Recognizing The Prevalence of Sleep-Disordered Breathing in the Hispanic Community

Mar 17, 2014   |  Zaher Fanari, MD, FACC

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Editor’s Note: Commentary based on Redline S, Sotres-Alvares D, Loredo J, et al. Sleep Disordered Breathing in Hispanic/Latino Individuals of Diverse Backgrounds: The Hispanic Community Health Study/Study of Latinos. Am J Respir Crit Care Med. 2014;189:335-44.

Background

Sleep-disordered breathing (SDB), defined as recurrent episodic partial and complete pharyngeal obstruction in sleep, snoring, sleep fragmentation, and daytime somnolence is associated with cardiovascular disease (CVD), diabetes, and stroke. Hispanic/Latino populations have a high prevalence of cardiovascular risk factors and may be at risk for sleep-disordered breathing (SDB).

Methods

Cross-sectional analysis from the baseline examination of the Hispanic Community Health Study/Study of Latinos (HCHS/SOL). HCHS/SOL is a community-based cohort study of 16,415 self-identified Hispanic/Latino persons 18–74 years old recruited from randomly selected households in four U.S. field centers (Bronx, NY; Chicago, IL; Miami, FL; San Diego, CA).

Sleep history and symptoms were assessed using the Sleep Heart Health Study Sleep Habits Questionnaire and the Epworth Sleepiness Scale (ESS). Respiratory events were identified as a 50% or greater reduction in airflow lasting greater than or equal to 10 seconds. The apnea–hypopnea index (AHI) is the number of respiratory events per estimated sleep hour. SDB severity was defined using AHI thresholds of AHI greater than or equal to 5, 15, and 30, indicating minimal, moderate, and severe SDB, respectively. Sleep apnea syndrome (SAS) was defined as having both an AHI3 greater than or equal to 5 and sleepiness defined by an ESS score greater than or equal to 10.

Results

The age-adjusted prevalence of minimal SDB (AHI>5), moderate SDB (AHI>15), and severe SDB (AHI>30) was 25.8, 9.8, and 3.9%, respectively. Only 1.3% had sleep apnea. Moderate SDB was associated with being male (adjusted odd ratio [OR] 2.7; 95%CI 2.3–3.1), obese (OR 16.8; 95%CI 11.6–24.4), and older. SDB was associated with an increased incidence of impaired glucose tolerance (OR 1.7; 95%CI 1.3–2.1), diabetes (OR 2.3; 1.8–2.9), and hypertension. The association with hypertension varied across background groups with the strongest associations among individuals of Puerto Rican and Central American background.

Conclusion

The study shows a high prevalence of SDB and related symptoms across Hispanic/Latino population. In this population at high risk for cardiometabolic morbidity, this study also shows a significant association of SDB with diabetes and hypertension independent of obesity.

Commentary/Perspective

Sleep-disordered breathing (SDB) prevalence is increasing especially in the hispanic population secondary to a rising prevalence of obesity.1 SDB is associated with increased risk of cardiovascular disease (CVD), diabetes, and stroke.  While most epidemiologic studies of SDB in the United States have consisted predominantly of non-Hispanic white populations, data on the Hispanic population is, mainly derived from either questionnaire-based or small size studies.2 The results of these studies are reporting inconsistent data when comparing the SDB prevalence in Hispanic with other groups, as while some reports a higher prevalence in Hispanic patient,2,3 others shows no difference.4,5

HCHS/SOL is to-date the biggest study following Hispanic patients with SDB. Results show a high prevalence of SDB with approximately 19% of women and 33% of men had minimal or more SDB and 6% and 14% of women and men, respectively, had moderate or more severe SDB. These results are consistent with those of the general US population.6 Similarly the increased risk of men to have a SDB is also consistent with those of other population.7

Overweight and obesity were associated respectively with a five fold and 17-fold increase in the risk of SDB. This is consistent with prior data that showed a 50% increase in risk of SDB with each one standard deviation in BMI.8,9 SBD was responsible for increased risk of hypertension of diabetes even after adjusting for BMI and waist circumference. Which was again consistent with data from other populations.10,11 Although the hispanic population had a higher burden of obesity, hypertension and diabetes, it is surprising that the prevalence of SDB and the associated risk of hypertension and diabetes was comparable with that of non-hispanic population.

This study done by Redline et al.12 should be praised for providing the biggest data base for SDB in the hispanic population, reporting the detailed evaluation of associated risk factors and outcomes in different subgroups while utilizing a strict quality control procedures, and standardized measurements, including objective measurements of SDB. However the study had multiple limitations. First, The use of limited number of signals for SDB assessment, not accounting for better evaluation of arousal, sleep architecture, and central sleep apnea. Second, the inconsistency of night-to-night measurement may be responsible of misclassification of the SDB and may affect the validity of the results. Finally and importantly, the retrospective observational design of the study is subject to selection bias and unmeasured confounding that cannot be completely eliminated.

References

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  3. Ramos AR, Wohlgemuth WK, Dong C et al. Race-ethnic differences of sleep symptoms in an elderly multi-ethnic cohort: the Northern Manhattan Study. Neuroepidemiology 2011;37:210-5.
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  5. Skolarus LE, Lisabeth LD, Morgenstern LB, Burgin W, Brown DL. Sleep apnea risk among mexican american and non-Hispanic white stroke survivors. Stroke 2012;43:1143-5.
  6. Peppard PE, Young T, Barnet JH, Palta M, Hagen EW, Hla KM. Increased Prevalence of Sleep-Disordered Breathing in Adults. Am J Epidemiol 2013. [Epub Ahead of Print].
  7. Young T, Palta M, Dempsey J, Skatrud J, Weber S, Badr S. The occurrence of sleep-disordered breathing among middle-aged adults. N Engl J Med 1993;328:1230-5.
  8. Young T, Peppard PE, Taheri S. Excess weight and sleep-disordered breathing. J Appl Physiol 2005;99:1592-9.
  9. Redline S, Schluchter MD, Larkin EK, Tishler PV. Predictors of longitudinal change in sleep-disordered breathing in a nonclinic population. Sleep 2003;26:703-9.
  10. Peppard PE, Young T, Palta M, Skatrud J. Prospective study of the association between sleep-disordered breathing and hypertension. N Engl J Med 2000;342:1378-84.
  11. Seicean S, Kirchner HL, Gottlieb DJ et al. Sleep-disordered breathing and impaired glucose metabolism in normal-weight and overweight/obese individuals: the Sleep Heart Health Study. Diabetes Care 2008;31:1001-6.
  12. Redline S, Sotres-Alvarez D, Loredo J et al. Sleep-disordered Breathing in Hispanic/Latino Individuals of Diverse Backgrounds. The Hispanic Community Health Study/Study of Latinos. Am J Resp Crit Care Med 2014;189:335-44.

Keywords: Cardiovascular Diseases, Diabetes Mellitus, Sleep Apnea Syndromes, Stroke


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