Introduction: Obesity has become a major health problem worldwide due to high comorbidity and an increasing prevalence. It is the greatest risk factor for obstructive sleep apnea (OSA). Owing to lack of data on the association of obesity and OSA within the country, the present study was designed to evaluate the pattern of sleep disordered breathing (SDB) among obese Indian subjects.
Material and Method: The study was prospectively carried out in Sleep Laboratory of LRS Institute of Tuberculosis and Respiratory Diseases, New Delhi. 30 obese [having body mass index BMI > 27.5 kg/m2] and 10 non-obese (having BMI < 27.5 kg/m2) subjects were consecutively enrolled into the study (obesity) and the control (non-obese) groups respectively as per the World Health Organization (WHO) Criteria of Obesity for Asians. Detailed clinical history including that of sleep was taken, a physical examination along with anthropometric measurements like neck circumference (NC), waist circumference (WC) and hip circumference (HC) was done and laboratory investigations were performed in all subjects, who thereafter, underwent an overnight polysomnography (PSG) on Compumedics E-Series sleep software. Sleep was staged as per Rechtshaffen and Kales (R & K) rules and SDB evaluated as per standard criteria. Data was subjected to statistical analysis.
Results: There were 16 obese, 8 severely obese & 6 morbidly obese subjects. Respective characteristics of the obesity and the control group subjects showed a mean age of 47.73 and 40.90 years, a male-female ratio of 19: 11 and 7:3, and a mean BMI of 33.46 and 23.73 kg/m2. Mean Apnoea-Hypopnoea Index (AHI) was significantly higher among the subjects of the obesity group as compared to the controls. Similarly, mean AHI was significantly higher among the obese males, those having NC between 35 to < 45 cms, symptomatics, those having 4 to 6 number of symptoms, and those having co-morbidities as compared to the respective non-obese counterparts. Mean value of sleep latency was higher, while that of Total Sleep Time (TST) & sleep efficiency lower in the obesity than the control group. Oxygen De-saturation Index (ODI) and indices of arousal, Periodic Limb Movement (PLM) in Sleep (PLMS) & PLM with arousals were significantly higher in the obesity as compared to the control group respectively. No significant differences were noticed between the groups with regard to sleep stage percentages.
SDB was present in 86.6% (26/30) of obesity subjects, of whom 80% (24/30) had mild, moderate and severe OSA (with 2/3rd having moderate to severe OSA and more than half having severe OSA), and 6.6% (2/30) had Upper Airway Resistance Syndrome (UARS) or Respiratory Effort Related Arousal (RERA). Obesity Hypoventilation Syndrome (OHS) co-existed in 37.5% (9/24) of subjects with OSA constituting one-third of total cases. PLMS co-existed in 7 subjects with OSA. All 6 morbidly obese subjects had some form of SDB with OSA in 5 and RERA in 1 of them.
Among the control subjects, 50% had a normal sleep study and others had only mild (40%; 4/10) and moderate OSA (10%; 1/10), while none had severe OSA. Further, OSA coexisted with PLMS in only 1 subject.
Conclusions: Mean AHI is higher among the subjects of obesity group as compared to nonobese subjects. Mean AHI is also higher among the obese males, those having NC between 35 to < 45 cms, symptomatics, those having 4 to 6 number of symptoms, and those having co-morbidities in comparison to the respective non-obese subjects. The obese subjects sleep for less time taking longer time to sleep, have higher number of arousals and PLMS per hour, and have greater nocturnal oxygen de-saturation (NOD) than the non-obese. OSA is present in 80% of subjects with obesity and SDB exists in all morbidly obese subjects. A need exists for all obese subjects to undergo a thorough clinical assessment with inclusion of a sleep history, a polysomnographic evaluation and an arterial blood gas analysis to detect and manage SDB early.
Hensrud DD, Klein S. Extreme obesity: a new medical crisi in the United States. Mayo Clin Proc 2006; 81 (10 suppl): S5- S10.
Deitel M. Overweight and obesity worldwide now estimated to involve 1.7 billion people. Obesity Surgery 2003; 13: 329- 330.
Wang Y, Beydoun MA. The obesity epidemic in United States- Gender, age, socioeconomic, racial/ethnic and geographic characteristics: a systematic review and meta regression analysis. Epidemiologic Review 2007; 29(1):6-28.
Dixon JB, Schacter LM, O'Brien PE. Predicting sleep apnea and excessive daytime sleepiness in the severely obese. Chest 2003; 123: 1134-1141.
Kyzer S, Charuzi I. Obstructive sleep apnea in the obese. World J Surg 1998; 22: 998-1001.
Sergi M, Rizzi M, Comi AL, et al. Sleep apnea in moderatesevere obese patients. Sleep Breath 1999; 3(2): 47-52.
Valencia-Flores M, Orea A, Castano VA, et al. Prevalence of sleep apnea and electrocardiographic disturbances in morbidly obese patients. Obesity Research 2000; 8: 262-269.
Udwadia ZF, Doshi AV, Lonkar SG, Singh CI. Prevalence of sleep disordered breathing and sleep apnea in middle aged urban Indian men. Am J Respir Crit Care Med 2004; 169: 168-173.
WHO Expert Consultation. Appropriate body-mass index for Asian populations and its implication for policy and intervention strategies. Lancet 2004; 363 (9403): 157- 163.
Johns MW. A new method for measuring daytime sleepiness: the Epworth Sleepiness Scale. Sleep 1991; 14: 540-545.
Feinsilver SH. Current and future methodology for monitoring sleep. Clinic Chest Med 1998; 19 (1): 213-218.
Laube DI, Gay PC, Strohl KP, Pack AI, White DP, Collop NA. Indications for positive airway pressure treatment of adult obstructive sleep apnea patients. A consensus statement. Chest 1999; 115 (3) : 863-866.
Guilleminault C, Stoohs R, Clerk A, Cetel M, Maistros P. A cause of excessive daytime sleepiness. The upper airway resistance syndrome. Chest 1993; 104: 781-787.
Guilleminault C, Stoohs R, Clerk A, Simmons JL. From obstructive sleep apnea syndrome to upper airway resistance syndrome: consistency of daytime sleepiness. Sleep 1992;15:S13-S16.
The Report of American Academy of Sleep Medicine Task force. Sleep- related breathing disorders in adults: recommendation for syndrome definition and measurement techniques in clinical research. Sleep 1999; 22 (5): 667- 689.
Olson AL, Zwillich C. The obesity hypoventilation syndrome. Am J Med 2005;118:948-956.
Levi-Valensi P, Weitzenblum E, Rida Z, et al. Sleep related oxygen desaturation and daytime pulmonary hemodynamics in COPD patients. Eur Respir J. 1992; 5 (3): 301-307.
British Thoracic Society. Facilities for the diagnosis and treatment of abnormal breathing during sleep including nocturnal ventilation. BTS News 1990; 5: 7-10.
The Atlas Task Force. Recording and scoring leg movements. Sleep 1993; 16(8):749-759.
Hening WA, Allen RP, Earley CJ, Picchietti DL, Silber MH. An update on the dopaminergic treatment of restless legs syndrome and periodic limb movement disorder. Sleep 2004; 27(3):560-83.
American Sleep Disorders Association. International classification of sleep disorders, revised: diagnostic and coding manual. Rochester, MN : American Sleep Disorders Association, 1997.
Trenkwalder C, Walters AS, Hening W. Periodic limb movements and restless legs syndrome. Neurol Clin 1996; 14: 629-650.
Vgontzas AN, Tan TL, Bixler EO, Martin LF, Shubert D, Kales A. Sleep apnea and sleep disruption in obese patients. Arch Intern Med 1994; 154: 1705-1711.
Peppard PE, Young T, Palta M, Dempsey J, Skatrud J. Longitudinal study of moderate weight change and sleepdisordered breathing. JAMA 2000; 284: 3015-3021.
Young T, Peppard PE, Taheri S. Excess weight and sleep disordered breathing. J Appl Physiol 2005; 99: 1592-1599.
Resta O, Foschino-Barbaro MP, Legari G, et al. Sleep related breathing disorders, loud snoring and excessive day time sleepiness in obese subjects. Int J obesity 2001;25: 669675.
Itasaka Y, Miyazaki S, Ishikawa K, Togawa K. The influence of sleep position and obesity on sleep apnea. Psychiatry and Clinical Neurosciences 2000; 54: 340-341.
Namyslowski G, Scierski W, Mrowka-Kata K, Kawecka I, Kawecki D, Czecior E. Sleep study in patients with overweight and obesity. J Physiol Pharmacol 2005; 56 Suppl 6: 59-65.
Redline S, Tishler PV, Hans MG, Tosteson TD, Strohl KP, Spry K. Racial differences in sleep-disordered breathing in Africans- Americans and Caucasians. Am J Resp Crit Care Med 1997; 155 (1): 186-192.
Carswell JJ, Koenig SM. Obstructive sleep apnea: Part I. Pathophysiology, diagnosis, and medical management. Journal of Long-term Effects of Medical Implants 2004; 14(3): 167- 176.
Young T, Shahar E, Nieto FJ, et al. Predictors of sleepdisordered breathing in community-dwelling adults: the Sleep Heart Health Study. Arch Intern Med 2002; 162: 893–900.
Redline S, Strohl KP. Recognition and consequences of obstructive sleep apnea hypopnea syndrome. Clin Chest Med 1998; 19(1): 1-19.
Sharma SK, Kurian S, Malik V, et al. A stepped approach for prediction of obstructive sleep apnea in overtly asymptomatic obese subjects: a hospital based study. Sleep Med 2004; 5 (4): 351-357.
Olson LG, Cole MF, Ambrogetti A. Correlations among Epworth sleepiness scale scores, multiple sleep latency tests & psychological symptoms. J Sleep Res 1998;7:248-253.
Punjabi NM, O'Hearn DJ, Neubauer DN, et al. Modeling hypersomnolence in sleep-disordered breathing: a novel approach using survival analysis. Am J Respir Crit Care Med 1999; 159: 1703–1709.
Polysomnographic Task Force, American Sleep Disorders Association Standards of Practice Committee. Practice parameters for the indications for polysomnography and related procedures. Sleep 1997; 20: 406-422.
Sjostrom C, Lindberg E, Elmasry A, Hagg A, Svardsudd K, Janson C. Prevalence of sleep apnea and snoring in hypertensive men: a population based study. Thorax 2002; 57(7): 602-607.
Dhouib A, Ayad M, Harrabi S, Beltaief N, Gouiaa R, Baccour M. Obstructive sleep apnea in patients with refractory hypertension: prevalence and severity in Tunisian population. Chest 2007; 132(4): 644 S.
Shahar E, Whitney CW, Redline, et al. Sleep disordered breathing and cardiovascular disease: cross-sectional results of the Sleep Heart Health Study. Am J Respir Crit Care Med 2001; 163 (1): 19-25.
Hui DSC, Choy DKL, Wong LKS, et al. Prevalence of sleepdisordered breathing and continuous positive airway pressure compliance: results in Chinese patients with first-ever ischaemic stroke. Chest 2002; 122: 852-860.
West SD, Nicoll DJ, Stradling JR. Prevalence of obstructive sleep apnoea in men with type 2 diabetes. Thorax 2006;61(11): 945-950.
Sharma SK, Reddy, Mohan A, Handa KK, Mukhopadhyay S, Pande JN. Sleep disordered breathing in chronic obstructive pulmonary disease. Indian J Chest Dis Allied Sci 2002; 44(2): 99-105.
Sanders MH, Newman AB, Haqqerty CL, et al. Sleep and sleep-disordered breathing in adults with predominantly mild obstructive airway disease. Am J Respir Crit Care Med 2003; 167(1): 7-14.
Vgontzas AN, Legro RS, Bixler EO, Grayev A, Kales A, Chrousos GP. Polycystic ovary syndrome is associated with obstructive sleep apnea and daytime sleepiness: Role of insulin resistance. J Clin Endocrinol Metab 2001; 86 (2): 517-520.
McTigue K, Larson JC, Valoski A, et al. Mortality and cardiac and vascular outcomes in extremely obese women. JAMA 2006; 296: 79-86.
Must A, Spadano J, Coakley EH, Field AE, Colditz G, Dietz WH. The disease burden associated with overweight and obesity. JAMA 1999; 282: 1523-1529.
Foster GD, Sanders MH, Millman R, et al. Obstructive sleep apnea among obese patients with type 2 diabetes. Diabetes Care 2009; 32: 1017–1019.
Worsnop CJ, Naughton MT, Barter CE, Morgan TO, Anderson AI, Pierce RJ. The prevalence of obstructive sleep apnea in hypertensives. Am J Respir Crit Care Med 1998; 157 (1): 111-115.
Rasmussen MH, Wildschiodtz G, Juul A, Hilsted J. Polysomnographic Sleep, Growth Hormone Insulin-like Growth Factor-I Axis, Leptin, and Weight Loss. Obesity 2008;16:1516-1521.
Liu X, Forbes EE, Ryan ND, Rofey D, Hannon TS, Dahl RE. Rapid eye movement sleep in relation to overweight in children and adolescents. Arch Gen Psychiatry. 2008; 65(8): 924–932.
Misra A, Chowbey P, Makkar BM, et al. Consensus statement for diagnosis of obesity, abdominal obesity and the metabolic syndrome for Asian Indians and recommendations for physical activity, medical and surgical management. J Assoc Physicians India 2009; 57:163-170.
Pressman MR. Primer of polysomnogram interpretation. Boston: Butterworth Heinemann.2002.
Dauvilliers Y, Pennestri MH, Petit D, Dang-Vu T, Lavigne G, Montplaisir J. Periodic leg movements during sleep and wakefulness in narcolepsy. J Sleep Res 2007; 16: 333–339.
Yu X, Fujimoto K, Urushibata K, Matsuzawa Y, Kubo K. Cephalometric analysis in obese and non obese patients with obstructive sleep apnea syndrome. Chest 2003; 124: 212- 218.
Antczak J, Horn B, Richter A, Jernajczyk W, Bodenschatz R, Schmidt EW. The influence of obesity on sleep quality in male sleep apnea patients before and during therapy. J Physiol Pharmacol 2008; 59: S123–S134.
Seicean S, Kirchner HL, Gottlieb DJ, et al. Sleep-disordered breathing and impaired glucose metabolism in normal-weight and overweight/obese individuals. Diabetes Care 2008; 31:1001–1006.
Pillar G, Shehadeh N. Abdominal fat and sleep apnea: the chicken or the egg? Diabetes Care 2008; 31: S303– S309.
Hilloowalla RA, Trent B, Gunel E, Pifer RG. Proposed cephalometric diagnosis for osteogenic obstructive sleep apnea (OSA): the mandibular/pharyngeal ratio. Cranio 1999; 17: 280-288.
Ng TP, Seow A, Tan WC. Prevalence of snoring and sleep related breathing disorders in Chinese, Malay and Indian adults in Singapore. Eur Respir J 1998;12;198-202.
Frey WC, Pilcher J. Obstructive sleep-related breathing disorders in patients evaluated for bariatric surgery. Obesity Surgery 2003; 13 (5): 676-683.
Mokhlesi B, Tulaimat A. Recent advances in obesity hypoventilation syndrome. Chest 2007; 132: 1322-1336.
Rao A, Tey BH, Ramalingam G, Poh AGH. Obstructive sleep apnoea (OSA) patterns in bariatric surgical practice and response of OSA to weight loss after laparoscopic adjustable gastric banding (LAGB). Ann Acad Med Singapore 2009; 38: 587-93.