Faculty Bibliography

Study Objectives: This study assessed knowledge and attitudes toward obstructive sleep apnea (OSA) among community physicians and explored factors that are associated with referrals for OSA evaluation. Methods: Medical students and residents collected data from a convenience sample of 105 physicians practicing at community-based clinics in a large metropolitan area. Average age was 48 +/- 14 years; 68% were male, 70% black, 24% white, and 6% identified as "other." Physicians completed the Obstructive Sleep Apnea Knowledge and Attitudes questionnaire. Results: The average year in physician practice was 18 +/- 19 years. Of the sample, 90% reported providing care to black patients. The overall OSA referral rate made by physicians was 75%. OSA knowledge and attitudes scores ranged from 5 to 18 (mean = 14 +/- 2) and from 7 to 20 (mean = 13 +/- 3), respectively. OSA knowledge was associated with white race/ethnicity (rp = 0.26, p < 0.05), fewer years in practice (rp = -0.38, p < 0.01), patients inquiring about OSA (rp = 0.31, p < 0.01), and number of OSA referrals made for OSA evaluation (rp = 0.30, p < 0.01). Positive attitude toward OSA was associated with patients inquiring about OSA (rp = 0.20, p < 0.05). Adjusting for OSA knowledge and attitudes showed that physicians whose patients inquired about OSA were nearly 10 times as likely to make a referral for OSA evaluation (OR = 9.38, 95% CI: 2.32 - 38.01, p < 0.01). Conclusion: Independent of physicians' knowledge and attitudes toward obstructive sleep apnea, the likelihood of making a referral for obstructive sleep apnea evaluation was influenced by whether patients inquired about the condition.

Introduction: Short and long sleep duration are an important public health burden in the United States. They are influenced by race/ethnicity and socioeconomic status. Little is known about the relationships between psychological health and short and long sleep across race/ethnicity. Our study examined the racial/ethnic influence on the relationship between psychological distress and sleep duration. Methods: Data from the 2009 National Health Interview Survey (NHIS), N = 27,731 participants ages > 18 years, were analyzed to investigate the associations of psychological distress with inadequate sleep duration, adjusting for socio-demographic factors, health risk behaviors, and chronic diseases. Short sleep was coded as 8 hours. Psychological distress (PD), based on Kessler's 6 scale, assessed the frequency of feeling sad, nervous, restless, hopeless, worthless, and burdened over a 30-day period. Scores range from 0 to 24 and scores > 13 likely indicate serious mental illness. Results: Of the sample, 51.6% were female; 76.2%, White and 15.6%, Black/African-American, with a mean age of 35.79 +/- 22.4 yrs. Of the sample, 8.1%) of Blacks vs. 7.1% of Whites reported PD. Logistic regression analysis indicated that blacks and whites with PD have similar odds of reporting short sleep (Blacks: OR = 2.33, p < 0.05 and Whites: OR = 2.36, p < 0.05). However, different odds for long sleep were observed (Blacks: OR = 1.23, p < 0.05 and Whites: OR = 1.63, p < 0.05). These analyses adjusted for demographic, health risk behaviors, and chronic diseases. We also found discrepancies in the predictive model. For Whites, gender, marital status, family income, body mass index, arthritis, diabetes, hypertension, heart condition and PD predicted short sleep. For Blacks, only age, family income, hypertension and PD predicted short sleep. Conclusion: Psychological distress was the strongest predictor of short and long sleep for both groups. PD and short and long sleep were more prevalent among blacks than among whites. Our study underscored the significant role of PD in racial/ethnic sleep disparities

Introduction: We assessed associations of sleep duration and socio-demographic factors with severe headaches/migraine. Methods: National Health Interview Survey (NHIS) data collected from 1997-2013 was utilized. NHIS applied a multistage area probability sampling design. Descriptive statistics were used to characterize the sample, and multivariate logistic regression model was used to test associations of sleep duration and socioeconomic factors with severe headaches/migraine. Results: Of 515,456 adults surveyed, the mean (+/- SEM) age was 54.3 +/- 0.016 ranging from 18 to 85 years; the mean body mass index (BMI) in kg/m² was 26.8 +/- 0.007 A greater proportion of women reported headaches compared to men (20.1% vs 9.5%, p < 0.001). Individuals with headaches were younger (42.2 +/- 0.05 vs. 48.1 +/- 0.02, p < 0.01) and had higher BMI (27.3 +/- 0.02 vs. 26.7 +/- 0.01, p < 0.01). Headaches were more common among short sleepers, < 7 hours (21.5%) and long sleepers, > 8 hours (15.7%), compared to those averaging 7-8 hours (12%), p < 0.01. Headaches were more common among blacks, compared to whites and Asians (16.5%, 15.4% and 10.9%, respectively), p < 0.01. Headaches were reported by individuals who were separated (23.1%), divorced (18.3%), never married individuals (16.8%,) married (14.6%) or 9 widowed (6%), p < 0.01. After adjusting for age, BMI and sleep duration, the odds ratio (OR) for headaches for married was 1.126 (95% CI = 1.093-1.159), p < 0.01; for widowed: OR was 1.28 (95% CI = 1.207-1.36), p < 0.01; for divorced: OR was 1.57 (95% CI = 1.52-1.63), p < 0.01 and for separated: OR was 1.85 (95% CI = 1.75-1.95), p < 0.01, using never married as a referent. Headaches were more common among individuals below (23.0%), compared to those above (14.8%) poverty level, p < 0.01. Conclusion: Both short and long sleep durations were associated with higher frequency of headaches. Female sex, increasing BMI and younger age were also associated with increased headaches. Compared to individuals who were never married, those of other marital status had increased odds of having headaches. Poverty level was significantly associated with increased headaches

Introduction: Studies have shown a significant association between long sleep (defined as > 8 hours) and various chronic conditions such as cardiovascular disease, obesity, cancer, and stroke. Moreover, research suggests that long sleep may be more detrimental to one's health than is short sleep. The purpose of this study was to determine the mediating role of body mass index (BMI), physical activity, and emotional distress on the relationship between long sleep and chronic conditions. Methods: The study utilized data from the National Health Interview Survey, an ongoing, nationally representative, cross-sectional study of noninstitutionalized U.S. adults (> 18 years) between 2003 and 2014 (n = 911,773). Structural equation modeling was employed to assess mediation of observed and latent factors using Path Coefficient Estimate (PCE). Physical activity was defined as 10+ minutes of either moderate or vigorous activity. We measured emotional distress with Kessler's 6 scale. Chronic diseases included hypertension, coronary heart disease, diabetes, stroke, kidney disease, cancer and history of heart attack. Results: Of the sample, 51.6% were female; 76.2%, White; and 15.6%, Black/African-American with a mean age of 35.79 +/- 22.4 yrs. Physical activity significantly mediated relationships between long sleep and presence of all chronic diseases (p < 0.001), while emotional distress only mediated relationships between long sleep and kidney disease, diabetes, stroke, and heart attack. Physical activity showed a negative relationship with long sleep (PCE = -0.012, p < 0.001), while emotional distress was positively associated with long sleep (PCE = 0.134, p < 0.01). Of interest, BMI did not significantly mediate relationships between long sleep and chronic conditions (PCE = -0.008, p = 0.322). Covariates included age, sex, income, race, and marital status. Conclusion: Our analysis revealed that the dynamic relationships between long sleep and chronic conditions were mediated by physical activity and emotional distress. Future research should explore the relationships between long sleep and BMI, which in our analyses did not prove significant

Introduction: This study ascertained whether inadequate sleep places unequal burden on blacks, relative to their white counterparts. Methods: Analysis was based on data obtained from adult Americans (age range: 18-85 years) who participated in the National Health Interview Survey, an important surveillance study of the health of the US population providing sociodemographic, health risk, and medical data from 1977-2009. Sleep duration was coded as either very short sleep [VSS] (< 5 hours), short sleep [SS] (5-6 hours), or long sleep [LS] (> 8 hours), referenced to 7-8 hour sleepers. Overweight was defined as BMI > 25.0 and < 29.9 kg/m² and obesity, BMI > 30 kg/m², referenced to normal weight (BMI = 18.5-24.9 kg/m²). Results: Multivariate-adjusted regression analyses indicated that among whites VSS was associated with a 10% increased likelihood of being overweight and 51% increased likelihood of being obese, relative to 7-8 hour sleepers. SS was associated with a 13%) increased likelihood of being overweight and 45% increased likelihood of being obese. LS was not a significant predictor of overweight, but it was associated with 21%o increased likelihood of being obese. Among blacks, VSS was associated with a 76% increased likelihood of being overweight and 81%o increased likelihood of being obese. SS was associated with a 16%o increased likelihood of being overweight and 32%o increased likelihood of being obese. As for whites, LS was not a significant predictor of overweight, but it was associated with a 25%o increased likelihood of being obese. Conclusion: Our investigation demonstrates strong linkages between inadequate sleep and overweight/obesity among both black and white Americans. While it cannot be said that insufficient sleep causes overweight or obesity, it is apparent that blacks sleeping 5 hours or less may be unequally burdened by sleep-related overweight/obesity

Insufficient sleep is associated with cardiometabolic disease and poor health. However, few studies have assessed its determinants in a nationally representative sample. Data from the 2009 behavioral risk factor surveillance system were used (N = 323,047 adults). Insufficient sleep was assessed as insufficient rest/sleep over 30 days. This was evaluated relative to sociodemographics (age, sex, race/ethnicity, marital status, region), socioeconomics (education, income, employment, insurance), health behaviors (diet, exercise, smoking, alcohol), and health/functioning (emotional support, BMI, mental/physical health). Overall, insufficient sleep was associated with being female, White or Black/African-American, unemployed, without health insurance, and not married; decreased age, income, education, physical activity; worse diet and overall health; and increased household size, alcohol, and smoking. These factors should be considered as risk factors for insufficient sleep.

OBJECTIVE: The objective of the study was to examine the independent association of emotional distress with unhealthy sleep duration (defined as <7 or >8 hours). METHODS: Data from the 2009 National Health Interview Survey (NHIS), a cross-sectional household survey, were analyzed to investigate the associations of emotional distress with unhealthy sleep durations, adjusting for sociodemographic factors, health risks, and chronic diseases through hierarchical multiple logistic regression analysis. PARTICIPANTS: A total of 27,731 participants (age range 18-85 years) from the NHIS 2009 dataset were interviewed. MEASURES: Unhealthy sleep duration is defined as sleep duration <7 or >8 hours, whereas healthy sleep is defined as sleep duration lasting for 7-8 hours. Emotional distress is based on the Kessler 6 Non-Specific Distress Battery, which assesses the frequency of feeling sad, nervous, restless, hopeless, worthless, and burdened, over a 30-day period. RESULTS: Of the sample, 51.7% were female; 83.1% were white and 16.9% were black. Eleven percent experienced emotional distress and 37.6% reported unhealthy sleep. Adjusted logistic regression analysis revealed that individuals with emotional distress had 55% greater odds of reporting unhealthy sleep (odds ratio [OR] =1.55, 95% confidence interval [CI] =1.42, 1.68, P<0.001). CONCLUSION: Emotional distress, an important proxy for poor psychological health, was a significant predictor of unhealthy sleep, independent of the influences of several factors including demographic (age, education, sex, race/ethnicity, and family income), health risks (alcohol consumption and smoking status), and chronic diseases/conditions (diabetes, obesity, hypertension, heart disease, cancer, and arthritis).

INTRODUCTION: This study assessed associations of depression and anxiety with risk of obstructive sleep apnea (OSA) among non-Hispanic blacks in the Metabolic Syndrome Outcome (MetSO) study. METHOD: A total of 1,035 patients participated. ARESTM score >/=6 defined high OSA risk. Moderate depression was defined by a CES-D score >/=16. Moderate anxiety was measured by a BAI score >/=16. RESULTS: The mean age was 62 +/- 14 years; 70% were female. A total of 93% were diagnosed with hypertension; 61%, diabetes; and 72%, dyslipidemia; 90% were overweight/obese; 33% had a history of heart disease; and 10% had a stroke. Logistic regression analysis, adjusting for age and gender, showed that patients with depression had nearly two-fold increased odds of being at risk for OSA (OR 1.75, 95% CI 1.02-2.98, p < 0.05). Patients with anxiety had three-fold increased odds of being at risk for OSA (OR 3.30, 95% CI 2.11-5.15, p < 0.01). After adjusting for marital status and income, patients with anxiety had a 6% increase in OSA risk (OR 1.06, 95% CI 1.04-1.09, p < 0.05), but depression was no longer significant. CONCLUSION: Our results suggest that non-Hispanic blacks with metabolic syndrome who experience anxiety and/or depression should be screened for OSA. Key messages This study assessed associations of moderate to severe depression and anxiety with risk of obstructive sleep apnea (OSA) among non-Hispanic blacks with metabolic syndrome. Patients with depression had nearly two-fold increased odds of being at risk for OSA. Patients with anxiety had three-fold increased odds of being at risk for OSA.

BACKGROUND: Visual impairment (VI) is associated with increased mortality and health factors such as depression and cardiovascular disease. Epidemiologic studies consistently show associations between sleep duration with adverse health outcomes, but these have not systematically considered the influence of VI. The aim of this study was to ascertain the independent association between VI and sleep duration using the National Health Interview Survey (NHIS) data. We also examined whether race/ethnicity influenced these associations independently of sociodemographic and medical characteristics. METHODS: Our analysis was based on the 2009 NHIS, providing valid sleep and vision data for 29,815 participants. The NHIS is a cross-sectional household interview survey utilizing a multistage area probability design. Trained personnel from the US census bureau gathered data during face-to-face interview and obtained socio-demographic, self-reported habitual sleep duration and physician-diagnosed chronic conditions. RESULTS: The mean age of the sample was 48 years and 56% were female. Short sleep and long sleep durations were reported by 49% and 23% of the participants, respectively. Visual impairment was observed in 10%. Multivariate-adjusted logistic regression models showed significant associations between VI and short sleep (OR = 1.6, 95% CI = 1.5-1.9 and long sleep durations (OR = 1.6, 95% CI = 1.3-1.9). These associations persisted in multivariate models stratified by race-ethnic groups. CONCLUSION: Visual impairment was associated with both short and long sleep durations. Analysis of epidemiologic sleep data should consider visual impairment as an important factor likely to influence the amount of sleep experienced habitually.

A growing body of research demonstrates that psychosocial factors play an important role in the development of hypertension. Previous reviews have identified several key factors (i.e., occupational stress) that contribute to the onset of hypertension; however, they are now outdated. In this review, we provide an updated synthesis of the literature from 2010 to April 2014. We identified 21 articles for inclusion in the review, of which there were six categories of psychosocial stressors: occupational stress, personality, mental health, housing instability, social support/isolation, and sleep quality. Sixteen of the studies reported an association between the psychosocial stressor and blood pressure. While several findings were consistent with previous literature, new findings regarding mediating and moderating factors underlying the psychosocial-hypertension association help to untangle inconsistencies reported in the literature. Moreover, sleep quality is a novel additional factor that should undergo further exploration. Areas for future research based on these findings are discussed.