Faculty Bibliography

BACKGROUND: We investigated ethnic differences in sleep duration, and the contribution of socio-economic status (SES) to the observed differences in Amsterdam, the Netherlands. METHODS: 6959 participants (aged 18-71 years) from the multi-ethnic HELIUS cohort were studied. Outcome variables were short sleep (<7 h/night) and long sleep (>/=9 h/night). Comparisons among groups were made using Prevalence Ratios (PRs). RESULTS: Ethnic minority groups were more likely than ethnic-Dutch to report short sleep, with prevalence ranging from 15.1% to 49.7% in men and 16.3% to 41.4% in women. Among men, the age-adjusted PRs ranged from 2.15 (95% CI 1.72-2.69) in Turkish to 3.31 (2.75-3.99) in Ghanaians; and among women, from 1.62 (1.30-2.01) in Turkish to 2.52 (2.15-2.95) in African-Surinamese, respectively. The prevalence of long sleep was significantly higher only in Moroccan men and all the ethnic minority women than in ethnic-Dutch women except for African-Surinamese. Adjustment for SES explains the ethnic difference in long sleep, but not for short sleep. CONCLUSION: Ethnic minority groups reported more short sleep than ethnic-Dutch, while there were no ethnic differences in long sleep. Further study is needed to investigate how this finding on short sleep may contribute to ethnic differences in health outcomes.

BACKGROUND: Lack of adherence to recommended treatment for obstructive sleep apnea remains an ongoing public health challenge. Despite evidence that continuous positive airway pressure (CPAP) is effective and improves overall quality of life, compliance with the use of CPAP in certain racial/ethnic groups, especially blacks, is suboptimal. Evidence indicates that the incidence and prevalence of obstructive sleep apnea are higher among blacks, relative to whites, and blacks are less likely to adhere to recommended treatment compared with other racial/ethnic groups. METHODS: Using a two-arm randomized controlled design, this study will evaluate the effectiveness of a culturally and linguistically tailored telephone-delivered intervention to promote adherence to physician-recommended sleep apnea assessment and treatment among blacks with metabolic syndrome, versus an attention-control arm. The intervention is designed to foster adherence to recommended sleep apnea care using the stages-of-change model. The intervention will be delivered entirely over the telephone. Participants in the intervention arm will receive 10 phone calls to address challenges and barriers to recommended care. Outcomes will be assessed at baseline, and at 6- and 12-months post-randomization. DISCUSSION: This tailored behavioral intervention will improve adherence to sleep apnea assessment and treatment among blacks with metabolic syndrome. We expect to demonstrate that this intervention modality is feasible in terms of time and cost and can be replicated in populations with similar racial/ethnic backgrounds.Trial registration: The study is registered at clinicaltrials.gov NCT01946659 (February 2013).

OBJECTIVE: Improving and validating sleep scoring algorithms for actigraphs enhances their usefulness in clinical and research applications. The MTI(R) device (ActiGraph, Pensacola, FL) had not been previously validated for sleep. The aims were to (1) compare the accuracy of sleep metrics obtained via wrist- and hip-mounted MTI(R) actigraphs with polysomnographic (PSG) recordings in a sample that included both normal sleepers and individuals with presumed sleep disorders; and (2) develop a novel sleep scoring algorithm using spline regression to improve the correspondence between the actigraphs and PSG. METHODS: Original actigraphy data were amplified and their pattern was estimated using a penalized spline. The magnitude of amplification and the spline were estimated by minimizing the difference in sleep efficiency between wrist- (hip-) actigraphs and PSG recordings. Sleep measures using both the original and spline-modified actigraphy data were compared to PSG using the following: mean sleep summary measures; Spearman rank-order correlations of summary measures; percent of minute-by-minute agreement; sensitivity and specificity; and Bland-Altman plots. RESULTS: The original wrist actigraphy data showed modest correspondence with PSG, and much less correspondence was found between hip actigraphy and PSG. The spline-modified wrist actigraphy produced better approximations of interclass correlations, sensitivity, and mean sleep summary measures relative to PSG than the original wrist actigraphy data. The spline-modified hip actigraphy provided improved correspondence, but sleep measures were still not representative of PSG. DISCUSSION: The results indicate that with some refinement, the spline regression method has the potential to improve sleep estimates obtained using wrist actigraphy.

BACKGROUND: Epidemiologic studies show a curvilinear relationship between inadequate sleep (< 7 or > 8 hours) and obesity (Body Mass Index > 30 kg/m2), which have enormous public health impact. METHODS: Using data from the National Health Interview Survey, an ongoing nationally representative cross-sectional study of non-institutionalized US adults (>/=18 years) (1977 through 2009), we examined the hypothesis that inadequate sleep is independently related to overweight/obesity, with adjustment for socio-demographic, health risk, and medical factors. Self- reported data on health risks, physician-diagnosed medical conditions, sleep duration, and body weight and height were used. RESULTS: Prevalence of overweight and obesity increased from 31.2% to 36.9% and 10.2% to 27.7%, respectively. Whereas prevalence of very short sleep (<5 hours) and short sleep (5-6 hours) has increased from 1.7% to 2.4% and from 19.7% to 26.7%, it decreased from 11.6% to 7.8% for long sleep. According to multivariate-adjusted multinomial regression analyses, odds of overweight and obesity associated with very short sleep and short sleep increased significantly from 1977 to 2009. Odds of overweight and obesity conferred by long sleep did not show consistent and significant increases over the years. Analyses based on aggregated data showed very short sleepers had 30% greater odds of being overweight or were twice as likely to be obese, relative to 7-8 hour sleepers. Likewise, short sleepers had 20% greater odds of being overweight or 57% greater odds of being obese. Long sleepers had 20% greater odds of being obese, but no greater odds of being overweight. CONCLUSIONS: Our findings support the hypothesis that prevalence of very short and short sleep has gradually increased over the last 32 years. Inadequate sleep was associated with overweight and obesity for each available year.

INTRODUCTION: Over the past half century, evidence has been accumulating on the emergence of obstructive sleep apnea (OSA), the most prevalent sleep-disordered breathing, as a major risk factor for cardiovascular disease. A significant body of research has been focused on elucidating the complex interplay between OSA and cardiovascular risk factors, including dyslipidemia, obesity, hypertension, and diabetes mellitus that portend increased morbidity and mortality in susceptible individuals. CONCLUSION: Although a clear causal relationship of OSA and dyslipidemia is yet to be demonstrated, there is increasing evidence that chronic intermittent hypoxia, a major component of OSA, is independently associated and possibly the root cause of the dyslipidemia via the generation of stearoyl-coenzyme A desaturase-1 and reactive oxygen species, peroxidation of lipids, and sympathetic system dysfunction. The aim of this review is to highlight the relationship between OSA and dyslipidemia in the development of atherosclerosis and present the pathophysiologic mechanisms linking its association to clinical disease. Issues relating to epidemiology, confounding factors, significant gaps in research and future directions are also discussed.

BACKGROUND: Excessive daytime sleepiness (EDS) often occurs as a result of insufficient sleep, sleep apnea, illicit substance use, and other medical and psychiatric conditions. This study tested the hypothesis that blacks exhibiting EDS would have poorer self-reported adherence to hypertensive medication using cross-sectional data from the Counseling African-Americans to Control Hypertension (CAATCH) trial. METHODS: A total of 1,058 hypertensive blacks (average age 57+/-12 years) participated in CAATCH, a randomized controlled trial evaluating the effectiveness of a multilevel intervention for participants who receive care from community health centers in New York City. Data analyzed in this study included baseline sociodemographics, medical history, EDS, and medication adherence. We used the Epworth Sleepiness Scale, with a cutoff score of >/=10, to define EDS. Medication adherence was measured using an abbreviated Morisky Medication Adherence scale, with a score >0 indicating nonadherence. RESULTS: Of the sample, 71% were female, 72% received at least a high school education, 51% reported a history of smoking, and 33% had a history of alcohol consumption. Overall, 27% of the participants exhibited EDS, and 44% of those who exhibited EDS were classified as adherent to prescribed antihypertensive medications. Multivariable logistic regression analysis, adjusting for effects of age, body mass index, sex, education, and smoking and drinking history indicated that participants who exhibited EDS were more than twice as likely to be nonadherent (odds ratio 2.28, 95% confidence interval 1.42-3.67, P<0.001). CONCLUSION: Analysis of the CAATCH data showed a high prevalence of EDS among hypertensive blacks. EDS is a significant predictor of nonadherence to prescribed medications for hypertension. These findings point to a modifiable variable that can be targeted in future interventions focusing on medication adherence.

Introduction: Emerging empirical evidence suggests exposure to natural amenities (e.g., green-space, oceanfront) may improve health behaviors and mental health outcomes such as increased levels of physical activity and lower levels of depression associated with sleep quality. Little is known about the relationship between self-reported suficient sleep and natural amenities. Methods: A subsample (n = 253,550) of the US 2010 Behavioral Risk Factor Surveillance System, a randomized survey of risk factors among US adults > 18 years of age, was used to examine the association between self-reported sleep suficiency (the number of days individuals indicated as having suficient sleep in the past month) and access to natural amenities. Participants with geographically referenced data were assigned an amenity score based on an index developed by the United States Department of Agriculture to relect the natural landscape of counties including varied topography such as lakes, ponds, oceanfront, and climate to encompass all four seasons in the US (i.e., winter, spring, summer, fall). Multiple linear regression was performed in STATA 12 to explore the relationship between subjective sleep suficiency and natural amenities. Results: Higher number of days with suficient sleep were positively associated with higher scores for natural amenities (beta = 0.112, P = 0.05), controlling for age, gender, race, marital status, education, employment status, income level, physical activity, body mass index and asthma. Days with suficient sleep were negatively associated with Hispanic ethnicity (beta = -1.418), increased age (beta = -0.081), higher levels of education (beta = -0.411) and a propensity to snore (beta = -0.388) (all P < 0.00). Conclusion: In a nationally representative sample of US adults, access to natural amenities was shown to attenuate the risk for insuficient sleep. Additional studies may be needed to determine whether this relationship holds at smaller levels of geography and to disentangle whether spec!

Introduction: There is evidence indicating that Latinos in the U.S. experience short sleep duration. Socioeconomic and cultural factors may provide an explanation for why Latinos experience insuficient sleep. Insuficient sleep has negative physiologic and metal consequences. Because of the multiple life demands, such as childcare and work, and environmental factors, such as noise and light pollution, low-income Latino women experience insuficient sleep. However, few studies have examined the perceptions of sleep in this population. The purpose of this study was to describe the perceptions of sleep and its beneits, and the consequences of insuficient sleep among low-income Latino women of child-bearing age living in the U.S. Methods: Thirty-four low-income Latino women, between the ages of 21-35, responded in writing to ive semi-structured interview questions that elicited their perceptions of the importance of sleep and the impact of insuficient sleep on their health and daily lives. Responses to the ive interview questions were coded and collated into themes. The themes that emerged from the data analysis were used during four dissemination focus groups to validate results with the study participants. Results: The themes that emerged were "Sleep is the food for the body" where women explained how sleep was crucial to maintain and protect health. The second theme that emerged was "No sleep means I can't function." In this theme participants described how insuficient sleep affects their day-to-day activities and family duties. Conclusion: Understanding how this group of Latino women perceives sleep and the impact of sleep deprivation in their lives will facilitate the creation of culturally sensitive programs that promote sleep in this undeserved population

Introduction: Inadequate sleep duration is an important public health burden in the United States. However, there is a paucity of information on the relationships between psychological health and inadequate sleep. Our study examined the relationships between emotional distress and inadequate sleep. Methods: Data from the 2009 National Health Interview Survey (NHIS), N = 27,731 participants 18 years and older, were analyzed to investigate the associations of emotional distress with inadequate sleep duration, adjusting for socio-demographic factors, health risks, and chronic diseases. We deine inadequate sleep as less than 7 or greater than 8 hours sleep durations; compared to healthy sleep (7-8 hours). We measured emotional distress, based on Kessler's 6 scale, which assesses the frequency of feeling sad, nervous, restless, hopeless, worthless, and burdened over a 30-day period. Responses were used to generate a score ranging from 0 to 24. Scores of > 13 are considered likely to indicate serious mental illness. Results: Of the sample, 52% were female, 80% were white, 12% black, and 8% other; 30% hold a HS diploma and 31% reported a family income below 31K. Analysis also showed that 10.9% reported emotional distress and 37.2% reported inadequate sleep. Results of our logistic regression analysis revealed that individuals with emotional distress had 57% greater odd of reporting inadequate sleep (OR = 1.5795% C.I. 1.54, 1.61, p < 0.001); the model adjusted for age, sex, race/ethnicity, marital status, education, combined family income, body mass index, history of alcohol consumption, smoking status, and chronic diseases including, arthritis, hypertension, diabetes, cancer, coronary heart disease and heart conditions. Conclusion: Our indings showed that emotional distress, an important proxy for psychological health, was the strongest predictor of inadequate sleep. Other factors associated with inadequate sleep include demographic (age, education, sex, race/ethnicity, combined family income), health!

Introduction: Studies have shown that decreased sleep duration and later sleep timing (midpoint of sleep) are associated with an increased body mass index (BMI). However, previous research has not determined which of these two sleep parameters is a better predictor of BMI. This study sought to determine whether sleep timing is a better predictor of the likelihood of being overweight/obese than insuficient sleep. Methods: Volunteers consisted of 459 postmenopausal women (mean age = 67.71 + 7.87 years) participating in the Women's Health Initiative study. Of the sample, 72% were non-Hispanic white; 14% Hispanic; 9% black; and 5% other. Volunteers wore an actigraph (Actillume) (ACT) and kept a seven-day sleep diary (SD) to estimate habitual sleep durations. ACT data were scored using a validated algorithm (Cole-Kripke) provided by the Actillume manufacturer. Subjective and actigraphic data were averaged over a period of 7 days to obtain an index of both objective and subjective sleep duration. Sleep timing was derived by calculating the midpoint of reported bedtimes and rise times. Results: Analysis revealed that 20.6% of the volunteers experienced short sleep (< 6 hours) based on subjective data; 47.7% experienced short sleep based on actigraphic estimates. The average sleep timing occured at 03:08. Of the sample, 62% were categorized as overweight or obese. Multivariate-adjusted linear regression showed that only ACTderived sleep duration was signiicantly associated with being overweight/ obese (OR = 2.46 (95% CI: 1.39-4.35, p < .001). There were no statistically signiicant associations between subjective sleep duration or sleep timing with overweight/obesity. The model adjusted for age, race, physical activity and sleep medications. Conclusion: Results suggest that insuficient sleep as measured by actigraphy is the single most important predictor of the likelihood of being overweight/obese among older women. Unlike previous research, sleep timing was not signiicantly associated with being overw!