RACE AND INSUFFICIENT SLEEP

Bharati Prasad Department of Medicine, UIC

Objectives

1. To understand how insufficient sleep affects health.

2. To discuss how habitual, voluntary sleep restriction and sleep disordered breathing impacts quality of life in African Americans.

3. To examine if SES and access to care limitations in African Americans with symptoms of obstructive sleep apnea (OSA) can be overcome with new technology-based interventions.

What is “insufficient sleep” in adults?

• The National Sleep Foundation suggests that adults need 7-9 hours of sleep daily. http://www.sleepfoundation.org/article/white-papers/how-much-sleep-do-adults-need

• Shorter and longer sleep durations are associated with poorer health and higher all-cause mortality.

• Chronic sleep deprivation has a cumulative effect on mental and physical well-being and can exacerbate chronic diseases.

• It is not known whether these effects are reversible.

Causes of Insufficient Sleep

• Behavioral (voluntary) sleep restriction– Contributing factors include cell phone usage before

going to bed, ambient temperature, increased carbohydrate consumption, SES, exercise, noise, light

• Involuntary sleep restriction (curtailed sleep and/or non-restorative sleep)– Insomnia– Shift work– Chronic medical conditions: e.g., arthritis– Sleep disorders: e.g., restless legs syndrome, OSA

Health Consequences of Insufficient Sleep

Insufficient sleep results in: • Poor performance

– Motor vehicle accidents– Negative work outcomes, including occupational accidents,

absenteeism, and presenteeism Swanson LM, J Sleep Res 2011

• Adverse health effects– Obesity– Cardio-metabolic disorders (hypertension, diabetes)– Immune function– Hormone and sexual functionAndersen ML et al, Brain Res 2011; Patel SR et al, Obesity 2008; Walsh NP et al, Exerc Immunol Rev 2011

• All cause mortality: relative risk 1.12 (p < 0.01) and significantly modified by SES Cappucio FP et al, SLEEP 2010

Changing sleep habits of Americans

1960 1982 20054

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Average Daily Sleep Duration in Hours

*1960: American Cancer Society; 1982: Cancer prevention study II; 2005: National health and examination study (NHANES) III.

Insufficient Sleep in African Americans • A recent CDC report found that 37.1% of U.S. adults reported regularly

sleeping <7 hours per night.

• Perceived sleep-related difficulties (such as not being able to concentrate on doing things) were significantly more likely among persons reporting <7 hours of sleep than among those reporting 7-9 hours of sleep.

• The self-reported prevalence by race was:– non-Hispanic blacks (53.0%) – non-Hispanic whites (34.5%)– Mexican Americans (35.2%)– Other races/ethnicities (41.7%)

*Centers for Disease Control and Prevention (CDC). Effect of short sleep duration on daily activities--United States, 2005-2008. MMWR Morb Mortal Wkly Rep. 2011 Mar 4;60(8):239-42.

African Americans Sleep Less Objectively

• A similar observation was made in a sample of Chicago residents; for whom actigraphic daily sleep duration varied significantly by race:– Caucasian women 6.7 h– Caucasian men 6.1 h– African American women, 5.9 h– African American men, 5.1 h

* Lauderdale DS et al. Objectively measured sleep characteristics among early-middle-aged adults: the CARDIA study. Am J Epidemiol. 2006;164:5–16.

Role of sleep in health disparitiesEpidemiological Studies Examining Sleep as a Mediating Factor for Racial Differences in Disease Risk.

Source Study Design Sample Results

Brown et al, 2009

Cross-sectional household interview

n = 29,818, 18–85 y Adjusted risk of obesity associated with short sleep duration higher for African Americans: 1.8 fold vs. 1.4 fold

Knutson et al, 2009

Wrist actigraphy for three days

n = 578, 33–45 y Sleep duration mediated racial differences in blood pressure parameters

Knutson et al, 2006

Cross-sectional study

African Americans with type 2 DM, n = 161

In uncomplicated DM, sleep debt was a predictor of HbAlc level

Racial Differences in Insomnia and Sleep Disordered Breathing

*Ruiter ME et al. Sleep disorders in African Americans and Caucasian Americans: a meta-analysis.Behav Sleep Med 2010;8:246–259.

Sleep Disordered Breathing in African Americans

* Age, gender, and body mass index did not significantly moderate the racial difference.

Can we explain racial differences in sleep?

• Differential anatomic risk factors and biomarkers among ethnic groups indicate possible racial differences in the genetic underpinnings of sleep.*Buxbaum SG et al. Genetics of the apnea hypopnea index in Caucasians and African Americans: I. segregation analysis. Genet Epidemiol, 2002; 22:243–253.

• Inflammation pathway may mediate the link between reduced sleep duration and cardio-metabolic diseases, and this pathway may function differently in African Americans relative to Caucasians.*Simpson NS et al. Effects of sleep restriction on adiponectin levels in healthy men and women. Physiol Behav, 2010; 101:693–698.

Race, psychosocial factors, and sleep complaints

• The NSF 2010 sleep in America poll reported 76% African Americans compared to 83% Caucasians believed that insufficient or poor sleep was linked to health problems.

• The possibility of reporting bias (under-reporting) of sleep complaints in African Americans is currently being investigated.

• While this may bestow a unique ability to cope with challenges posed by sleep disturbances, this may be maladaptive for those with OSA.

Race, psychosocial factors, and OSA

• The reluctance to address sleep problems might explain in part why OSA is a public health problem in African American communities.

• Data collected at a sleep clinic in Brooklyn suggest that only 38% of African Americans are likely to adhere to recommendation for polysomnographic evaluations.

• This is alarming since 91% of African American patients undergoing polysomnographic recordings received a diagnosis of OSA.

*Jean-Louis G et al. Evaluation of sleep apnea in a sample of black patients. J Clin Sleep Med, 2008; 4:421–425.

Figure: Hypothetical model of sleep pathways to racial disparities in disease

Curtsey: Bosede Adenekan , Abhishek Pandey , Sharon McKenzie , Ferdinand Zizi , Georges J. Casimir , Girardin Jean-Louis

Sleep in America: Role of racial/ethnic differences

Sleep Medicine Reviews 2013

http://dx.doi.org/10.1016/j.smrv.2012.07.002

Purpose of Research: OSA in African AmericansBackground Summary:

African American ethnicity is a significant risk factor for OSA and associated morbidity. Villaneuva et al, Sleep Med Rev 2005.

Compared to European Americans, African Americans have early-onset and more severe disease and a lower SES. Redline S et al, AJRCCM 1997.

In the context of African Americans with OSA, lack of access to care and cost of care due to low SES are barriers to timely interventions; interventions that are known to improve quality of life, physical health, and mortality. Spilsbury JC et al, J Pediatr 2006.

Therefore, examination of easily applicable, effective, and lower-cost interventions for OSA among African Americans is important.

Project: “Comparative Effectiveness Research to Enhance Outcomes in African Americans with Sleep Apnea”

• Aim: i) To test the validity of an alternative home-based diagnostic test for OSA compared to the standard laboratory-based diagnostic test in a clinical population of African Americans. The potential advantages of the home-based testing include reducing expense and delays in diagnosis and treatment of OSA, thereby reducing the risk of adverse health outcomes.

ii) To determine factors that influence quality of life among African Americans with OSA, including habitual sleep duration.

• Data collected:• sociodemographic variables• symptom questionnaire• sleep log (a standardized self-reported sleep duration and sleep schedule instrument)• medical history and examination• a disease-specific quality of life measure (Functional Outcomes of Sleep

Questionnaire; FOSQ)

FOSQ: Domains Assessed

Materials and Methods

• Tertiary-care, single center, prospective, randomized cross-over study of home Portable Monitoring (PM) and in-laboratory simultaneous polysomnography + PM in 75 urban African Americans with high pre-test probability of OSA, identified with the Berlin questionnaire.

• All patients were trained in the self-application of PM (WatchPAT200, Itamar Medical Ltd.) prior to home-testing.

Results #1Demographic Characteristics (n = 75)Parameter Value

Gender (F/M) 57/18

Age (mean ±SD) 44.9 ±11.2Body mass index 42.8 ±12.5

Employed (n/%) 38/51%

Household income < $50,000 per annum (n/%) 58/77%

Education (n/%) ≤High School >1 Year of College

2451

Frequent Use of Technology Cell phone use Computer use

7459

Epworth Sleepiness Scale (mean ±SD) 12.0 ± 5.5

Functional Outcomes of Sleep Questionnaire (mean ± SD) 13.4 ±3.8

Results #2

• 38/63 (60%) participants reported sleeping 7-9 hours per day.

• Visual Analog Scale (VAS) of Satisfaction:– Laboratory 4.26 ± 0.95– Home 4.28 ± 0.89

• p = 0.55

• 56/68 (82%) preferred home testing• Data failure occurred in 5/75 patients (6.6%)

Results #3AUC: 0.91

Results #4

Sleep Duration and Quality of Life

R2 = 0.078

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Functional Outcomes of Sleep Questionnaire

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Result #5

• The adjusted regression model for predictors of FOSQ did not significantly change the relationship between sleep duration and quality of life.

• Other predictors: – Age, Gender, Body mass index,– OSA severity– symptom of daytime sleepiness measured by the

Epworth Sleepiness Scale (ESS)

Results #6

Sleepiness and Quality of Life R2 = 0.19p = 0.0001

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Epworth Sleepiness Scale

FOSQ

Conclusions…

• Home testing for OSA in urban African Americans is: – Satisfactory– Preferred– Accurate

• Insufficient Sleep by self-report does not appear to predict a poor quality of life in this sample.

• Symptoms of excessive daytime sleepiness is predictive of a poor quality of life.

Conclusions….

• Prevalence of insufficient sleep (< 7 hours per day) was lower than expected ~40%

• Measurement of habitual sleep duration limited: self-report, missing data

• Daytime sleepiness has been reported to be predictive of poor quality of life in national and international studies

Heath-care strategy level recommendations for African American patients:1) Assessment of sleep duration, quality, and sleep disorders

symptoms should be routine at every regular physical exam**.2) Culturally targeted education regarding the importance of

sleep for optimal health and strategies for regulating daily hours of sleep to 7–9 h.

3) Using culturally appropriate measures on questionnaires administered to reduce response bias.

4) Recognizing that lower SES may limit access to care: making culturally acceptable, cost effective health-care technology available.

*Adenekan B et al, Sleep in America: Role of racial/ethnic differences. Sleep Med Rev. 2013