Citation Information :
Joshi JM, Karkhanis VS. Obstructive sleep apnoea (OSA) in octroi employees of Mumbai: Evaluation of waist circumference, diabetes mellitus, metabolic syndrome as risk factors. Indian Sleep Med 2009; 4 (3):100-105.
Background: Obstructive sleep apnea (OSA), a complex disease is a growing health concern globally. Various global epidemiological studies have demonstrated prevalence of obstructive sleep apnea to vary from 0.3% to 5.1 %. Clinical scores (CS) are useful to estimate individuals at risk for OSA and predict prevalence of OSA in community based studies. Waist circumference, diabetes mellitus and metabolic syndrome are emerging as important risk factors for OSA. During a preventive health check Octroi employees were found to have sedentary habits and were hence assessed for OSA and its risk factors.
Aims and objective: The aims of the study were i) study the overall health status ii) estimate individuals at risk for OSA using the CS and iii) study waist circumference, diabetes mellitus and metabolic syndrome as a risk factor for OSA.
Methods: 262 Octroi employees, who received preventive health check up at the tertiary care hospital in Mumbai, were invited to participate in the study. A questionnaire was used to assess their demographic characteristics, diet, life styles, and medical history. Body mass index (BMI) was calculated as (weight in kg) / (height in meter)2. Waist circumference measurements were made directly above the iliac crest with minimal respiration. Laboratory investigations included complete haemogram, blood sugar estimation, and lipid profile and thyroid function tests. CS included the following parameters 1) loud, habitual snoring 2) interrupted breathing, both reported to the patient by spouse or family members 3) excessive day time sleepiness as evidenced by napping in company or while driving, and/or difficulty in staying awake in quiet surroundings 4) obesity, defined as BMI ≥25kg/m2 5) essential hypertension, identified by the use of hypotensive medications or a BP >/= 140/90 mm of Hg on more than two separate occasions. Each feature was assigned a score of 1 with a possible maximum score of 5. A score of more than 3 was used to predict individuals at risk for presence of OSA. Metabolic syndrome was diagnosed if 3 out of 5 following variables were present 1) hypertension (BP ≥130/≥85mm of Hg), 2) insulin resistance or glucose intolerance BS≥110 mg%), 3) Low HDL cholesterol <40mg% (men), <50mg% (women), 4) elevated triglycerides (>150mg%), 5) abdominal obesity – waist circumference >35inches. Statistical analysis was employed to estimate the association of significant CS with waist circumference, diabetes mellitus and metabolic syndrome.
Results: CS >3 indicating at risk for OSA was present in 12 (4.58%) employees. Ten (83.33%) patients with CS >3, had waist circumference >35 inches. The association of waist circumference was superior to body mass index (table 1). Metabolic syndrome (p 0.0000353), waist circumference (p 0.0015) but not diabetes mellitus (p 0.6374) showed statistically significant correlation with CS. (table 2)
Conclusion: The risk for OSA using CS was thus 4.58% in the study population. Waist circumference and metabolic syndrome were independent risk factors for OSA.
Young T, Peppard PE, Gottlieb DJ. Epidemiology of obstructive sleep apnea: a population health perspective. Am J Respir Crit Care Med 2002; 165:1217-39
Turkington PM, Sircar M, Sarralaya D, Elliottaet M W. Time course of changes in driving simulator performance with and without treatment in patients with sleep apnoea/ hypoapnoea syndrome. Thorax 2004; 59:56-59.
Engelman HM, Martin SE, Dreay IJ, Douglas NJ. Effect of CPAP Therapy on daytime function in patients with mild sleep Apnoea/hypoapnoea syndrome. Thorax 1997; 52:114-19.
George CF. Reduction in motor vehicle collisions following treatment of sleep apnoea with nasal CPAP. Thorax 2001; 56:508-12.
Young T, Palta M, Dempsey J. Skatrud J, Weber S, Badr S. Occurrence of sleep disordered breathing among middleaged adults. N Engl J Med.1993; 328:1230-35.
Sharma S K, Kumpawat S, Banga A, Goel A. Prevalence and Risk factors of Obstructive Sleep Apnea Syndrome in Population of Delhi, India. Chest.2006; 130:56.
Vijayan VK, Patial K. Prevalence of Obstructive Sleep Apnea Syndrome in Delhi, India. Chest 2006; 130:92.
Saxena S, Gothi D, Joshi JM. Prevalence of symptoms and risk of sleep disordered breathing in Mumbai (India). Indian J Sleep Med 2006; 11:27-31.
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: 168-73.
Reddy EV, Kadhiravan T, Mishra HK, Sreenivas V, Handa KK, Sinha S, Sharma SK. Prevalence and risk factors of obstructive sleep apnea among middle-aged urban Indians: a community-based study. Sleep Med. 2009; 10:913-18.
Ohayon M, Guillemenault C, Priest RG, Caulet M. Snoring breathing pauses during sleep: telephone interview survey of a UK population sample. BMJ 1997; 314:860-63.
Bearpark H, Elliott L, Grunstein R, Cullen S, Schneider H, Altaus W, Sllivan C. Snoring and sleep apnea: a population study in Australian Men. Am J Respir Crit Care Med 1995; 151:1459-65
Oslon LG, King MT, Hensley MJ, Saunders NA. A community study of snoring and sleep-disordered breathing: prevalence. Am J Respir Crit Care Med 1995; 152:711-16.
Gislason T, Almqvist M, Eriksson G, Taube A, Boman G. Occurrence of sleep apnoea syndrome among Swedish men: an epidemiological study. J clin Epidemiol 1988; 571- 76.
Lavie P. Incidence of sleep apnoea in a presumably healthy working population. Sleep 1983; 6:312-18
Pack AI, Dinges DF, Maislin G. A study of prevalence of sleep apnoea among commercial truck drivers. FMCSA, Publication No. DOT-RT-02-030, Washington, DC, 2002.
Hiestand DM, Britz P, Goldman M, Phillips B. Prevalence of symptoms and risk of sleep apnea in the US population: Results from the national sleep foundation sleep in America 2005 poll. Chest 2006; 130:780-86.
Williams AJ, Yu G, Santiago S, Stein M. Screening for sleep apnea using pulse oximetry and a clinical score. Chest 1991; 100:631-35.
Johns MW: A new method for measuring daytime sleepiness: the Epworth Sleepiness Scale. Sleep 1991; 14:540-45.
Deegan PC, McNicholas WT. Predictive value of clinical features for the obstructive sleep apnoea syndrome. Eur Respir J 1996; 9:117–24.
Hoffstein V, Szalai JP. Predictive value of clinical features in diagnosing obstructive sleep apnea. Sleep 1993; 16:118–22.
Crocker BD, Olson LG, Saunders NA, Hensley MJ, McKeon JL, Allen KM, Gyulay SG. Estimation of the probability of disturbed breathing during sleep before a sleep study. Am Rev Respir Dis 1990; 142:14–18.
Rauscher H, Popp W, Zwick H. Model for investigating snorers with suspected sleep apnea. Thorax 1993; 48:275– 79.
Flemons WW, McNicholas WT. Clinical prediction of the sleep apnoea syndrome. Sleep Medicine 1997; 1:19-32.
Rowley JA, Aboussouan LS, Badr MS. The use of clinical prediction formulas in the evaluation of obstructive sleep apnoea. Sleep 2000; 23:929-8.
Dixon JB, Schachter LM, O'Brien PE. Predicting sleep apnea and excessive day sleepiness in the severely obese: indicators for polysomnography. Chest 2003; 123:1134-41
Schafer H, Ewig S, Harper E, Luderitz B. Predictive diagnostic value of clinical assessment and non laboratory monitoring system recording in patients with symptoms suggestive of obstructive sleep apnea syndrome. Sleep 2000; 23: 929-38.
Santaolalla Montoya F, Iriondo Bedialauneta JR, Aguirre Larracoechea U, Martinez Ibargüen A, Sanchez Del Rey A, Sanchez Fernandez JM. The predictive value of clinical and epidemiological parameters in the identification of patients with obstructive sleep apnoea (OSA): a clinical prediction algorithm in the evaluation of OSA. European Archives of Oto-Rhino-Laryngology 2007; 264:637-43.
Mulgrew AT, Fox N, Ayas NT. Diagnosis and initial management of obstructive sleep apnoea without polysomnography; A randomized validation study. Ann Intern Med 2007; 146:157-66.
Viner S, Szalai JP, Hoffstein V. Are history and physical examination a good screening test for sleep apnea? Ann Intern Med 1991;115:356–59.
Antonio P, Michela D, Nicoletta C, Giuseppe R, Ilaria D'Amico, Ferruccio S, Aldo P. Sleep Apnea in Morbidly Obese Patients: Prevalence and Clinical Predictivity. Respiration 2009; 78:134–40.
Flemons WW, Whitelaw WA, Brant R, Remmers JE. Likelihood ratios for a sleep apnea clinical prediction rule. Am J Respir Crit Care Med. 1994; 150:1279-85.
Bertrand H, Nicolas R, Matthieu C, Catherine R, Vincent P, Gérard H. Value of Clinical, Functional, and Oximetric Data for the Prediction Obstructive Sleep Apnea in Obese Patients. Chest 1999; 116:1537–44.
McNicholas WT. Diagnosis of Obstructive Sleep Apnea in Adults Proc Am Thorac Soc 2008; 5:154–60.
Dhurandhar NV, Kulkarni PR. Prevalence of Obesity in Bombay. Int J Obes Relat Metab Disord 1992; 16:367-75.
Carotenuto M, Bruni O, Santoro N, Giudice E, Perrone L, Pascotto A. Waist circumference predicts the occurrence of sleep-disordered breathing in obese children and adolescents: A questionnaire-based study. Sleep Medicine 2006; 7:357-61.
Gruber A, Horwood F, Sithole J, Ali NJ, and Idris I. Obstructive sleep apnoea is independently associated with the metabolic syndrome but not insulin resistance state. Cardiovasc Diabetol 2006; 5:22.
Rivera CM, Abad J, Fiz JA, Rios J, Morera J. Usefulness of truncal obesity indices as predictive factors for obstructive sleep apnea syndrome. Obesity 2008; 16:113- 18.
Dixon JB, Schachter LM, O'Brien PE. Sleep Disturbance and Obesity. Arch Intern Med 2001; 161:102-06.
Rheeder P, Stolk RP, Veenhouwer J F, Grobbee DE .The metabolic syndrome in black hypertensive women–waist circumference more strongly related than body mass index. Afr Med J 2002; 92: 637–41.
Savva SC, Tornaritis M, Savva ME, Kourides Y Panagi A, Silikiotou N, Georgiou C, Kafatos A. Waist circumference and waist-to-height ratio are better predictors of cardiovascular disease risk factors in children than body mass index. Int J Obes Relat Metab Disord 2000; 24:1453–58.
Lee S, Bacha F, Arslanian SA. Waist circumference, blood pressure, and lipid components of the metabolic syndrome. J Pediatr 2006; 149:809-16.
Maffeis C, Corciulo N, Livieri C, Rabbone I, TrifiròG, Falorni A, et al. Waist circumference as a predictor of cardiovascular and metabolic risk factors in obese girls. Eur J Clin Nutr 2003; 57:566–72.
Janssen I, Heymsfield SB, Allison DB, Kotler DP, Ross R. Body mass index and waist circumference independently contribute to the prediction of non abdominal, abdominal subcutaneous and visceral fat. Am J Clin Nutr 2002; 75:683–88.
Onat A, Avci GS, Barlan MM, Uyarel H, UzunlarB, Sansoy V. Measures of abdominal obesity assessed for visceral adiposity and relation to coronary risk. Int J Obes 2004; 28:1018–25.
Deepa R, Sandeep S, Mohan V. Abdominal obesity, visceral fat and type 2 diabetes - ‘Asian Indian phenotype’. In: Mohan V, Gundu Rao, eds. Type 2 diabetes in South Asians: Epidemiology, risk factors and prevention. Jaypee Brothers Medical publishers 2006; 138-52.
Nieto FJ, Young TB, Lind BK, Shahar E, Samet JM, Redline S, et al. Association of sleep disordered breathing, sleep apnea, and hypertension in a large community-based study. JAMA 2000; 283:1829–36.
Lavie P, Herer P, Hofstein V. Obstructive sleep apnea as a risk factor for hypertension: population study. BMJ 2000; 320:479-82.
Peker Y, Hedner J, Norum J, Kraiczi H, Carlson J. Increased incidence of cardiovascular disease in middle-aged men with obstructive sleep apnea: a 7-year follow-up. Am J Respir Crit Care Med 2002; 166:159–65.
Kaneko Y, Floras JS, Usui K, Plante J, Tkacova R, Kubo T, Ando S, Bradley TD. Cardiovascular effects of continuous positive airway pressure in patients with heart failure and obstructive sleep apnea. N Engl J Med 2003; 348:1233–41.
Yaggi HK, Concat J, Kernan WN, Lichtman JH, Brass LM, Mohsenin V. Obstructive sleep apnea as a risk factor for stroke and death. N Engl J Med 2005; 343:2034–41.
Babu AR, Herdegen J, Fogelfeld L, Shott S, Mazzone T. Type 2 diabetes, glycemic control, and continuous positive airway pressure in obstructive sleep apnea. Arch Intern Med 2005; 165:447–52.
Goncalves MA, Guilleminault C, Ramos E, Palha A, Paiva T. Erectile dysfunction, obstructive sleep apnea syndrome, and nasal CPAP treatment. Sleep Med 2005; 6:333–39.
Ip MS, Lam B, Ng MM, WK, Tsang KW, Lam KS. Obstructive Sleep apnea is independently associated with insulin resistance. Am J Respir Crit Care Med 2002; 165:670-76.
Punjabi NM, Sorkin JD, Katzel LI Goldberg AP, Schwartz AR, Smith PL. Sleep-disordered breathing and insulin resistance in middle aged. And overweight men. Am J Respir Crit Care Med 2002; 165:677-82.
Wilcox I, McNamara SG, Collins FL, et al. Syndrome Z: the interaction of sleep apnoea, vascular risk factors and heart disease. Thorax 1998; 53:S25–S28.
Kanbay A, Ulukavak T, Kokturk O et al. Could Obstructive Sleep Apnea Syndrome be a Component of Metabolic Syndrome? Turk J Med Sci 2009; 39 : 161-66
Sasanabe R, Banno K, Otake K, et al. Metabolic syndrome in Japanese patients with obstructive sleep apnea syndrome. Hypertens Res 2006; 29:315– 22.
Coughlin SR, Mawdsley L, Mugarza JA, et al. Obstructive sleep apnea is independently associated with an increased prevalence of metabolic syndrome. Eur Heart J 2004; 25:735–41
Vgontzas AN, Bixler EO, Chrousos GP. Sleep apnea is a manifestation of the metabolic syndrome. Sleep Med Rev. 2005; 9:211–24.
Coughlin S, Calverley P, Wilding J. Sleep disordered breathing – a new component of syndrome x? Obes Rev. 2001; 2:267–74.
Parish JM, Adam T, Facchiano L. Relationship of metabolic syndrome and obstructive sleep apnea. J Clin Sleep Med. 2007; 3:467–72.
Kostoglou-Athanassiou É, Athanassiou P. Metabolic syndrome and sleep apnea. Hippokratia 2008, 12, 2: 81- 86