May 26, 2012
By Melissa Bynes Brooks
Public awareness has increased about the health risks associated with obstructive sleep apnea (OSA). While Blacks suffering from obesity and daytime sleepiness are more likely to seek initial sleep consultations, most Blacks are less likely to have a medical evaluation or seek treatment for OSA. They are not aware of the inherent risks of having OSA.
This may be because symptoms of sleep disorders are not routinely screened for or recognized in the primary care setting. To date, the United States Preventive Services Task Forces, the American Academy of Family Physicians, and the Center for Disease Control have not recommended routine screening for sleep disorders.
The use of validated questionnaires may be able to efficiently identify patients at risk for common sleep disorders though further study is required.
In a community-based sample of Black patients, of the 421 patients referred by their private care physicians, 38% followed the recommendation for a sleep consultation. Even when Blacks have adequate insurance coverage, they are not as likely as their White counterparts to utilize available services. This suggests that physicians practicing in those communities may have to develop innovative strategies to encourage participation of Black patients in healthcare practices.
Ethnic differences highlight the need to further examine social support, socioeconomic status, access to care, and cultural factors to guide future health-related quality of life (HR-QOL).
OSA, the most common breathing sleep disorder, sets off an unstable chain of physiological reactions.
It begins with a blockage in the upper airway which interferes with the ability to breathe normally while sleeping. The blockage leads to loud snoring followed by silence. Oxygen levels decrease in the blood. Then chemoreceptors in the brain detect increased carbon dioxide levels in the blood. This results in the person choking or gasping for air, arousing momentarily or waking up completely from their sleep. At the same time, rapid changes occur with the heart rate, heart rhythm, and blood pressure. The body works overtime to recover from each episode lasting at least 10 seconds.
Throughout all this, the individual is totally clueless. After awakening, the only traces of life threatening events are symptoms of tiredness, excessive daytime sleepiness, dry mouth, morning headaches, and sometimes memory loss. In fact, sleep interruption due to OSA is often times mistaken as a need to get up and use the bathroom. The alternative to the interruptions caused by the apnea is sudden death.
That scenario brings Reggie White to mind, the former NFL football player, who reportedly suffered from sleep apnea which was believed to play a role in his death from a fatal cardiac arrhythmia. Nighttime is the deadliest time of day in persons with obstructive sleep apnea, according to a report in The New England Journal of Medicine, 2005, by Apoor S. Gami, MD, and colleagues of the Mayo Clinic in Rochester, Minn.
Those at high risk for OSA are: Black, Hispanic or Pacific Islander; male; over the age of 65; related to someone who has sleep apnea; and a smoker. Demographics are steadily changing to include children and adolescents because of increased obesity and diabetes rates in these groups.
Physical risk factors are attributes of a thick neck, deviated septum, receding chin, enlarged tonsils or adenoids.
OSA is directly linked to high blood pressure, heart disease, diabetes, obesity, and cancer. Blacks have a higher risk of death from OSA because of greater genetic tendencies for these medical conditions.
First, more than 40 percent of non-Hispanic Blacks have high blood pressure (HBP) which is more severe in Blacks than Whites and develops earlier in life. It contributes to 14% of deaths occurring in the United States, and to nearly half of all cardiovascular disease-related deaths annually. From 1997 to 2007, the death rate caused by high blood pressure increased to 9.0%, and the actual number of deaths rose 35.6%.
OSA represents an independent risk factor for high blood pressure. Hypertension constitutes a significant predictor of cardiovascular deaths among patients with OSA. The prevalence of resistant hypertension itself among men with a diagnosis of OSA may be as high as 85%. Blacks exhibit greater resistance to treatment and black women have the highest prevalence of hypertension and the lowest blood pressure control.
Blacks with a family history of hypertension are likely to have higher baseline blood pressure, a greater number of lower blood oxygen levels, and more episodes of “not breathing” while asleep, when compared to Whites.
Second, the National Commission on Sleep Disorders Research estimated that sleep apnea is probably responsible for 38,000 cardiovascular deaths yearly, with an associated 42 million dollars spent on related hospitalizations. Obstructive sleep apnea increases the risk of heart failure by 140%, the risk of stroke by 60%, and the risk of coronary heart disease by 30%.
The evaluation, diagnosis, treatment, and management of OSA have significant positive effects in reducing cardiovascular disease risk.
Linkage between obstructive sleep apnea and cardiovascular disease has been corroborated by evidence that treatment of sleep apnea with continuous positive airway pressure (CPAP) reduces systolic blood pressure, improves left ventricular systolic function, and diminishes platelet activation.
CPAP is a treatment that uses mild air pressure to keep the airways open. CPAP typically is used by people who have breathing problems, such as sleep apnea. Sleep medicine care providers, generalists, and specialists focusing on cardiovascular disease in OSA patients, need to emphasize preventative and ongoing care for active cardiovascular diseases. Care for OSA should also be initiated.
Third, more than 24 million Americans have diabetes mellitus (DM), and nearly one million new cases of diabetes are diagnosed every year. Type 2 diabetes accounts for 90% to 95% of all cases of diabetes. Diabetes mellitus was the sixth leading cause of death in 2002, with the risk of death almost twice that of non-diabetic patients of similar age. According to the Centers for Disease Control and Prevention, Blacks have a 1.8-fold increase and Hispanics have a 1.7-fold increase in the prevalence of diabetes mellitus compared to Whites.
With diabetes, OSA is associated with impaired glucose tolerance and insulin resistance. Type 2 diabetes occurs when the body fails to use insulin effectively. Research suggests that OSA can contribute to the onset of diabetes.
Fourth, a little more than one-third of U.S. adults (35.7%) are obese. Non-Hispanic Blacks have the highest rates of obesity (44.1%) compared with Mexican Americans (39.3%), all Hispanics (37.9%) and non-Hispanic whites (32.6%). The link between OSA and obesity is somewhat of a “Catch 22.” While being overweight is a risk factor for OSA, OSA may promote weight gain by reducing daytime energy and physical activity, and disrupting metabolism. OSA may alter the levels of hormones that regulate your appetite, which may lead you to eat more.
Short sleep duration < 7 hours is associated with elevated prevalence of obesity.
Last, a recent study found that people with the most severe sleep apnea — those who have 30 or more episodes of low or no oxygen in an hour of sleep — had almost five times the risk of cancer death compared to someone without sleep apnea.
When you have cancer and you repeatedly have episodes of low or no oxygen, the cancer cells “try to compensate for the lack of oxygen by growing additional blood vessels to get more oxygen. It’s a defense mechanism,” Dr. Javier Nieto, Chair of the department of population health sciences at the University of Wisconsin School of Medicine and Public Health, in Madison said. And, as those blood vessels keep growing, it helps the tumor to spread, he explained.
In an effort to improve positive health outcomes, The Adult OSA Task Force of the American Academy of Sleep Medicine (AASM) recommends that questions regarding OSA should be incorporated into routine health evaluations. Suspicion of OSA should trigger a comprehensive sleep evaluation. The presence or absence and severity of OSA must be determined before initiating treatment in order to identify those patients at risk of developing the complications of sleep apnea.
Melissa Bynes Brooks is the editor of BrooksSleepReview.
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