@article {701, title = {Measures of cognitive function in persons with varying degrees of sleep-disordered breathing: the Sleep Heart Health Study.}, journal = {J Sleep Res}, volume = {11}, year = {2002}, month = {2002 Sep}, pages = {265-72}, abstract = {

Epidemiologic literature suggests that persons with clinically diagnosed sleep apnoea frequently have impaired cognitive function, but whether milder degrees of sleep-disordered breathing (SDB) are associated with cognitive dysfunction in the general population is largely unknown. Approximately 1700 subjects free of clinically diagnosed SDB underwent at-home polysomnography (PSG) as part of the Sleep Heart Health Study (SHHS) and completed three cognitive function tests within 1-2 years of their PSG: the Delayed Word Recall Test (DWR), the WAIS-R Digit Symbol Subtest (DSS), and the Word Fluency test (WF). A respiratory disturbance index (RDI) was calculated as the number of apnoeas and hypopnoeas per hour of sleep. After adjustment for age, education, occupation, field centre, diabetes, hypertension, body-mass index, use of CNS medications, and alcohol drinking status, there was no consistent association between the RDI and any of the three cognitive function measures. There was no evidence of a dose-response relation between the RDI and cognitive function scores and the adjusted mean scores by quartiles of RDI never differed from one another by more than 5\% for any of the tests. In this sample of free-living individuals with mostly mild to moderate levels of SDB, the degree of SDB appeared to be unrelated to three measures of cognitive performance.

}, keywords = {Aged, Body Mass Index, Brain, Cognition Disorders, Cohort Studies, Female, Humans, Hypoxia, Male, Middle Aged, Neuropsychological Tests, Oxygen, Polysomnography, Severity of Illness Index, Sleep Apnea, Central}, issn = {0962-1105}, doi = {10.1046/j.1365-2869.2002.00308.x}, author = {Boland, Lori L and Shahar, Eyal and Iber, Conrad and Knopman, David S and Kuo, Tracy F and Nieto, F Javier} } @article {686, title = {Predictors of sleep-disordered breathing in community-dwelling adults: the Sleep Heart Health Study.}, journal = {Arch Intern Med}, volume = {162}, year = {2002}, month = {2002 Apr 22}, pages = {893-900}, abstract = {

BACKGROUND: Sleep-disordered breathing (SDB) is common, but largely undiagnosed in the general population. Information on demographic patterns of SDB occurrence and its predictive factors in the general population is needed to target high-risk groups that may benefit from diagnosis.

METHODS: The sample comprised 5615 community-dwelling men and women aged between 40 and 98 years who were enrolled in the Sleep Heart Health Study. Data were collected by questionnaire, clinical examinations, and in-home polysomnography. Sleep-disordered breathing status was based on the average number of apnea and hypopnea episodes per hour of sleep (apnea-hypopnea index [AHI]). We used multiple logistic regression modeling to estimate cross-sectional associations of selected participant characteristics with SDB defined by an AHI of 15 or greater.

RESULTS: Male sex, age, body mass index, neck girth, snoring, and repeated breathing pause frequency were independent, significant correlates of an AHI of 15 or greater. People reporting habitual snoring, loud snoring, and frequent breathing pauses were 3 to 4 times more likely to have an AHI of 15 or greater vs an AHI less than 15, but there were weaker associations for other factors with an AHI of 15 or greater. The odds ratios (95\% confidence interval) for an AHI of 15 or greater vs an AHI less than 15 were 1.6 and 1.5, respectively, for 1-SD increments in body mass index and neck girth. As age increased, the magnitude of associations for SDB and body habitus, snoring, and breathing pauses decreased.

CONCLUSIONS: A significant proportion of occult SDB in the general population would be missed if screening or case finding were based solely on increased body habitus or male sex. Breathing pauses and obesity may be particularly insensitive for identifying SDB in older people. A better understanding of predictive factors for SDB, particularly in older adults, is needed.

}, keywords = {Adult, Age Factors, Aged, Aged, 80 and over, Cohort Studies, Continental Population Groups, Female, Humans, Male, Middle Aged, Obesity, Predictive Value of Tests, Residence Characteristics, Risk Factors, Sex Factors, Sleep Apnea Syndromes, Snoring}, issn = {0003-9926}, doi = {10.1001/archinte.162.8.893}, author = {Young, Terry and Shahar, Eyal and Nieto, F Javier and Redline, Susan and Newman, Anne B and Gottlieb, Daniel J and Walsleben, Joyce A and Finn, Laurel and Enright, Paul and Samet, Jonathan M} } @article {688, title = {The relationship between chronically disrupted sleep and healthcare use.}, journal = {Sleep}, volume = {25}, year = {2002}, month = {2002 May 01}, pages = {289-96}, abstract = {

STUDY OBJECTIVES: To determine whether chronic sleep deprivation, sleep disruption, sleepiness, insomnia, and OSA are associated with increased healthcare use in a community-based population.

DESIGN: Cross-sectional study.

SETTING/PARTICIPANTS: 6440 Sleep Heart Health Study (SHHS) participants recruited from ongoing cohort studies.

INTERVENTIONS: N/A.

MEASUREMENTS: Polysomnography results (Apnea Hypopnea Index (AHI), percent of sleep time with oxyhemoglobin saturation below 90\% (CT90), arousal index) as well as data on sleep related symptoms, medication use, and chronic illness. The indirect measure of predicted healthcare utilization was the modified Chronic Disease Score (CDS) calculated from medication data.

RESULTS: After adjustment for age, gender, BMI and study site, subjects in the highest quartiles of AHI, CT90 and Epworth score had CDS that were 6\%-9\% higher than the lowest quartiles. The adjusted mean CDS for subjects with sleep apnea was similar to that for subjects with hypertension, chronic bronchitis or asthma and 18\% greater than the mean CDS for subjects without sleep apnea. Among subjects who did not have significant sleep-disordered breathing, complaints of insomnia, sleepiness, fatigue, and not getting enough sleep were associated with increased CDS.

CONCLUSIONS: This study demonstrated an association between subjective complaints of daytime sleepiness, inadequate sleep time, insomnia as well as objective measures of severity of SDB, and an indirect measure of healthcare utilization in a community-based sample. Though the percent increases in healthcare utilization observed were modest, the prevalence of these factors in the general population is high, and may therefore be associated with a substantial cost burden to the healthcare system.

}, keywords = {Adult, Chronic Disease, Cohort Studies, Community Health Services, Cross-Sectional Studies, Disorders of Excessive Somnolence, Female, Health Status, Humans, Male, Middle Aged, Patient Acceptance of Health Care, Polysomnography, Prevalence, Severity of Illness Index, Sleep Apnea, Obstructive, Sleep Deprivation}, issn = {0161-8105}, author = {Kapur, Vishesh K and Redline, Susan and Nieto, F Javier and Young, Terry B and Newman, Anne B and Henderson, Jeffrey A} } @article {714, title = {Short-term variability of respiration and sleep during unattended nonlaboratory polysomnography--the Sleep Heart Health Study. [corrected].}, journal = {Sleep}, volume = {25}, year = {2002}, month = {2002 Dec}, pages = {843-9}, abstract = {

STUDY OBJECTIVES: To determine the short-term variability of indices of disturbed respiration and sleep during 2 nights of unattended nonlaboratory polysomnography conducted several months apart.

DESIGN: Participants were randomly selected using a block design with stratification on preliminary estimates of 2 criteria: respiratory disturbance index [RDI3\% (apnea or hypopnea events associated with > or = 3\% O2 desaturation): < 15/hour total sleep time, > or = 15/hour total sleep time] and sleep efficiency (SEff: < 85\% and > or = 85\%). The RDI and sleep data from initial and repeated polysomnography were compared.

SETTING: NA.

PARTICIPANTS: A subset of 99 participants in the Sleep Heart Health Study who agreed to have a repeat polysomnogram within 4 months of their original study.

INTERVENTIONS: NA.

MEASUREMENTS AND RESULTS: Acceptable repeat polysomnograms were obtained in 91 subjects (mean study interval: 77 +/- 18 [sd] days; range: 31-112 days). There was no significant bias in RDI between study nights using several different RDI definitions including RDI3\% and RDI4\% (apnea or hypopnea events associated with > or = 4\% O2 desaturation). Variability between studies estimated using intraclass correlations (ICC) ranged from 0.77 to 0.81. For subjects with a RDI3\% < 15, variability increased as a function of increasing RDI, but for those with a RDI3\% > or = 15, variability was constant. Body mass index, SEff, gender, or age did not directly predict RDI variability. Using RDI4\% cutpoints of < or = 5, < or = 10 and < or = 15 events per hour of sleep demonstrated that 79.1\%, 85.7\%, and 87.9\% of subjects, respectively, had the same classification of SDB status on both nights of study. There also was no significant bias in sleep staging, sleep efficiency, or arousal index between studies. However, variability was greater with ICC values ranging from 0.37 (\% time in REM) to 0.76 (arousal index).

CONCLUSION: In the Sleep Heart Health Study, accurate estimates of the severity of sleep-disordered breathing and the quality of sleep were obtained from a single night of unattended nonlaboratory polysomnography. These findings may be applicable to other large epidemiologic studies provided that similar recording techniques and quality-assurance procedures are followed.

}, keywords = {Adult, Aged, Aged, 80 and over, Apnea, Arousal, Body Mass Index, Circadian Rhythm, Electrocardiography, Electromyography, Electrooculography, Female, Humans, Male, Middle Aged, Oxygen Consumption, Polysomnography, Respiration, Sleep Apnea Syndromes, Sleep Stages, Time Factors}, issn = {0161-8105}, author = {Quan, Stuart F and Griswold, Michael E and Iber, Conrad and Nieto, F Javier and Rapoport, David M and Redline, Susan and Sanders, Mark and Young, Terry} } @article {744, title = {A prospective analysis of risk factors for white matter disease in the brain stem: the Cardiovascular Health Study.}, journal = {Neuroepidemiology}, volume = {22}, year = {2003}, month = {2003 Sep-Oct}, pages = {275-82}, abstract = {

BACKGROUND AND PURPOSE: White matter disease (WMD) in the brain stem may be a predictor of poor clinical outcome, independent of WMD in the periventricular and subcortical areas of the brain. Many cardiovascular risk factors such as older age, hypertension, and smoking have been suggested as risk factors for WMD in the periventricular and subcortical areas of the brain. However, no epidemiologic study has examined the associations between cardiovascular risk factors and WMD in the brain stem.

METHODS: A total of 789 participants, aged 65 years or older, from the Cardiovascular Health Study constituted the present study population. WMD, defined as hyperintensive lesions on magnetic resonance imaging (MRI), in the brain stem was measured in 1992/1993 and 1997/1998.

RESULTS: Of the 789 participants, 212 (26.9\%) had WMD in the brain stem in 1997/1998. In multivariate logistic regression analysis, the presence of WMD in the brain stem in 1997/1998 was significantly associated with several variables measured in 1992/1993: an increase by 5 years of age (OR = 1.51, 95\% CI: 1.25-1.83), a 10-pack-years increase in smoking (OR = 1.12, 95\% CI: 1.04-1.21), a 0.1-liter increase in first-second forced expiratory volume (OR = 0.95, 95\% CI: 0.92-0.99), a 1 micromol/l increase in fibrinogen level (OR = 1.13, 95\% CI: 1.03-1.23), and MRI infarction (OR = 2.58, 95\% CI: 1.78-3.74). Excluding those (n = 167) with WMD in the brain stem in 1992/1993, the pattern remained. Hypertension was not associated with WMD in the brain stem.

CONCLUSIONS: Increased age, smoking, lower forced expiratory volume, increased fibrinogen level, and MRI infarction, but not hypertension, may be independent risk factors for WMD in the brain stem in older adults.

}, keywords = {Age Factors, Aged, Brain Diseases, Brain Infarction, Brain Stem, Cardiovascular Diseases, Female, Fibrinogen, Forced Expiratory Volume, Humans, Magnetic Resonance Imaging, Male, Prospective Studies, Regression Analysis, Risk Factors, Smoking}, issn = {0251-5350}, doi = {10.1159/000071190}, author = {Ding, Jingzhong and Nieto, F Javier and Beauchamp, Norman J and Longstreth, W T and Manolio, Teri A and Hetmanski, Jacqueline B and Fried, Linda P} } @article {728, title = {Variation in symptoms of sleep-disordered breathing with race and ethnicity: the Sleep Heart Health Study.}, journal = {Sleep}, volume = {26}, year = {2003}, month = {2003 Feb 01}, pages = {74-9}, abstract = {

STUDY OBJECTIVES: To examine the relation of sleep-related symptoms to race and ethnicity in a diverse sample of middle-aged and older men and women.

DESIGN: Cross-sectional questionnaire survey.

SETTING: In the initial phase of the Sleep Heart Health Study, men and women enrolled in participating epidemiologic cohort studies were surveyed.

PARTICIPANTS: 13,194 men and women 40 years of age and older, including 11,517 non-Hispanic white, 648 black, 643 American Indian, 296 Hispanic, and 90 Asian-Pacific Islander.

INTERVENTIONS: Not applicable.

MEASUREMENTS AND RESULTS: After adjustment for BMI and other factors, frequent snoring was more common among Hispanic women (odds ratio (OR) = 2.25, 95\% confidence interval (CI) = 1.48, 3.42) and black women (OR = 1.55, 95\% Ci = 1.13, 2.13) than among non-Hispanic white women. Hispanic men were significantly more likely to report frequent snoring than non-Hispanic white men (OR = 2.30, 95\% CI = 1.43, 3.69). Black, American Indian, and Asian men did not differ significantly from white men in snoring prevalence. American Indian women were significantly more likely to report breathing pauses during sleep than their white, non-Hispanic counterparts (OR = 1.52, 95\% CI 1.03, 2.24), although polysomnography data on a subset of the sample suggested that the association between this symptom reported on questionnaire and objective evidence of sleep-disordered breathing may be weaker among American Indians than among other groups. Mean Epworth Sleepiness Scale scores were slightly higher in black men and women than in their white, non-hispanic counterparts.

CONCLUSIONS: Frequent snoring was more common among black and Hispanic women and Hispanic men than among their white non-Hispanic counterparts, even after adjusting for BMI and other factors. Further research including polysomnography and objective measurements of sleepiness is needed to assess the physiologic and clinical significance of these findings.

}, keywords = {Adult, Cross-Sectional Studies, Electroencephalography, Electrooculography, Ethnic Groups, Female, Heart Rate, Humans, Male, Polysomnography, Severity of Illness Index, Sleep Apnea Syndromes, Snoring, Surveys and Questionnaires}, issn = {0161-8105}, author = {O{\textquoteright}Connor, George T and Lind, Bonnie K and Lee, Elisa T and Nieto, F Javier and Redline, Susan and Samet, Jonathan M and Boland, Lori L and Walsleben, Joyce A and Foster, Gregory L} } @article {777, title = {Associations between gender and measures of daytime somnolence in the Sleep Heart Health Study.}, journal = {Sleep}, volume = {27}, year = {2004}, month = {2004 Mar 15}, pages = {305-11}, abstract = {

STUDY OBJECTIVES: To examine the relationship of gender to subjective measures of sleepiness, including the Epworth Sleepiness Scale (ESS), in a community-based population.

DESIGN: A cross-sectional study.

SETTING/PARTICIPANTS: Multicenter Sleep Heart Health Study participants (N = 6.440, 52\% women) recruited from ongoing cohort studies.

INTERVENTIONS: N/A.

MEASUREMENTS: Scores from the ESS, Sleep Heart Health Study daytime sleepiness and feeling unrested questions, polysomnography results (respiratory disturbance index at 4\% desaturation), as well as data on difficulty initiating and maintaining sleep, insufficient sleep, sedative use, alcohol use, cardiovascular or respiratory disease, frequent awakening due to leg cramps.

RESULTS: Women reported feeling sleepy as often as men did (odds ratio [OR] = 1.06; confidence interval [CI], 0.86-1.32), but women were less likely to have an ESS score > 10 (adjusted OR = 0.77; CI, 0.66-0.90) and more likely to report feeling unrested (adjusted OR = 1.39; CI, 1.14-1.69) than men. In men, the ESS score was more strongly correlated with reports of feeling unrested or sleepy compared to women.

CONCLUSIONS: Men and women answer questions on sleepiness differently. Findings indicate that using the ESS to detect subjective sleepiness is more likely to identify men with sleepiness. Since the ESS is more strongly related to other subjective measures in men, the ESS may be a more sensitive measure of subjective sleepiness in men than in women.

}, keywords = {Aged, Cardiovascular Diseases, Cohort Studies, Cross-Sectional Studies, Disorders of Excessive Somnolence, Female, Health Status, Humans, Hypertension, Male, Middle Aged, Polysomnography, Severity of Illness Index, Sex Factors}, issn = {0161-8105}, doi = {10.1093/sleep/27.2.305}, author = {Baldwin, Carol M and Kapur, Vishesh K and Holberg, Catharine J and Rosen, Carol and Nieto, F Javier} } @article {776, title = {Sleep and reported daytime sleepiness in normal subjects: the Sleep Heart Health Study.}, journal = {Sleep}, volume = {27}, year = {2004}, month = {2004 Mar 15}, pages = {293-8}, abstract = {

STUDY OBJECTIVES: To describe the distribution of nocturnal sleep characteristics and reports of daytime sleepiness in a large well-defined group of healthy adults.

DESIGN: The Sleep Heart Health Study is a multicenter study examining sleep and cardiopulmonary parameters through nocturnal polysomnography in adults enrolled in geographically distinct cardiovascular cohorts.

SETTING: Community setting.

PARTICIPANTS: 470 subjects enrolled in the Sleep Heart Health Study (n = 6440) were selected as a {\textquoteright}normative{\textquoteright} group based on screening of health conditions and daily habits that could interfere with sleep.

MEASUREMENTS AND RESULTS: Home-based nocturnal polysomnography was obtained on all participants and centrally scored for sleep and respiratory parameters. Demographic and health-related data were obtained and updated at the time of the home visit. Sleep efficiency decreased by 1.6\% for each 10 years of increased age. Sleep time decreased by 0.1 hours (6.0 minutes) for each 10-year age increase and was longer in women. The arousal index increased by 0.8 for each 10-year increase in age and was lower by 1.4 in women. Women had a lower mean percentage of stage 1 and stage 2 sleep. Mean percentage of slow-wave sleep was higher in women (by 6.7\%). Percentage of slow-wave sleep decreased with increased age for men only (by 1.9\% for each 10-year age change).

CONCLUSIONS: Data suggest a clear lessening in the quantity and quality of sleep with age that appears to be more rapid in males compared to females.

}, keywords = {Aged, Aged, 80 and over, Cardiovascular Diseases, Circadian Rhythm, Cohort Studies, Disorders of Excessive Somnolence, Female, Health Status, Humans, Male, Middle Aged, Polysomnography, Sleep, Sleep Stages, Surveys and Questionnaires}, issn = {0161-8105}, doi = {10.1093/sleep/27.2.293}, author = {Walsleben, Joyce A and Kapur, Vishesh K and Newman, Anne B and Shahar, Eyal and Bootzin, Richard R and Rosenberg, Carl E and O{\textquoteright}Connor, George and Nieto, F Javier} } @article {752, title = {Sleep apnea and markers of vascular endothelial function in a large community sample of older adults.}, journal = {Am J Respir Crit Care Med}, volume = {169}, year = {2004}, month = {2004 Feb 01}, pages = {354-60}, abstract = {

Clinical studies have suggested that sleep apnea is associated with impaired brachial artery flow-mediated dilation, a surrogate of endothelial dysfunction. We examined this question among older participants in the baseline examination of the Sleep Heart Health/Cardiovascular Health Study cohort (n = 1,037, age 68 years or older, 56\% female). Indices of sleep apnea, derived from 12-channel home polysomnography, were the apnea-hypopnea index (average number of apneas/hypopneas per hour) and the hypoxemia index (percentage of time below 90\% O2 saturation). Baseline arterial diameter and percentage of flow-mediated dilation were measured by ultrasound. Sleep apnea measures were associated with baseline diameter and the percentage of flow-mediated dilation, although these associations were weakened after adjustment for other cardiovascular risk factors, particularly body mass index. However, a statistically significant linear association between the hypoxemia index and baseline diameter was observed even after adjustment for body mass index and other confounders (p < 0.01). The associations were stronger among participants who were younger than 80 years and among those who with hypertension. This study adds to the growing body of evidence linking sleep apnea with vascular dysfunction in older subjects. Whether these relationships are entirely independent of obesity is unclear. This association might be one of the mechanisms explaining the relationship between sleep apnea, hypertension, and cardiovascular disease.

}, keywords = {Age Factors, Aged, Aged, 80 and over, Biomarkers, Body Mass Index, Brachial Artery, Cardiovascular Diseases, Cohort Studies, Comorbidity, Endothelium, Vascular, Female, Humans, Hypertension, Linear Models, Male, Polysomnography, Prevalence, Probability, Residence Characteristics, Risk Assessment, Sampling Studies, Severity of Illness Index, Sleep Apnea Syndromes, Ultrasonography, Doppler}, issn = {1073-449X}, doi = {10.1164/rccm.200306-756OC}, author = {Nieto, F Javier and Herrington, David M and Redline, Susan and Benjamin, Emelia J and Robbins, John A} } @article {822, title = {Age-dependent associations between sleep-disordered breathing and hypertension: importance of discriminating between systolic/diastolic hypertension and isolated systolic hypertension in the Sleep Heart Health Study.}, journal = {Circulation}, volume = {111}, year = {2005}, month = {2005 Feb 08}, pages = {614-21}, abstract = {

BACKGROUND: Sleep-disordered breathing (SDB) is associated with hypertension in the middle-aged. The association is less clear in older persons. Most middle-aged hypertensives have systolic/diastolic hypertension, whereas isolated systolic hypertension (ISH) is common among persons over 60 years. Mechanistically, only systolic/diastolic hypertension is expected to be associated with SDB, but few studies of SDB and hypertension distinguish systolic/diastolic hypertension from ISH. Prior investigations may have underestimated an association between SDB and systolic/diastolic hypertension in the elderly by categorizing individuals with ISH as simply hypertensive.

METHODS AND RESULTS: We conducted cross-sectional analyses of 6120 participants in the Sleep Heart Health Study, stratified by age: 40 to 59 (n=2477) and > or =60 years. Outcome measures included apnea-hypopnea index (AHI; average number of apneas plus hypopneas per hour of sleep), systolic/diastolic hypertension (> or =140 and > or =90 mm Hg), and ISH (> or =140 and <90 mm Hg). With adjustment for covariates, ISH was not associated with SDB in either age category. In those aged<60 years, AHI was significantly associated with higher odds of systolic/diastolic hypertension (AHI 15 to 29.9, OR=2.38 [95\% CI 1.30 to 4.38]; AHI > or =30, OR=2.24 [95\% CI 1.10 to 4.54]). Among those aged > or =60 years, no adjusted association between AHI and systolic/diastolic hypertension was found.

CONCLUSIONS: SDB is associated with systolic/diastolic hypertension in those aged <60 years. No association was found between SDB and systolic/diastolic hypertension in those aged > or =60 years or between SDB and ISH in either age category. These findings have implications for SDB screening and treatment. Distinguishing between hypertensive subtypes reveals a stronger association between SDB and hypertension for those aged <60 years than previously reported.

}, keywords = {Adult, Age Factors, Aged, Antihypertensive Agents, Cross-Sectional Studies, Diastole, Female, Humans, Hypertension, Male, Middle Aged, Risk Factors, Sleep Apnea Syndromes, Sleep Apnea, Central, Systole}, issn = {1524-4539}, doi = {10.1161/01.CIR.0000154540.62381.CF}, author = {Haas, Donald C and Foster, Gregory L and Nieto, F Javier and Redline, Susan and Resnick, Helaine E and Robbins, John A and Young, Terry and Pickering, Thomas G} } @article {834, title = {Association of sleep time with diabetes mellitus and impaired glucose tolerance.}, journal = {Arch Intern Med}, volume = {165}, year = {2005}, month = {2005 Apr 25}, pages = {863-7}, abstract = {

BACKGROUND: Experimental sleep restriction causes impaired glucose tolerance (IGT); however, little is known about the metabolic effects of habitual sleep restriction. We assessed the cross-sectional relation of usual sleep time to diabetes mellitus (DM) and IGT among participants in the Sleep Heart Health Study, a community-based prospective study of the cardiovascular consequences of sleep-disordered breathing.

METHODS: Participants were 722 men and 764 women, aged 53 to 93 years. Usual sleep time was obtained by standardized questionnaire. Diabetes mellitus was defined as a serum glucose level of 126 mg/dL or more (> or =7.0 mmol/L) fasting or 200 mg/dL or more (> or =11.1 mmol/L) 2 hours following standard oral glucose challenge or medication use for DM. Impaired glucose tolerance was defined as a 2-hour postchallenge glucose level of 140 mg/dL or more (> or =7.8 mmol/L) and less than 200 mg/dL. The relation of sleep time to DM and IGT was examined using categorical logistic regression with adjustment for age, sex, race, body habitus, and apnea-hypopnea index.

RESULTS: The median sleep time was 7 hours per night, with 27.1\% of subjects sleeping 6 hours or less per night. Compared with those sleeping 7 to 8 hours per night, subjects sleeping 5 hours or less and 6 hours per night had adjusted odds ratios for DM of 2.51 (95\% confidence interval, 1.57-4.02) and 1.66 (95\% confidence interval, 1.15-2.39), respectively. Adjusted odds ratios for IGT were 1.33 (95\% confidence interval, 0.83-2.15) and 1.58 (95\% confidence interval, 1.15-2.18), respectively. Subjects sleeping 9 hours or more per night also had increased odds ratios for DM and IGT. These associations persisted when subjects with insomnia symptoms were excluded.

CONCLUSIONS: A sleep duration of 6 hours or less or 9 hours or more is associated with increased prevalence of DM and IGT. Because this effect was present in subjects without insomnia, voluntary sleep restriction may contribute to the large public health burden of DM.

}, keywords = {Age Factors, Aged, Aged, 80 and over, Blood Glucose, Diabetes Mellitus, Disease Progression, Female, Glucose Intolerance, Humans, Male, Middle Aged, Odds Ratio, Prevalence, Prospective Studies, Sleep, Surveys and Questionnaires, Time Factors, United States}, issn = {0003-9926}, doi = {10.1001/archinte.165.8.863}, author = {Gottlieb, Daniel J and Punjabi, Naresh M and Newman, Ann B and Resnick, Helaine E and Redline, Susan and Baldwin, Carol M and Nieto, F Javier} } @article {966, title = {Associations of sleep-disordered breathing and cerebral changes on MRI.}, journal = {J Clin Sleep Med}, volume = {1}, year = {2005}, month = {2005 Apr 15}, pages = {159-65}, abstract = {

STUDY OBJECTIVES: Population-based studies have demonstrated associations between sleep-disordered breathing (SDB), hypertension, and cardiovascular disease; few large-scale studies have examined associations of SDB with objective measures of cerebrovascular disease. This study tested the significance of associations of SDB with evidence of brain injury or ischemia determined by cerebral magnetic resonance imaging (MRI) studies.

DESIGN: Cross-sectional and longitudinal analyses in a nested sample of Cardiovascular Health Study participants in the Sleep Heart Health Study.

PARTICIPANTS: The 843 individuals (mean age 77, SD 4.3 years, 58\% women) who had MRI studies as part of the Cardiovascular Health Study before and after polysomnography obtained as part of the Sleep Heart Health Study.

MEASUREMENTS: A 12-channel polysomnogram was used to derive indexes of sleep-disordered breathing. Repeated MRI measurements provided indexes of infarct (presence and size) and white matter disease. Logistic regression analyses were used to model MRI changes of infarct-like lesions and white matter disease as a function of age, baseline white matter grade, and indexes of central and obstructive sleep-disordered breathing.

RESULTS: Individuals who showed progression in white matter disease compared to those who did not were significantly more likely to show a Cheyne-Stokes respiration pattern and to have an increased number of central but not obstructive apneas.

CONCLUSIONS: An association between change in white matter grade and measures of central sleep apnea was demonstrated that was consistent with a causal pathway in which central sleep apnea contributes to the progression of white matter disease; alternatively, central sleep apnea may be a marker of subclinical cerebrovascular or cardiovascular disease.

}, keywords = {Aged, Brain, Cerebral Infarction, Cerebrovascular Circulation, Female, Humans, Magnetic Resonance Imaging, Male, Polysomnography, Severity of Illness Index, Sleep Apnea Syndromes, Sleep Apnea, Obstructive}, issn = {1550-9389}, author = {Robbins, John and Redline, Susan and Ervin, Ann and Walsleben, Joyce A and Ding, Jingzhong and Nieto, F Javier} } @article {871, title = {Progression and regression of sleep-disordered breathing with changes in weight: the Sleep Heart Health Study.}, journal = {Arch Intern Med}, volume = {165}, year = {2005}, month = {2005 Nov 14}, pages = {2408-13}, abstract = {

BACKGROUND: The relationship of weight changes to the incidence, progression, and remission of sleep-disordered breathing (SDB) is not well defined. This study aims to determine the relationship between change in weight and progression or remission of SDB by polysomnography.

METHODS: We performed a longitudinal cohort study of the cardiovascular consequences of sleep apnea in diverse US communities. Sleep apnea and polysomnographic indicators of SDB were assessed 5 years apart.

RESULTS: A total of 2968 men and women (mean age, 62 years) participated in the study. Men were more likely to have an increase in Respiratory Disturbance Index (RDI) with a given increase in weight than were women, and this was not explained by differences in starting weight, waist circumference, age, or ethnicity. In a linear regression analysis, both men and women had a greater increase in RDI with weight gain than a decrease in RDI with weight loss. In a categorical analysis of larger degrees of change, this sex difference was also evident. Associations were similar in diverse ethnic groups. However, SDB progressed over time, even in those with stable weight.

CONCLUSION: Modest changes in weight were related to an increase or decrease in SDB, and this association was stronger in men than in women.

}, keywords = {Body Weights and Measures, Causality, Cohort Studies, Comorbidity, Female, Follow-Up Studies, Humans, Linear Models, Male, Middle Aged, Obesity, Odds Ratio, Sex Distribution, Sleep Apnea Syndromes, United States, Weight Gain, Weight Loss}, issn = {0003-9926}, doi = {10.1001/archinte.165.20.2408}, author = {Newman, Anne B and Foster, Greg and Givelber, Rachel and Nieto, F Javier and Redline, Susan and Young, Terry} } @article {858, title = {Sleepiness in patients with moderate to severe sleep-disordered breathing.}, journal = {Sleep}, volume = {28}, year = {2005}, month = {2005 Apr}, pages = {472-7}, abstract = {

BACKGROUND: Population-based studies suggest that complaints of sleepiness are absent in many individuals with sleep-disordered breathing. We investigated the prevalence of sleepiness as well as factors associated with sleepiness in individuals with moderate to severe sleep-disordered breathing (apnea-hypopnea index > or = 15).

DESIGN: Cross-sectional study.

SETTING: The Sleep Heart Health Study.

PARTICIPANTS: Sleep Heart Health Study participants (N = 6440).

MEASUREMENTS AND RESULTS: Sleepiness was defined as an Epworth Sleepiness Scale score >10 or a report of at least frequently feeling unrested or sleepy. Forty-six percent of participants with moderate to severe sleep-disordered breathing (n = 1149) reported sleepiness. Characteristics associated with sleepiness after adjustment for confounders included presence of respiratory disease, shorter self-reported weekday and weekend sleep, sleep durations, complaints of insufficient sleep, complaints of sleep maintenance insomnia, early morning awakening, habitual snoring, and complaints of awakening with leg cramps or leg jerks. Some respiratory polysomnography measures were associated with sleepiness, but sleep-stage percentages and measures of sleep disruption were not.

CONCLUSIONS: In this community-based cohort, subjective sleepiness is absent in many individuals with significant sleep-disordered breathing. Comorbid conditions, including respiratory disease, sleep restriction, insomnia, and nocturnal leg complaints, are important risk factors for sleepiness in individuals with moderate to severe sleep-disordered breathing.

}, keywords = {Aged, Body Mass Index, Cohort Studies, Cross-Sectional Studies, Disorders of Excessive Somnolence, Female, Humans, Male, Middle Aged, Oxygen, Polysomnography, Prevalence, Risk Factors, Severity of Illness Index, Sleep Apnea Syndromes, Sleep Arousal Disorders, Sleep Stages, Surveys and Questionnaires}, issn = {0161-8105}, doi = {10.1093/sleep/28.4.472}, author = {Kapur, Vishesh K and Baldwin, Carol M and Resnick, Helaine E and Gottlieb, Daniel J and Nieto, F Javier} } @article {915, title = {Association of usual sleep duration with hypertension: the Sleep Heart Health Study.}, journal = {Sleep}, volume = {29}, year = {2006}, month = {2006 Aug}, pages = {1009-14}, abstract = {

STUDY OBJECTIVES: Limited experimental data suggest that sleep restriction acutely elevates blood pressure; however, little is known about the relationship between usual sleep duration and hypertension. This study assesses the relationship between usual sleep duration and hypertension in a community-based cohort.

DESIGN: Cross-sectional observational study.

SETTING: The Sleep Heart Health Study, a community-based prospective study of the cardiovascular consequences of sleep-disordered breathing.

PARTICIPANTS: Two thousand eight hundred thirteen men and 3097 women, aged 40 to 100 years.

INTERVENTIONS: None.

MEASUREMENTS AND RESULTS: Usual weekday and weekend sleep durations were obtained by questionnaire, and their weighted average were categorized as less than 6, 6 to less than 7, 7 to less than 8, 8 to less than 9, and 9 or more hours per night. Hypertension was defined as a systolic blood pressure of 140 mm Hg or greater, a diastolic blood pressure of 90 mm Hg or greater, or use of medication to treat hypertension. The relationship between sleep duration and hypertension was examined using categorical logistic regression with adjustment for age, sex, race, apnea-hypopnea index, and body mass index. Compared to subjects sleeping 7 to less than 8 hours per night, those sleeping less than 6 and between 6 and 7 hours per night had adjusted odds ratios for hypertension of 1.66 (95\% confidence interval 1.35-2.04) and 1.19 (1.02-1.39), respectively, whereas those sleeping between 8 and 9 and 9 or more hours per night had adjusted odds ratios for hypertension of 1.19 (1.04-1.37) and 1.30 (1.04-1.62), respectively (p < .0001 for association of sleep duration with hypertension). These associations persisted when analyses were further adjusted for caffeine and alcohol consumption, current smoking, insomnia symptoms, depression symptoms, sleep efficiency, and prevalent diabetes mellitus or cardiovascular disease.

CONCLUSIONS: Usual sleep duration above or below the median of 7 to less than 8 hours per night is associated with an increased prevalence of hypertension, particularly at the extreme of less than 6 hours per night.

}, keywords = {Adult, Aged, Aged, 80 and over, Body Mass Index, Cohort Studies, Comorbidity, Cross-Sectional Studies, Female, Health Surveys, Humans, Hypertension, Male, Middle Aged, Odds Ratio, Prospective Studies, Sleep, Sleep Apnea, Obstructive, Sleep Deprivation, Statistics as Topic}, issn = {0161-8105}, doi = {10.1093/sleep/29.8.1009}, author = {Gottlieb, Daniel J and Redline, Susan and Nieto, F Javier and Baldwin, Carol M and Newman, Anne B and Resnick, Helaine E and Punjabi, Naresh M} }