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 technologybased 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 function
Andersen 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
Average Daily Sleep Duration in Hours
10
9
8
7
6
5
4
1960
1982
2005
*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 disparities
Epidemiological 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 cardiometabolic 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 Americans
Background 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 earlyonset 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 lowercost 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 #1
Demographic Characteristics (n = 75)
Parameter
Value
Gender (F/M)
57/18
Age (mean ±SD)
44.9 ±11.2
Body 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
24
51
Frequent Use of Technology
Cell phone use
Computer use
74
59
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 #3
AUC: 0.91
Results #4
Sleep Duration and Quality of Life
Usual Daily Sleep
Duration in Hours
12
R2 = 0.078
10
8
6
4
2
0
0
5
10
15
20
Functional Outcomes of Sleep Questionnaire
25
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
R2 = 0.19
p = 0.0001
FOSQ
Sleepiness and Quality of Life
25
20
15
10
5
0
0
5
10
15
20
Epworth Sleepiness Scale
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 healthcare technology available.
*Adenekan B et al, Sleep in America: Role of racial/ethnic differences.
Sleep Med Rev. 2013