Background. Prediabetes is a preclinical stage in the hyperglycemia continuum where subjects are at increased risk of developing diabetes. Several studies reported a positive association between markers of sleep-disordered breathing (SDB) and diabetes. However, few studies investigated the relationship between SDB markers and prediabetes. Methods. We examined 5,685 participants ≥20 years from the National Health and Nutrition Examination Survey (NHANES) 2005–2008. The exposure of interest was SDB markers including sleep duration, snoring, snorting, and daytime sleepiness. The outcome was prediabetes (n = 2058), among subjects free of diabetes. Results. SDB markers were associated with prediabetes. Compared to those without any sleep disturbance, the multivariable odds ratio (OR) (95% confidence interval (CI)) of prediabetes among those with three or more SDB markers was 1.69 (1.28–2.22). In subgroup analyses, the association between SDB markers and prediabetes was stronger among women (OR (95% CI) = 2.09 (1.36–3.23) when compared to men (1.52 (1.00–2.35)) and was present among non-Hispanic whites (2.66 (1.92–3.69)) and Mexican Americans (1.99 (1.13–3.48)), but not among non-Hispanic blacks (1.10 (0.70–1.73)). Conclusion. SDB markers were associated with prediabetes. This association was stronger in women and was present mainly in non-Hispanic whites and Mexican Americans.
Background. Previous studies indicated sleep-disordered breathing (SDB) is associated with cardiovascular disease (CVD). Systemic inflammation is recognized as a risk factor for CVD. Studies examining SDB and inflammation are limited. Methods. We studied sleep duration, snoring, snorting, and daytime sleepiness, and an additive SDB score. The main outcome was a C-reactive protein (CRP) of >1 mg/dL. Results. Snoring, snorting, daytime sleepiness, and sleeping >7 or <7 hours, and the additive score were significantly associated with high CRP. The additive score was not associated in men but moderately associated in women in a multivariable model adjusting for age, gender, race/ethnicity, education, smoking, hypertension, alcohol intake, physical activity, body mass index, depression, diabetes, hypertension, and total cholesterol (P-interaction = 0.42). For race/ethnicity, the association was strongest in Mexican Americans/others, modest in Non-Hispanic whites, and absent in Non-Hispanic blacks (P-interaction = 0.07). Conclusions. The association between SDB and high CRP was present mainly in women and Mexican Americans, implying SDB has a residual, independent association with inflammation after controlling for lifestyle and metabolic risk factors like BMI, physical activity, depression, diabetes, and cholesterol.
Rationale: The impact of REM-predominant sleep-disordered breathing (SDB) on sleepiness, quality of life (QOL), and sleep maintenance is uncertain.
Objective: To evaluate the association of SDB during REM sleep with daytime sleepiness, health-related QOL, and difficulty maintaining sleep, in comparison to their association with SDB during non-REM sleep in a community-based cohort.
Methods: Cross-sectional analysis of 5,649 Sleep Heart Health Study participants (mean age 62.5 [SD = 10.9], 52.6% women, 22.6% ethnic minorities). SDB during REM and non-REM sleep was quantified using polysomnographically derived apnea-hypopnea index in REM (AHIREM) and non-REM (AHINREM) sleep. Sleepiness, sleep maintenance, and QOL were respectively quantified using the Epworth Sleepiness Scale (ESS), the Sleep Heart Health Study Sleep Habit Questionnaire, and the physical and mental composites scales of the Medical Outcomes Study Short Form (SF)-36.
Measurements and Main Results: AHIREM was not associated with the ESS scores or the physical and mental components scales scores of the SF-36 after adjusting for demographics, body mass index, and AHINREM. AHIREM was not associated with frequent difficulty maintaining sleep or early awakening from sleep. AHINREM was associated with the ESS score (β = 0.25; 95% confidence interval [CI], 0.16 to 0.34) and the physical (β = −0.12; 95% CI, −0.42 to −0.01) and mental (β = −0.20; 95% CI, −0.20 to −0.01) components scores of the SF-36 adjusting for demographics, body mass index, and AHIREM.
Conclusions: In a community-based sample of middle-aged and older adults, REM-predominant SDB is not independently associated with daytime sleepiness, impaired health-related QOL, or self-reported sleep disruption.
epidemiology; sleep apnea syndromes; sleep, REM; hypersomnia
To investigate age-related changes in sleepiness symptoms associated
with sleep disordered breathing (SDB).
Wisconsin Sleep Cohort participants were assessed with
polysomnography, Epworth Sleepiness Scale (ESS) and Multiple Sleep Latency
Test (MSLT). SDB was defined as an apnea/hypopnea index≥15
events/hour, sleepiness as ESS≥10 and MSLT≤5 minutes. Odds
ratios were calculated using generalized estimating equations associating
sleepiness with SDB, and conditional logistic regression examining changes
in longitudinal sleepiness status (ESS only). Models were, a priori,
stratified by gender.
ESS was measured in 1281 participants and MSLT in 998, at multiple
time points (ESS n=3695; MSLT n=1846). Significant interactions were found
between SDB and age in men, but not women. The odds ratios (OR) modeled for
sleepiness in a 40 year old male with SDB were significant, compared to a
male without SDB (OR: ESS 2.1; MSLT 2.9); however, these associations were
not significant at 60 years. The within-subject odds ratio for sleepiness
was also significant at 40 years (OR: 3.4), but not at 60 years.
The age-related reductions in the association between sleepiness and
SDB may have clinical implications for the diagnosis and treatment of SDB in
older people since sleepiness is often used as a therapeutic marker.
Sleep disordered breathing; Obstructive sleep apnea; Aging; Sleepiness
We examined gender and ethnic differences in the association between sleep disordered breathing (SDB) and diabetes among 6,522 participants aged ≥20 years from the National Health and Nutrition Examination Survey 2005–08. SDB severity was defined based on an additive summary score including sleep duration, snoring, snorting, and daytime sleepiness. We found that the summary SDB score was significantly associated with diabetes after adjusting for potential confounders in the whole population. Compared to those without any sleep disturbance, the multivariable odds ratio (OR) (95% confidence interval (CI)) of diabetes among those with ≥3 sleep disturbances was 2.04 (1.46–2.87). In sex-specific analyses, this association was significant only in women (OR (95% CI) = 3.68 (2.01–6.72)) but not in men (1.10 (0.59–2.04)), P-interaction = 0.01. However, there were no ethnic differences in this association, P-interaction = 0.7. In a nationally representative sample of US adults, SDB was independently associated with diabetes only in women, but not in men.
Objectives To determine whether snoring, sleep position, and other sleep practices in pregnant women are associated with risk of late stillbirth.
Design Prospective population based case-control study.
Setting Auckland, New Zealand
Participants Cases: 155 women with a singleton late stillbirth (≥28 weeks’ gestation) without congenital abnormality born between July 2006 and June 2009 and booked to deliver in Auckland. Controls: 310 women with single ongoing pregnancies and gestation matched to that at which the stillbirth occurred. Multivariable logistic regression adjusted for known confounding factors.
Main outcome measure Maternal snoring, daytime sleepiness (measured with the Epworth sleepiness scale), and sleep position at the time of going to sleep and on waking (left side, right side, back, and other).
Results The prevalence of late stillbirth in this study was 3.09/1000 births. No relation was found between snoring or daytime sleepiness and risk of late stillbirth. However, women who slept on their back or on their right side on the previous night (before stillbirth or interview) were more likely to experience a late stillbirth compared with women who slept on their left side (adjusted odds ratio for back sleeping 2.54 (95% CI 1.04 to 6.18), and for right side sleeping 1.74 (0.98 to 3.01)). The absolute risk of late stillbirth for women who went to sleep on their left was 1.96/1000 and was 3.93/1000 for women who did not go to sleep on their left. Women who got up to go to the toilet once or less on the last night were more likely to experience a late stillbirth compared with women who got up more frequently (adjusted odds ratio 2.28 (1.40 to 3.71)). Women who regularly slept during the day in the previous month were also more likely to experience a late stillbirth than those who did not (2.04 (1.26 to 3.27)).
Conclusions This is the first study to report maternal sleep related practices as risk factors for stillbirth, and these findings require urgent confirmation in further studies.
The well-known excessive daytime sleepiness (EDS) assessment, Epworth Sleepiness Scale (ESS), is not consistently qualified for patients with diverse living habits. This study is aimed to build a modified ESS (mESS) and then to verify its feasibility in the assessment of EDS for patients with suspected sleep-disordered breathing (SDB) in central China.
A Ten-item Sleepiness Questionnaire (10-ISQ) was built by adding two backup items to the original ESS. Then the 10-ISQ was administered to 122 patients in central China with suspected SDB [among them, 119 cases met the minimal diagnostic criteria for obstructive sleep apnea by sleep study, e.g., apnea and hypopnea index (AHI) ≥ 5 h−1] and 117 healthy central Chinese volunteers without SDB. Multivariate exploratory techniques were used for item validation. The unreliable item in the original ESS was replaced by the eligible backup item, thus a modified ESS (mESS) was built, and then verified.
Item 8 proved to be the only unreliable item in central Chinese patients, with the least factor loading on the main factor and the lowest item-total correlation both in the 10-ISQ and in the original ESS, deletion of it would increase the Cronbach’s alpha (from 0.86 to 0.87 in the 10-ISQ; from 0.83 to 0.85 in the original ESS). The mESS was subsequently built by replacing item 8 in the original ESS with item 10 in the 10-ISQ. Verification with patients’ responses revealed that the mESS was a single-factor questionnaire with good internal consistency (Cronbach’s alpha = 0.86). The sum score of the mESS not only correlated with AHI (P < 0.01) but was also able to discriminate the severity of obstructive apnea (P < 0.01). Nasal CPAP treatment for severe OSA reduced the score significantly (P < 0.001). The performance of the mESS was poor in evaluating normal subjects.
The mESS improves the validity of ESS for our patients. Therefore, it is justified to use it instead of the original one in assessment of EDS for patients with SDB in central China.
Epworth Sleepiness Scale; Excessive daytime sleepiness; Sleep-disordered breathing
Depression is frequently observed in patients with untreated sleep-disordered breathing (SDB) in the general population. Pregnant women are particularly vulnerable since pregnancy increases the risk of both SDB and depressive symptoms. However, no study has investigated whether SDB symptoms prior to or in early pregnancy are associated with such mood problems.
A retrospective chart review of pregnant women. Women were included if they attended prenatal clinics between June 2007 and July 2010, were ≥18 years old, pregnant with a single fetus, and had been screened for habitual snoring as well as depressive symptoms using the Edinburgh Postnatal Depression Scales (EPDS).
In total, 362 women were included and 32.3% reported habitual snoring. Twenty-nine percent of women had an EPDS score ≥10. Significantly more snoring women, compared to non-snorers, had an EPDS score ≥10 (42.7% vs. 22.9%, p < 0.001) despite the mean EPDS values not reaching statistical significance (6.1 ± 4.9 vs. 5.4 ± 5.0, p = 0.2). In a logistic regression model controlling for parity, the presence of pre-pregnancy obesity, presence of a partner, sleep quality, African American race, maternal educational level, pre-eclampsia, and diabetes, snoring was independently associated with a prenatal EPDS score ≥10 (O.R. 2.0, 95%CI 1.13-3.46; p = 0.023).
Maternal snoring may be a risk factor for prenatal depressive symptoms. Further investigation of the temporal relationship between maternal snoring and depressive symptoms is warranted.
Pregnancy; Snoring; Sleep quality; Depressive symptoms; EPDS
Sleep disturbances in late pregnancy are common. This study aimed to survey sleep problems in third trimester pregnant women and to compare sleep in the pre-pregnancy period with the third trimester.
Third-trimester women (n=650) were sent a postal survey containing questions relating to sleep experience, including perceived sleep quality, sleep difficulties, night waking, sleep environment, snoring, daytime tiredness and daytime napping. Time periods reported on were before pregnancy and in the last week.
Respondents numbered 244 (38%). Before pregnancy, the mean reported duration of night-time sleep was 8.1 (SD 1.1) hours; in the last week this had decreased to 7.5 (SD 1.8) hours (p<.0001). Only 29% rated their sleep quality in the last week as very good or fairly good, compared with 82% rating their sleep this way before the pregnancy. The main reasons for sleeping difficulties were discomfort (67%) and pain (36%). Snoring increased significantly over the course of the pregnancy, with 37% reporting snoring often or every night in the last week. Those with a pre-pregnancy body mass index of greater than 25 were significantly more likely to snore (p=.01). Only 4% of women had an abnormal Epworth Sleepiness Scale score (i.e. >10) prior to pregnancy, whereas in the last week 33% scored in the abnormal range. Likewise, 5% had regularly napped during the daytime before pregnancy, compared with 41% in the last week.
Sleep problems are common in women in late pregnancy, and increase markedly compared with before pregnancy.
Pregnancy; Sleep disturbances; Sleep quality; Snoring; Daytime sleepiness
Previous studies have documented an association between markers of sleep-disordered breathing (SDB) and metabolic syndrome. However, it is not clear if there are gender or ethnic differences in this association. We examined 6,122 participants aged ≥20 years from the National Health and Nutrition Examination Survey 2005–08. Metabolic syndrome was defined as the presence of ≥3 of the following components: (1) abdominal obesity, (2) elevated blood triglycerides, (3) low HDL cholesterol, (4) high BP, and (5) hyperglycemia. SDB severity was defined based on an additive summary score including sleep duration, snoring, snorting, and daytime sleepiness. We found that short sleep duration, snoring, snorting, daytime sleepiness and the summary SDB score were significantly associated with metabolic syndrome independent of potential confounders. Compared to those without any sleep disturbance, the multivariable odds ratio (OR) (95% confidence interval [CI]) of metabolic syndrome among those with three or more sleep disturbances was 3.92 (2.98–5.16). In subgroup analyses, this association was consistently present among men and women and all race-ethnic groups. In summary, SDB was independently associated with metabolic syndrome in a nationally representative sample of US adults.
To determine the incidence and remission of sleep disordered breathing in adolescent children.
319 children completed two home polysomnograms approximately 5 years apart. Sleep disordered breathing (SDB) was determined to be present if a child had a respiratory disturbance index ≥ 1 event per hour associated with a ≥3% oxygen desaturation. Subjective symptoms such as witnessed apnea, excessive daytime sleepiness, difficulty initiating and maintaining sleep, and habitual loud snoring were considered present if they occurred frequently or almost always. BMI percentiles were calculated using CDC childhood growth charts adjusted for sex and age.
The mean age at assessment was 8.5 years at Baseline and 13.7 years at Follow-up respectively. Incident SDB was more common in boys (OR=3.93, p=.008, CI= 1.41-10.90). Children with Prevalent SDB were more likely to be boys (OR=2.48, p=.006) and had a greater increase in BMI percentile change (OR 1.01, p=.034). Children with Prevalent SDB also had 3.41 greater odds of developing obesity from Baseline to Follow-up in comparison with children with Prevalent NoSDB.
Adolescent boys are more likely to have persistent and incident SDB than girls. Children with prevalent SDB are more likely to have developed obesity. These risks are similar to those observed in adults.
The association between diabetes and abnormalities in autonomic function is well-known, but it is not clear if this association can be extended to subjects with prediabetic impaired glucose metabolism (IGM). Sleep-disordered breathing (SDB), which commonly occurs in this population, is often overlooked. We sought to determine how autonomic function, monitored in an overnight sleep study setting, may be impaired in subjects with IGM and/or SDB.
Polysomnograms (PSGs) selected from the Cleveland Family Study database were categorized into four groups: normal, SDB (respiratory disturbance index > 5/h), IGM, and both SDB and IGM. Impaired glucose metabolism was defined as an oral glucose tolerance test (OGTT) level > 140 mg/dl. Time-domain and frequency-domain indices of heart rate variability were used to quantify autonomic impairment. Baroreflex sensitivity determined using pulse transit time (BRSPTT), an indirect measure of baroreflex sensitivity based on spontaneous pulse transit time fluctuations, was used as a surrogate measure of baroreflex sensitivity.
Based on 31 PSGs from subjects (16 males, 15 females) ages 20.8–61.2 years, both SDNN and BRSPTT were found to be 20-25% lower in SDB and ~40% lower in IGM and SDB + IGM as compared to subjects without either condition. In analyses of continuous measures, mean standard deviation of 5 min R–R intervals (SDNN) and BRSPTT were found to be negatively correlated with OGTT following adjustment for age and body mass index. Oral glucose tolerance test and age were the two most significant factors for predicting SDNN and BRSPTT.
Our analyses suggest that cardiac autonomic control is impaired in IGM, regardless of whether SDB is present. The abnormal autonomic function involves degradation of baroreflex regulation.
autonomic nervous system; baroreflex sensitivity; glucose tolerance; heart rate variability; pulse transit time; sleep apnea
Sleep disordered breathing (SDB) is more common in obese adults, but not all obese adults have SDB. The aim of these analyses was to determine what predicted SDB in a sample of obese adults.
We conducted cross-sectional analysis of 139 obese men and women aged 18–50 years who are chronic short sleepers. Habitual sleep duration and sleep efficiency were estimated using 2 weeks of wrist actigraphy. Respiratory Disturbance Index (RDI) was assessed by a portable screening device. SDB was defined as RDI≥15 events/hour. Subjective sleep quality, sleepiness, and sociodemographic characteristics were evaluated by questionnaires.
Increased sleep duration from actigraphy was associated with reduced odds of SDB (OR 0.44 per hour, p=.043). Neither subjective sleep quality nor sleepiness was associated with SDB. Male sex, older age, and increased waist circumference were associated with increased odds of SDB.
In this sample of obese adults, subjective measures of sleep quality and sleepiness were not indicators of SDB. These results suggest that in obese patients, physicians should not rely on subjective measures to determine who should be referred for a clinical sleep study. A wider use of portable apnea screening devices should be considered in non symptomatic, Non-Hispanic white males.
sleep-disordered breathing; obese; actigraphy; subjective sleep quality; sleepiness; apnea
An adult cohort with tuberous sclerosis complex was investigated for the prevalence of sleep disturbances and the relationship with seizure variables, medication, and psychological functioning. Information on 35 adults was gathered using four questionnaires: Epworth Sleepiness Scale (ESS), Sleep and Epilepsy Questionnaire (SEQ), Sleep Diagnosis List (SDL), and Adult Self-Report Scale (ASR). In addition, clinical, genetic and electrophysiological data were collected. Of 35 respondents, 25 had a history of epilepsy. A subjective sleep disorder was found in 31% of the cohort. Insomnia scores showed a significant positive correlation with obstructive sleep apnea syndrome and restless legs syndrome scores. Significant correlations were found between daytime sleepiness and scores on depression, antisocial behavior, and use of mental health medication. A subgroup using antiepileptic medication showed high correlations between daytime sleepiness, attention deficits, and anxiety scores.
Epilepsy; Sleep; Tuberous sclerosis complex; Behavior
The recent SLEEMSA study that evaluated excessive daytime sleepiness (EDS) in Caucasian patients with multiple system atrophy (MSA) demonstrated that EDS was more frequent in patients (28%) than in healthy subjects (2%). However, the prevalence and determinants of EDS in other ethnic populations have not been reported to date.
We performed a single-hospital prospective study on patients with probable MSA. To ascertain the prevalence and determinants of EDS in Japanese MSA patients, we assessed the patients’ degree of daytime sleepiness by using the Japanese version of the Epworth Sleepiness Scale (ESS). In addition, we investigated the effects of sleep-disordered breathing (SDB) and abnormal periodic leg movements in sleep (PLMS), which were measured by polysomnography, on the patients’ ESS scores.
A total of 25 patients with probable MSA (21 patients with cerebellar MSA and 4 patients with parkinsonian MSA) were included in this study. All patients underwent standard polysomnography. The mean ESS score was 6.2 ± 0.9, and EDS was identified in 24% of the patients. SDB and abnormal PLMS were identified in 24 (96%) and 11 (44%) patients, respectively. The prevalences of EDS in patients with SDB and abnormal PLMS were 25% and 18%, respectively. No correlations were observed between ESS scores and the parameters of SDB or abnormal PLMS.
The frequency of EDS in Japanese patients with MSA was similar to that in Caucasian MSA patients. SDB and abnormal PLMS were frequently observed in MSA patients, although the severities of these factors were not correlated with EDS. Further investigations using objective sleep tests need to be performed.
Multiple system atrophy; Excessive daytime sleepiness; Epworth Sleepiness Scale; Sleep-disordered breathing; Abnormal periodic leg movements in sleep
Objective To assess the effects of didgeridoo playing on daytime sleepiness and other outcomes related to sleep by reducing collapsibility of the upper airways in patients with moderate obstructive sleep apnoea syndrome and snoring.
Design Randomised controlled trial.
Setting Private practice of a didgeridoo instructor and a single centre for sleep medicine.
Participants 25 patients aged > 18 years with an apnoea-hypopnoea index between 15 and 30 and who complained about snoring.
Interventions Didgeridoo lessons and daily practice at home with standardised instruments for four months. Participants in the control group remained on the waiting list for lessons.
Main outcome measure Daytime sleepiness (Epworth scale from 0 (no daytime sleepiness) to 24), sleep quality (Pittsburgh quality of sleep index from 0 (excellent sleep quality) to 21), partner rating of sleep disturbance (visual analogue scale from 0 (not disturbed) to 10), apnoea-hypopnoea index, and health related quality of life (SF-36).
Results Participants in the didgeridoo group practised an average of 5.9 days a week (SD 0.86) for 25.3 minutes (SD 3.4). Compared with the control group in the didgeridoo group daytime sleepiness (difference -3.0, 95% confidence interval -5.7 to -0.3, P = 0.03) and apnoea-hypopnoea index (difference -6.2, -12.3 to -0.1, P = 0.05) improved significantly and partners reported less sleep disturbance (difference -2.8, -4.7 to -0.9, P < 0.01). There was no effect on the quality of sleep (difference -0.7, -2.1 to 0.6, P = 0.27). The combined analysis of sleep related outcomes showed a moderate to large effect of didgeridoo playing (difference between summary z scores -0.78 SD units, -1.27 to -0.28, P < 0.01). Changes in health related quality of life did not differ between groups.
Conclusion Regular didgeridoo playing is an effective treatment alternative well accepted by patients with moderate obstructive sleep apnoea syndrome.
Trial registration ISRCTN: 31571714.
Sleep disordered breathing as well as high serum uric acid levels are independent risk factors for cardiovascular disease. However, studies evaluating the relationship between sleep-disordered breathing and hyperuricemia are limited. We examined the 2005–2008 National Health and Nutrition Examination survey's sleep variables and high serum uric acid among 6491 participants aged ≥20 years. The sleep variables included sleep duration, snoring, snorting, and daytime sleepiness. The main outcome was high serum uric acid level, defined as levels of serum uric acid >6.8 mg/dL in males and >6.0 mg/dL in females. We found that snoring more than 5 nights per week, daytime sleepiness, and an additive composite score of sleep variables were associated with high serum uric acid in the age- , sex-adjusted model and in a multivariable model adjusting for demographic and lifestyle/behavioral risk factors. The association was attenuated with the addition of variables related to clinical outcomes such as depression, diabetes, hypertension, and high-cholesterol levels. Our results indicate a positive relationship between sleep variables, including the presence of snoring, snorting, and daytime sleepiness, and high serum uric acid levels.
To determine the prevalence and clinical and metabolic correlates of sleep disordered breathing (SDB) and excessive daytime sleepiness (EDS) in adolescent girls with polycystic ovarian syndrome (PCOS).
Standardized questionnaires were administered to subjects with PCOS and age-, sex-, ethnicity-, and BMI Z-score-matched controls. Medical records were reviewed for anthropometric and metabolic data.
We studied 103 subjects with PCOS (16.9±1.5 years) and 90 controls (16.8±1.7 years). Compared with controls, girls with PCOS had a higher prevalence of SDB (45.6% vs. 27.8%, p=0.01) and EDS (54.4% vs.35.6%, p<0.01). Within PCOS, those with SDB had higher BMI Z-score (2.1±0.5 vs.1.7±0.6, p< 0.01), higher homeostatic model assessment (HOMA) (5.1±2.3 vs. 4.1±3.5, p<0.01), and higher prevalence of the metabolic syndrome (MetS) (42.6% vs. 16.1%, p=0.003), compared with those without SDB. Similarly, subjects with PCOS and EDS had higher BMI-Z score (2.0±0.6 vs.1.7±0.6, p=0.03), higher HOMA (5.1±2.9 vs.3.8±3.1, p=0.01), and higher rate of MetS (39.3% vs. 14.9% p<0.01), compared with those without EDS. MetS was independently associated with SDB (OR 3.2, CI-1.0–10.1) and EDS (OR 4.5, CI-1.2–16).
SDB and EDS are highly prevalent in adolescent girls with PCOS compared with matched controls. The MetS is independently associated with SDB and EDS in this group.
Pediatric Sleep Questionnaire (PSQ); Epworth Sleepiness Scale (ESS); metabolic syndrome (MetS)
To test the hypothesis that sleep disorders are relevant to the risk of ischaemic stroke and ischaemic heart disease events in older men.
A cohort study.
The Caerphilly cohort, a representative population sample of older men in South Wales, UK.
1986 men aged 55–69 years completed a questionnaire on sleep patterns with help from their partners. This asked about symptoms of disturbed sleep: insomnia, snoring, restless legs, obstructive sleep apnoea, and about daytime sleepiness. During the following 10 years 107 men experienced an ischaemic stroke and 213 had an ischaemic heart disease event.
Up to one third of the men reported at least one symptom suggestive of sleep disturbance, and one third reported daytime sleepiness. Compared with men who reported no such symptoms, the adjusted relative odds of an ischaemic stroke were significantly increased in men with any sleep disturbance, the strongest association being with sleep apnoea (relative odds 1.97; 1.26 to 3.09). The association with daytime sleepiness was not significant for stroke. Relations with ischaemic heart disease events were all raised in men with symptoms of sleep disturbance, but none was significant, other than daytime sleepiness (relative odds: 1.41; 1.04 to 1.92). There were no significant relations with blood pressure.
The risk of an ischaemic stroke is increased in men whose sleep is frequently disturbed, and daytime sleepiness is associated with a significant increase in ischaemic heart disease events.
sleep; ischaemic heart disease; ischaemic stroke
Objective. This study examined the association between obstructive sleep apnea (OSA), daytime sleepiness, functional activity, and objective physical activity. Setting. Subjects (N = 37) being evaluated for OSA were recruited from a sleep clinic. Participants. The sample was balanced by gender (53% male), middle-aged, primarily White, and overweight or obese with a mean BMI of 33.98 (SD = 7.35; median BMI = 32.30). Over 40% reported subjective sleepiness (Epworth Sleepiness Scale (ESS) ≥10) and had OSA (78% with apnea + hypopnea index (AHI) ≥5/hr). Measurements. Evaluation included questionnaires to evaluate subjective sleepiness (Epworth Sleepiness Scale (ESS)) and functional outcomes (Functional Outcomes of Sleep Questionnaire (FOSQ)), an activity monitor, and an overnight sleep study to determine OSA severity. Results. Increased subjective sleepiness was significantly associated with lower scores on the FOSQ but not with average number of steps walked per day. A multiple regression analysis showed that higher AHI values were significantly associated with lower average number of steps walked per day after controlling patient's age, sex, and ESS. Conclusion. Subjective sleepiness was associated with perceived difficulty in activity but not with objectively measured activity. However, OSA severity was associated with decreased objective physical activity in aging adults.
The objective of this study is to assess the risk of sleep-disordered breathing (SDB) in patients with Parkinson’s disease (PD) in a cross-sectional survey of PD subjects and controls in a university-based movement disorders clinic.
One hundred thirty-four consecutive PD subjects and 94 control subjects without prior diagnosis of SDB were assessed. Participants were assessed with clinical history, Unified Parkinson’s Disease Rating Scale, Geriatric Depression Scale, Berlin Questionnaire to classify SDB risk, Epworth Sleepiness Scale, Parkinson’s Disease Sleep Scale, and SF-36 to examine quality of life. The presence of risk for SDB was assessed by the Berlin Questionnaire.
High risk for SDB was apparent in 66 (49.3%) of the PD patients and 32 (34.8%) of the controls. After adjustment for age, gender, and body mass index (BMI), PD subjects in comparison to controls showed higher risk for SBD (odds ratio=2.81; 95% confidence interval, 1.36–5.82). Quality of life (physical component score) was significantly diminished in PD patients at high risk for SDB. PD severity did not correlate well with SDB risk. PD patients at high risk for SDB had higher BMIs and Epworth scores.
PD patients have features suggesting increased risk for SDB. This frequently undiagnosed sleep disorder may have a substantial impact on quality of life of PD patients.
Sleep-disordered breathing; Obstructive sleep apnea; Parkinson’s disease; Berlin questionnaire; Sleepiness; Depression; Quality of life
Sleep disordered breathing (SDB) is a medical condition that has increasingly recognized adverse health effects. Obesity is the primary risk factor for the development of SDB and contributes to cardiovascular and metabolic abnormalities in this population. However, accumulating evidence suggests that SDB may be related to the development of these abnormalities independent of obesity. Periodic apneas and hypopneas during sleep result in intermittent hypoxemia, arousals and sleep disturbances. These pathophysiologic characteristics of SDB are likely mechanisms underlying cardiovascular and metabolic abnormalities including hypertension and other cardiovascular diseases, altered adipokines, inflammatory cytokines, insulin resistance, and glucose intolerance. It appears that treatment of SDB with continuous positive airway pressure reverses some but not all of these abnormalities; however, studies to date have demonstrated inconsistent findings. Weight loss strategies, including diet, exercise, medications and bariatric surgery have been evaluated as a treatment strategy for SDB. In preliminary studies, dietary intervention and exercise have reduced severity of SDB. One study demonstrated mild reductions in weight and subsequent improvements in SDB severity using the weight-reducing medication, sibutramine. In morbidly obese subjects, bariatric surgery effectively induces weight loss and improvement in SDB severity and symptoms, but long-term benefits remain uncertain. Large randomized trials are required to determine the utility of these strategies as long-term approaches to improving SDB and reducing associated complications.
Sleep disordered breathing; obesity; glucose intolerance; weight loss; cytokines
To explore the relationship between sleep-disordered breathing (SDB) and behavioral problems among inner-city children with asthma.
Patients and Methods
We examined data for 194 children (age 4–10 yrs) who were enrolled in a school-based asthma intervention program (response rate: 72%). SDB was assessed using the Sleep-Related Breathing Disorder (SRBD) questionnaire that contains 3 subscales: snoring, sleepiness, and attention/hyperactivity. For the current study, we modified the SRBD by removing the 6 attention/hyperactivity items. A sleep score of >.33 was considered indicative of SDB. To assess behavior, caregivers completed the Behavior Problem Index (BPI) which includes 8 behavioral subdomains. We conducted bivariate analyses and multiple linear regression to determine the association of SDB with BPI scores.
The majority of children (mean age 8.2 yrs) were male (56%), African American (66%), and insured by Medicaid (73%). Overall, 33% of children experienced SDB. In bivariate analyses, children with SDB had significantly higher (worse) behavior scores compared to children without SDB on total BPI (13.7 vs 8.8, p<.001), externalizing (9.4 vs 6.3, p<.001), internalizing (4.4 vs 2.5, p<.001), anxious/depressed (2.4 vs 1.3, p<.001), headstrong (3.2 vs 2.1, p<.001), antisocial (2.3 vs 1.7, p=.013), hyperactive (3.0 vs 1.8, p<.001), peer conflict (.74 vs .43, p=.011), and immature (2.0 vs 1.5, p=.001). In multiple regression models adjusting for several important covariates, SDB remained significantly associated with total BPI, externalizing, internalizing, anxious/depressed, headstrong, and hyperactive behaviors. Results were consistent across SBD subscales (snoring, sleepiness).
We found that poor sleep was independently associated with behavior problems in a large proportion of urban children with asthma. Systematic screening for SDB in this high-risk population might help to identify children who would benefit from further intervention.
childhood asthma; inner-city; behavior; sleep-disordered breathing
To estimate the prevalence of sleep abnormalities and their association with glucose intolerance and metabolic syndrome (MS) in the normal-weight urban South Indian population.
This population-based, cross-sectional study was carried out in 358 subjects aged 20–76 years randomly selected from the Chennai Urban Rural Epidemiology Study in South India. A validated questionnaire assessing various sleep abnormalities (snoring, daytime sleepiness, lack of refreshing sleep, and number of hours of sleep) was administered. All subjects underwent an oral glucose tolerance test, and anthropometric biochemical measurements were obtained to assess cardiometabolic risk factors including glucose intolerance. Diabetes risk was assessed using a previously validated Indian Diabetes Risk Score (IDRS).
The overall prevalence of snoring and daytime sleepiness was 40% and 59%, respectively. Snorers were more male, older, smokers, and had higher levels of cardiometabolic risk factors. Subjects with daytime sleepiness had higher body mass index (BMI) and abdominal obesity. Both snoring (50.9% vs 30.2%, p < 0.001) and daytime sleepiness (68% vs 49.7%, p < 0.001) were more prevalent among subjects with impaired glucose metabolism compared to those with normal glucose metabolism. Both sleep measures were associated with higher diabetes risk scores, as assessed by the IDRS (snoring: trend χ2, 11.14, p = 0.001; daytime sleepiness: trend χ2, 5.12, p = 0.024). Metabolic syndrome was significantly associated with snoring even after adjusting for age, sex, family history of diabetes, physical activity, smoking, and alcohol.
The prevalence of snoring and daytime sleepiness is high among urban South Indians and these two sleep measures are associated with glucose intolerance, MS, and higher diabetes risk scores.
sleep abnormalities; snoring; daytime sleepiness; cardiometabolic risk factors; metabolic syndrome; Asian Indians
Sleep abnormalities, including obstructive sleep apnea (OSA), have been associated with insulin resistance.
To determine the relationship between sleep, including OSA, and glucose parameters in a prospectively assembled cohort of chronically sleep-deprived obese subjects.
Cross-sectional evaluation of a prospective cohort study.
Tertiary Referral Research Clinical Center.
Main Outcome Measure(s)
Sleep duration and quality assessed by actigraphy, sleep diaries and questionnaires, OSA determined by a portable device; glucose metabolism assessed by oral glucose tolerance test (oGTT), and HbA1c concentrations in 96 obese individuals reporting sleeping less than 6.5 h on a regular basis.
Sixty % of subjects had an abnormal respiratory disturbance index (RDI≥5) and 44% of these subjects had abnormal oGTT results. Severity of OSA as assessed by RDI score was associated with fasting glucose (R = 0.325, p = 0.001) and fasting insulin levels (ρ = 0.217, p = 0.033). Subjects with moderate to severe OSA (RDI>15) had higher glucose concentrations at 120 min than those without OSA (RDI<5) (p = 0.017). Subjects with OSA also had significantly higher concentrations of plasma ACTH (p = 0.009). Several pro-inflammatory cytokines were higher in subjects with OSA (p<0.050). CRP levels were elevated in this sample, suggesting increased cardiovascular risk.
OSA is associated with impaired glucose metabolism in obese, sleep deprived individuals. Since sleep apnea is common and frequently undiagnosed, health care providers should be aware of its occurrence and associated risks.
This study was conducted under the NIDDK protocol 06-DK-0036 and is listed in ClinicalTrials.gov NCT00261898