How Socioeconomics Impacts Proper Sleep Apnea Diagnosis And Treatment

This article discusses why people from lower socioeconomic backgrounds are disproportionately effected by sleep apnea.

A wide range of serious health problems disproportionately afflict individuals from economically disadvantaged backgrounds. These conditions, which reduce quality of life and shorten lifespan, include heart disease, stroke, diabetes, asthma, and cancer. Other health problems commonly associated with poverty are obesity, pregnancy complications, increased infant mortality, HIV/AIDS and dental disease. The U.S. Department of Health and Human Service's "Healthy People 2020," which sets 10-year national objectives for improving the health of the nation, has prioritized the need to close the gap in these "health disparities." There are numerous potential targets for improving the health of low-income people, such as improving nutrition and access to health care. In addition, accumulating research points to a need to improve sleep as means for improving alertness and daily functioning, as well as for reducing the risk of developing chronic diseases such as diabetes and heart disease.

Sleep disorders and sleep deficiency (akin to a vitamin deficiency, reflecting a lack of an essential ingredient for healthy functioning) afflict a high proportion of both children and adults. Notably, individuals from disadvantaged neighborhoods and racial/ethnic minorities are at increased risk for poor sleep and for sleep disorders due to a variety of environmental exposures, occupational and psychosocial conditions, and possibly genetic factors. As will be discussed next week by Drs. Buxton and Okechukwu, persons of color and from poor neighborhoods are significantly more likely to be sleep-deprived and to have poor sleep quality, which often leads to elevations in blood pressure, abnormalities in blood sugar, weight gain and obesity, and other health problems.

The sleep disorder sleep apnea is also especially common in minority groups and individuals from disadvantaged neighborhoods. This disorder occurs when the throat closes during sleep, resulting in snoring (vibration of the tissues of the throat as the air passages narrow and increase) and periods when breathing briefly but repeatedly stops ("apnea"=no breathing). These interruptions in breathing, which may occur hundreds of times during the night in individuals with sleep apnea, can lead to marked decreases in the body's oxygen levels, frequent awakenings, release of stress hormones, and marked spikes in blood pressure. These stresses, however, are not confined to the night, but also often lead to persistent physiological abnormalities that affect the cardiovascular and endocrine systems. In fact, sleep apnea results in a marked increase in risk for developing high blood pressure, heart failure, stroke, diabetes, abnormal heart rhythms (atrial fibrillation), and early death. Sleep apnea is also is associated withpregnancy complications. In children, sleep apnea is associated with elevations in blood pressure, a predisposition to diabetes, and behavioral problems such as attention-deficient hyperactivity disorder.

Why are minority and low-income people at increased risk for sleep apnea? The answer is not completely clear, but it appears that some of the risk is associated with elevated exposure to poor air quality due to environmental tobacco smoke and air pollution-factors that may cause chronic inflammation of the tissues near the throat. The increased risk is partly associated with higher frequencies of overweight, which itself may be a result of sleep deprivation, a cause of overeating. Sleep apnea tends to run in families, and it appears that genetic factors may also contribute to disease risk.

Despite the relatively high prevalence of sleep apnea in low-income populations, it is often under-recognized and inadequately treated in these groups. Recognition may be hampered when individuals do not receive regular medical care, when health care providers only focus on their patient's known medical problems and do not ask about sleep problems, when patients themselves do not recognize the potential dangers of their poor sleep and snoring and do not discuss these issues with their doctors.

Treatment of sleep apnea also is often inadequate in individuals with more limited resources. The "gold standard" treatment of sleep apnea involves using a device on a nightly basis that keeps the throat from collapsing (a CPAP machine). This treatment is highly effective, but often requires initial support from an experienced team of sleep specialists to make sure the device is properly fit for the patient, who may need to be supported while adjusting to this new treatment. This requires a solid partnership between the patient and medical team, which sadly, is less common for many low-income patients. Research indeed shows that use of prescribed CPAP is often suboptimal in minority and low-income patients. Thus, it is likely that large numbers of patients with sleep apnea are left undiagnosed and/or untreated for a treatable condition that can have profound health effects.

Colleen Lance

Recognizing the importance of this emerging public health issue, this past June, Harvard University and its partner institutions sponsored a symposium "Sleep Health Disparities: Opportunities to Improve the Health of the Community" to bring together experts in health disparities research, sleep medicine, population health, community outreach, and environmental science to foster new dialogue, consider emerging questions, and identify important next steps to move forward the field of sleep health disparities. Presenters and participants explored the mediating role of sleep disorders in health disparities, potential mechanisms linking sleep disorders to chronic health conditions, and barriers to clinical recognition and treatment of sleep deficiency and sleep disorders in disadvantaged populations. Participants endorsed a need to better identify the determinants of poor sleep in low-income populations, including focusing on risk factors operating in households and the work place and behaviors that influence parents and their children. The consensus: a clear need to improve recognition of sleep apnea by primary care providers and to understand how to best support treatment in minority and low-income populations.

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