Faculty Bibliography

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!

Introduction: Many risk factors have been implicated in the pathophysiology of obstructive sleep apnea (OSA). Recent evidence suggests that medical risk factors, such as uncontrolled/high blood pressure (BP), high cholesterol, triglycerides, high body mass index, diabetes, and dyslipidemia (all indicators of metabolic syndrome) are highly comorbid with OSA. However, data on the relationships between these risk factors and OSA among blacks with metabolic syndrome are lacking. Methods: Data for the present study were collected from 340 participants from the Metabolic Syndrome Outcome (MetSO) study, a NIHfunded cohort study of 1,035 blacks with metabolic syndrome (mean age = 62 + 13 years, 69% female, and 43% with annual family income < $10K). During initial interviews, patients provided sociodemographic, health risks, and history of chronic diseases. Patients with a score > 6 on the Apnea Risk Evaluation System (ARES) were considered at high OSA risk. Logistic regression analyses were employed to investigate whether metabolic syndrome indicators, particularly uncontrolled blood pressure, increased the odds of OSA. Results: Of the sample, 77.1% was at risk for OSA and 16.8% had uncontrolled BP. Analysis also showed 60.4% were diabetic, 8.9% had a stroke history, 74.3% had dyslipidemia, 91.1% were either overweight or obese and 30.9% had heart disease. Mean systolic BP was 134.8 + 18.4; diastolic BP was 75.6 + 11.9; LDL cholesterol was 105.6 + 36.9; HDL cholesterol was 48.0 + 17.3; triglycerides was 135.8 + 81.2; glucose was 138.4 + 68.3; and HbA1c was 7.93 + 1.63. Logistic regression analysis showed that uncontrolled BP independently increased the odds of OSA risk (OR = 1.94, 95% CI = 1.12-3.32, p < 0.01). Conclusion: Our indings suggest that uncontrolled BP was associated with a twofold greater risk of OSA in blacks. The clinical implication of this inding is that blacks with metabolic syndrome and who have uncontrolled BP should be screened for the presence of OSA

Introduction: Identiication of risk factors for obstructive sleep apnea (OSA) is important to enable comprehensive intervention to reduce associated cardiovascular (CV) morbidity and mortality. The Metabolic Syndrome Outcome Study provides a unique opportunity to assess the presence of these factors among blacks, a group that is at high risk for adverse CV outcomes. The purpose of this study was to investigate risk of OSA among blacks with metabolic syndrome Methods: The present study utilized data from the Metabolic Syndrome Outcome (MetSO) study, an NIH-funded cohort study of blacks with metabolic syndrome. A total of 1,035 patients provided data for the present analysis. Patients were diagnosed with metabolic syndrome using criteria articulated in the joint interim statement for harmonizing the metabolic syndrome. OSA risks for all patients were assessed with the Apnea Risk Evaluation System (ARES). Those with an ARES score > 6 were considered at high OSA, based on previous validation studies. Data was coded and analyzed by an experienced statistician using SPSS 19.0. Results: The average age of the sample was 62 + 14 years (range: 20- 97); 71% were female. Of the sample, 93% were diagnosed with hypertension; 61%, diabetes; 72%, dyslipidemia; 90% were overweight/ obese; 33% had a history of heart disease and 10% had a stroke. ARES data indicated that 48% were at high OSA risk. Using multivariate logistic regression analysis, adjusting for age and gender, we observed that obesity was the strongest predictor of OSA risk (OR = 1.59, 95%CI = 1.24-2.04, p < 0.0001). This inding remained signiicant even after adjustment for blood pressure, LDL, HDL, and glucose levels (OR = 1.44, 95%CI = 1.11-1.86, p < 0.001). Conclusion: Of all of the markers of the metabolic syndrome, obesity is the most important predictor of increased risk of OSA among blacks. Our inding is consistent with previous research regarding the obesityapnea link

Introduction: Sleep among blacks with metabolic syndrome is not well characterized. Our study examined sleep characteristics of black men and women with a diagnosis of metabolic syndrome. Methods: The present study utilized data from the Metabolic Syndrome Outcome Study (MetSO), an NIH-funded cohort study of blacks with metabolic syndrome (N = 1,035). Patients [mean age = 62 + 14 years; female = 71%] were diagnosed with metabolic syndrome using criteria articulated in the joint interim statement for harmonizing the metabolic syndrome. They provided self-reported data including sleep habits and insomnia symptoms. They were administered the Apnea Risk Evaluation System (ARES) to ascertain risk of obstructive sleep apnea (OSA). Patients with a score of > 6 on the ARES scale were considered at high OSA risk, based on validation studies. Results: Of the sample, 60% were diagnosed with diabetes; stroke, 10%; heart disease, 31%; hypertension, 93%; overweight/obese, 90%. Based on ARES data, 48% were at risk for OSA. Analysis also showed that 53% reported feeling sleepy during the day, and 10% had an insomnia diagnosis. Speciic insomnia symptoms included dificulty falling asleep (38%), dificulty maintaining sleep (42%), early morning awakening (46%); 53% reported daytime naps, and 12% used sleep medication. Prevalence of short sleepers (< 6 hrs) and long sleepers (> 9 hrs), referenced to healthy sleepers (7-8 hrs), was 70% and 19%, respectively. Based on chi-squared analysis, there was signiicant difference between males and females in regard to reported daytime sleepiness (41% vs. 56%; x2 = 7.736, p < 0.05), dificulty falling asleep (34% vs. 41%; x2 = 5.252, p < 0.05), and daytime naps (60% vs. 50%, x2 = 8.338, p < 0.05). No other signiicant gender differences were observed. Conclusion: Our indings suggest that a large number of blacks with metabolic syndrome experience insomnia symptoms, use sleep aids, and are both short and long sleepers. These sleep-related problems are associated with a myriad of !

Introduction: Although the relationship between sleep duration and body mass index (BMI) has been well-characterized, the underlying mechanisms have not. Understanding which factors explain this relationship would provide important insights in developing effective public health interventions to reduce associated cardiometabolic risks. The present study investigated 5 potential mediators of the relationship between sleep duration and BMI. Methods: Data from the 2009 Behavioral Risk Factor Surveillance System (BRFSS) was used in our analysis. BRFSS is a CDC-sponsored project representing the world's largest ongoing, state-speciic, randomized telephone survey that measures behavioral risk factors among U.S. adults [mean age = 56 + 16 years, female = 63%]. Analysis focused on interviews conducted in six representative states, soliciting sociodemographic, medical, sleep, and health-risk data, yielding observations for n = 35,895 respondents. A bootstrapping method was employed to generate conidence intervals (BCCI) ascertaining total and unique mediation across all 5 hypothesized mediators simultaneously (using 1,000 bootstrap samples) of the sleep duration and BMI relationship. The hypothesized mediators included: alcohol use, diet, physical activity, general health status, and life satisfaction. Age and sex were adjusted in all tested models. Results: Analysis showed that for each additional hour of sleep BMI decreases by 0.15 unit. Evidence of unique mediation was noted for: physical activity (BCCI = 0.0017 to 0.0102; SE = 0.0022), diet (BCCI =-0.0138 to-0.0052; SE = 0.0022), and general health status (BCCI =-0.0379 to-0.0079; SE = 0.0423). However, there was no evidence of unique mediation for: alcohol use (BCCI =-0.0013 to 0.0019; SE = 0.0008) or life satisfaction (BCCI =-0.0057 to 0.0057; SE = 0.0028). Conclusion: These indings suggest that the sleep and BMI relationship may be partially mediated by physical activity, diet, and general health. This is consistent with previous hypotheses regard!

Introduction: Blacks are less likely to adhere to sleep apnea treatment compared with whites. This study explored the unique perspectives of blacks with metabolic syndrome who were referred for treatment of obstructive sleep apnea (OSA) at local sleep clinics. Methods: A total of 340 adults from the Metabolic Syndrome Outcome Study (MetSO), an NIH-funded cohort study of blacks, were randomly assigned to receive either Tailored-Telephone Intervention or regular standard of care. Prior to randomization, participants provided a detailed sleep history assessing sleep habits and OSA risk. The qualitative study involved 4 focus groups (mean age = years; 4 Males, 22 Females). A focus group guide was used to elicit responses from participants. Interviews were audio-taped and transcribed verbatim. Initial a priori codes were developed to guide initial coding. Analysis was guided by grounded theory. We explored 3 important questions: Q1) What are the potential barriers and facilitators of OSA evaluation? Q2) What are the potential barriers and facilitators of CPAP adherence? Q3) What are the experiences of blacks who participated in the intervention? Results: Themes for each question were as follows: Q1 a) general sleep disturbances, b) presence of other health conditions, c) encouragement from loved ones and d) rapport with medical provider plays a key role in adhering to OSA evaluation. Q2 a) improvement in sleep apnea, b) CPAP side effects, c) mistrust of the medical system, d) socio-economic factors limiting ability to participate and e) perception that CPAP device is not necessary were barriers and facilitators of CPAP adherence. Q3 a) having received meaningful information about sleep disorders, sleep hygiene b) increase in health information and c) rapport with the health educator were the experiences of participants in the intervention. Conclusion: To our knowledge, this is the irst study to describe qualitative indings of blacks with metabolic syndrome that participated in an OSA-related interve!

Introduction: Sleep disturbance is a common complaint in the general population. Studies have shown that there are substantial differences between and within racial/ethnic groups with respect to reporting sleep problems, with blacks being less likely to report such problems. Previous studies, however, have not speciically examined black patients with symptoms of obstructive sleep apnea (OSA). This study sought to investigate further whether blacks at risk for OSA are likely to report sleep problems, which would suggest no bias in reporting. Methods: We analyzed data from the Metabolic Syndrome Outcome (MetSO) study, an NIH-funded cohort study of 1,035 blacks (mean age: 62.3 + 13.5 years, women = 69%) with metabolic syndrome. Metabolic syndrome was diagnosed using criteria articulated in the joint interim statement for harmonizing the metabolic syndrome. Patients with a score > 6 on the Apnea Risk Evaluation System (ARES) were considered at high OSA risk. To assess sleep habits and problems, we administered the Sleep Disorders Screening questionnaire. The data was coded and analyzed using SPSS 19.0. Results: Of the sample, 60.4% had diabetes; 92.3%, hypertension; 74%, dyslipidemia; and 66.9%, obesity. Overall, 48.9% of the patients were at high OSA risk. Patients at OSA risk were more likely to report having trouble falling asleep (58.3% vs. 43.7%, p < 0.001), trouble staying asleep (60.5% vs. 41.2%, p < 0.001), complaint of early morning awakenings (58.4% vs. 42.2%, p < 0.001), daytime naps (53.4% vs. 44.4%, p < 0.001), excessive daytime sleepiness (56.8% vs. 40.2%, p < 0.001), and being diagnosed with insomnia (63.7% vs. 47.9, p < 0.001). Conclusion: Nearly half of the blacks with metabolic syndrome were at risk for OSA. Those at OSA risk were more likely to report sleep problems. Compared with previous studies, our analysis does not show a reporting bias among blacks, at least among those at risk for OSA

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).

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.

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.