so they may not always show the underlying rhythm of the endogenous circadian pacemaker In conclusion, the latest set of research articles suggest that in the clinical setting, actigraphy is reliable for evaluating sleep patterns in patients with insomnia, for studying the effect of treatments designed to improve sleep, in the diagnosis of circadian rhythm disorders (including shift work), and in evaluating sleep in individuals who are less likely to tolerate PSG, such as infants and demented elderly While actigraphy has been used in research studies for many years, up to now, methodological issues had not been systematically addressed in clinical research and practice Those issues have now been addressed and actigraphy may now be reaching the maturity needed for application in the clinical arena

The role of actigraphy in the study of sleep and circadian rhythms.

1.0 BACKGROUND ACTIGRAPHY HAS BEEN USED TO STUDY SLEEP/WAKE PATTERNS FOR OVER 20 YEARS. The advantage of actigraphy over traditional polysomnography (PSG) is that actigraphy can conveniently record continuously for 24-hours a day for days, weeks or even longer. In 1995, Sadeh et al.,1 under the auspices of the American Sleep Disorders Association (now called the American Academy of Sleep Medicine, AASM), reviewed the current knowledge about the role of actigraphy in the evaluation of sleep disorders. They concluded that actigraphy does provide useful information and that it may be a “cost-effective method for assessing specific sleep disorders...[but that] methodological issues have not been systematically addressed in clinical research and practice.” Based on that task force’s report, the AASM Standards of Practice Committee concluded that actigraphy was not indicated for routine diagnosis or for assessment of severity or management of sleep disorders, but might be a useful adjunct for diagnosing insomnia, circadian rhythm disorders or excessive sleepiness.2 Since that time, actigraph technology has improved, and many more studies have been conducted. Several review papers have concluded that wrist actigraphy can usefully approximate sleep versus wake state during 24 hours and have noted that actigraphy has been used for monitoring insomnia, circadian sleep/wake disturbances, and periodic limb movement disorder.3,4 This paper begins where the 1995 paper left off. Under the auspices of the AASM, a new task force was established to review the current state of the art of this technology.

The Role of Actigraphy in the Study of Sleep and Circadian Rhythms AMERICAN ACADEMY OF SLEEP MEDICINE REVIEW PAPER

Objectives. To describe the current prevalence of pediatric hypertension and the relationships between gender, ethnicity, overweight, and blood pressure. Methods. School-based screening was performed in 5102 children (13.5 ± 1.7 years) from May through November 2002. Age, gender, ethnicity, weight, and height were ascertained, and body mass index (BMI) was calculated as weight (kg)/height (m2). Overweight was defined as BMI ≥95th percentile. Students with blood pressure >95th percentile on the first screening underwent a second screening 1 to 2 weeks later, and then a third screening if blood pressure was >95th percentile at the second screening. Results. Ethnicity distribution was 44% white, 25% Hispanic, 22% African American, and 7% Asian. Overall, overweight prevalence was 20%, which varied significantly by ethnicity (31% Hispanic, 20% African American, 15% white, and 11% Asian). The prevalence of elevated blood pressure after first, second, and third screenings was 19.4%, 9.5%, and 4.5%, respectively. Elevated blood pressure on first screening was highest among Hispanics (25%) and lowest among Asians (14%). Ethnic differences in the prevalence of hypertension (elevated blood pressure on 3 screenings) were not significant after controlling for overweight. The prevalence of hypertension increased progressively as the BMI percentile increased from ≤5th percentile (2%) to ≥95th percentile (11%). After adjustment for gender, ethnicity, overweight, and age, the relative risk of hypertension was significant for gender (relative risk: 1.50; confidence interval: 1.15, 1.95) and overweight (relative risk: 3.26; confidence interval: 2.50, 4.24). Conclusions. These results confirm an evolving epidemic of cardiovascular risk in youth, as evidenced by an increase in the prevalence of overweight and hypertension, notably among ethnic minority children.

Overweight, Ethnicity, and the Prevalence of Hypertension in School-Aged Children

Obesity has become an increasingly important medical problem in children and adolescents. In national surveys from the 1960s to the 1990s, the prevalence of overweight in children grew from 5% to 11%. Outcomes related to childhood obesity include hypertension, type 2 diabetes mellitus, dyslipidemia, left ventricular hypertrophy, nonalcoholic steatohepatitis, obstructive sleep apnea, orthopedic problems, and psychosocial problems. Once considered rare, primary hypertension in children has become increasingly common in association with obesity and other risk factors, including a family history of hypertension and an ethnic predisposition to hypertensive disease. Obese children are at approximately a 3-fold higher risk for hypertension than nonobese children. In addition, the risk of hypertension in children increases across the entire range of body mass index (BMI) values and is not defined by a simple threshold effect. As in adults, a combination of factors including overactivity of the sympathetic nervous system (SNS), insulin resistance, and abnormalities in vascular structure and function may contribute to obesity-related hypertension in children. The benefits of weight loss for blood pressure reduction in children have been demonstrated in both observational and interventional studies. Obesity in childhood should be considered a chronic medical condition that is likely to require long-term management. Ultimately, prevention of obesity and its complications, including hypertension, is the goal.

Obesity Hypertension in Children. A Problem of Epidemic Proportions

This paper reviews child and adolescent adiposity measures and associated long-term health risks. The first section argues that anthropometric measures are practical for large scale epidemiological studies, particularly the body mass index. Limitations of this and other measures are presented. The second section summarises the evidence on the relationship between child and adolescent and adult adiposity. This is based on a search for relevant literature in the following computerised databases: Medline (1985-96), BIDS (EMBASE and Science Citation Index 1985-96). The literature search revealed that the child to adult adiposity relationship is now well-documented, although methodological differences hinder comparisons. Nonetheless, consistently elevated risks of adult obesity are evident for fatter children, although the prediction of adult obesity from child and adolescent adiposity measures is only moderate. Fewer studies could be identified in relation to long-term health risks of child and adolescent adiposity. It is therefore difficult to specify categories of risk associated with childhood adiposity without more information from long-term studies. Further evidence is also required to confirm the suggestion from some studies that adult disease risks are associated with a change in adiposity from normal weight in childhood to obesity in adulthood. However, on the basis of the evidence available, it is argued that population-based approaches to the prevention of obesity are likely to be more effective than approaches targeted as fat children. Population-based approaches are desirable, first because of the poor prediction of adult obesity from child and adolescent measures, and second, because of risks of adult mortality and morbidity may be elevated for individuals who become overweight after adolescence.

Measurement and long-term health risks of child and adolescent fatness.

Changes in Fasting Lipids during Puberty.

Trajectories of fat mass index, fat free-mass index, and waist circumference in children: Project HeartBeat!

For several decades, high blood pressure and elevated cholesterol have been established as risk factors for atherosclerosis and, thus, for most cardiovascu­ lar morbidity and mortality of industrialized countries. More recently, de­ veloping countries are recognizing the public health burden of high blood pressure and elevated cholesterol, as a result of demographic changes, which have seen increasing proportions of populations reach the sixth decade of life and beyond, and social and behavioral changes, which have fostered the development of the risk factors (12). Thus, the consequences of high blood pressure and elevated cholesterol, in addition to cigarette smoking and other factors, now constitute a global public health problem. The causes of coronary heart disease and other complications of atheroscle­ rosis and hypertensive disease must be sought earlier in life than the age range in which these events become especially common, i.e. at age 40 and older. The theoretical foundation for this concept is reinforced strongly by patholog­ ical evidence, including that from postmortem examinations of young military casualties. These examinations show that the vascular lesions of atherosclero­ sis commonly are present in the coronary arteries and aorta before age 20 (see, for example, Ref. 40). Geographically widespread evidence that aortic

https://www.annualreviews.org/doi/pdf/10.1146/annurev.pu.12.050191.002511

Childhood precursors of high blood pressure and elevated cholesterol.

Health promotion strategies to encourage physical activity in infants, toddlers, and preschoolers.

In epidemiologic studies of the relation between circumcision and sexually transmitted infections, it is necessary to rely on self-report of circumcision status. The purpose of this 2002 study in Houston, Texas, was to determine whether adolescent males could make correct self-reports. During physical examinations, adolescents were asked whether they were circumcised. The authors then examined the adolescents' genitalia. Circumcision status was recorded as complete (glans penis fully exposed), partial (glans partly covered), or uncircumcised (glans completely covered). The mean age of the 1,508 subjects was 15.0 (standard deviation, 1.63) years; 64% were Black, 29% Hispanic, and 7% White. Forty-nine percent had full, 1% partial, and 50% no circumcision. Of the 738 fully circumcised subjects, 512 (69%) considered themselves circumcised, 54 (7%) considered themselves uncircumcised, and 172 (23%) did not know. Of the 751 uncircumcised youth, 491 (65%) described themselves as uncircumcised, 27 (4%) reported being circumcised, and 233 (31%) did not know. The sensitivity of self-report among those who thought they knew their status was 90.5%, and the specificity was 94.8%; 27% did not know their status. In this population, self-report of circumcision status did not result in accurate information mainly because many adolescents were unsure of their status.

/pdf/self-assessment-of-circumcision-status-by-adolescents-zs0no1lkuo.pdf

Mona A. Eissa

Papers

Changes in Fasting Lipids during Puberty.

Trajectories of fat mass index, fat free-mass index, and waist circumference in children: Project HeartBeat!

Childhood precursors of high blood pressure and elevated cholesterol.

Health promotion strategies to encourage physical activity in infants, toddlers, and preschoolers.

Self-assessment of circumcision status by adolescents.