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Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
C
URRENT
O
PINION
Roles of gender, age, race/ethnicity, and residential
socioeconomics in obstructive sleep apnea
syndromes
Frank M. Ralls
a,c
and Madeleine Grigg-Damberger
b,c
Purpose of review
Review recent research on the roles of gender, race/ethnicity, residential socioeconomics and age in
obstructive sleep apnea syndromes (OSA) and their treatment.
Recent findings
Men have a higher prevalence of OSA than women and require higher continuous positive airway
pressure (CPAP) pressures for treatment, given similar severity of OSA. When comparing age, women have
less severe apnea at all ages. Menopause, pregnancy and polycystic ovarian syndrome increase the risk
for OSA in women. Neck fat and BMI influence apnea–hypopnea index (AHI) severity in women;
abdominal fat and neck-to-waist ratio do so in men. Obesity, craniofacial structure, lower socioeconomic
status and neighborhood disadvantage may better explain ethnic/racial differences in the prevalence and
severity of OSA. Ethnicity was no longer significantly associated with OSA severity when WHO criteria for
obesity were used.
Summary
OSA has a male predominance; women have a lower AHI than men during certain stages of sleep;
women require less CPAP pressure for treatment of similar severity of OSA, and there are ethnic/racial
differences in the prevalence and severity of OSA but these may be due to environmental factors, such as
living in disadvantaged neighborhoods.
Keywords
epidemiology, ethnicity/race, obstructive sleep apnea
INTRODUCTION
Obstructive sleep apnea (OSA) consists of recurrent
episodes of complete or partial upper airway
collapse during sleep associated with frequent
oxyhemoglobin desaturations and/or sleep frag-
mentation. Untreated OSA can lead to significant
neurologic, cardiovascular and behavioral comor-
bidities [1
&
,2,3]. This review identifies and helps
the reader understand the roles of gender, race/
ethnicity and residential socioeconomics on the
presence, severity and treatment of OSA.
Obstructive sleep apnea more common in
men
Earlier epidemiological studies reported that OSA
was eight to 10 times more common in men than
women referred to sleep clinics. However, general
population studies show that men are only two to
three times more likely to have OSA than women
[4]. In the landmark study of the Wisconsin
Sleep Cohort (602 employed men and women,
30–60 years of age), 24% of men and 9% of women
had an apnea–hypopnea index (AHI) more than 5,
and 9% of men and 4% of women had an AHI more
than 15 [5]. Four percent of men and 2% of women
met diagnostic criteria for OSA syndrome [defined
in this study as an AHI 5 or more and excessive
a
Division of Pulmonary, Critical Care, and Sleep Medicine, Department of
Internal Medicine,
b
Department of Neurology, University of New Mexico
School of Medicine and
c
University of New Mexico Hospital Sleep
Disorders Center, Albuquerque, New Mexico, USA
Correspondence to Frank M. Ralls, MD, Assistant Professor of Internal
Medicine, Medical Director, Adult Sleep Medicine Services and Program
Director, Fellowship in Sleep Medicine, University of New Mexico Hos-
pital Sleep Disorders Center, 1101 Medical Arts Avenue NE, Building
#2, Albuquerque, NM 87102, USA. Tel: +1 505 272 6110; fax: +1 505
272 6112; e-mail: fralls@salud.unm.edu
Curr Opin Pulm Med 2012, 18:568–573
DOI:10.1097/MCP.0b013e328358be05
www.co-pulmonarymedicine.com Volume 18 Number 6 November 2012
REVIEW
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
daytime sleepiness (EDS)]. Prospective data from the
Sleep Heart Health Study have shown that male
sex is an independent risk factor for OSA, increasing
the risk for moderate-to-severe OSA (AHI 15) by
approximately 1.5 times [6].
A recently published large retrospective
study analyzed overnight polysomnogram (PSG)
data from 23 806 patients to characterize the
phenotypesofmenandwomenofdifferentages
with a laboratory diagnosis of OSA using demo-
graphic information, subjective complaints and
medical history [7
&&
]. The mean age of the cohort
was 51 years, 74% were men and the mean BMI was
30 kg/m
2
. Seventy-one percent had an AHI more
than10(meanAHI22)andmenhadconsistently
higher AHI than women. The cohort was stratified
into 24 age gender groups in 5-year intervals,
and AHI was separately calculated for each of
them. The investigation found that women had
lower AHI than men for all groups, but the
differencesweremostnotableinthe20–50years
ofagerange;AHIincreasedlinearlywithagein
women, but the relationship was more complex
in men, with a steep increase from age 20 to 40
and a moderate linear increase thereafter; linear
regressionsfittedtotheAHIcurvesrevealed
that women had a larger increase in AHI with each
5-year change in age than men but approximately
one-third the AHI at the youngest age than that of
men; in men, the effect of age and BMI on AHI
interacted such that AHI in obese men increased
from age 20 to 40 years and remained stable there-
after, and a linear increase in AHI with age was
noted in both obese and nonobese women. The
authors concluded that OSA severity varies with
ageinbothsexes,althoughwomenhavelesssevere
degrees of obstructive sleep disordered breathing
at all ages. Obesity, snoring, hypertension and EDS
were predictors for OSA in both sexes.
Women with obstructive sleep apnea often
present complaining of insomnia, nightmares
or depression
The diagnosis of OSA may be missed in women
because they complain of different symptoms
than men. Habitual snoring has less predictive value
for OSA in women than men [6]. Women with OSA
often present to sleep specialists complaining of
insomnia, nightmares or depression [8,9]. A recent
study found insomnia was a common complaint
in women and men with OSA but more common
in women [10
&
]. In this study, insomnia was more
prevalent among patients with OSA (84%) than
the reported 30% in the general adult population.
Sleep-onset insomnia was reported more frequently
by women (62%) than men (53%). Similarly,
self-reported characteristics of psychophysiological
insomnia also showed a female preponderance
(53% women vs. 45% men). White women had
the highest rate of self-reported sleep maintenance
insomnia (80%). Hispanic women were more likely
to complain of symptoms suggestive of psycho-
physiological insomnia (58%). Other recent studies
also report that women with OSA are far more
likely to complain of anxiety, depression and other
psychological comorbidities than men [11,12].
Sex differences in anthropometric and
craniofacial measures
Anthropometric measures may contribute to the
higher prevalence of OSA in men than women
[13]. A recently published retrospective review
evaluated the influence of waist-to-hip and neck-
to-height ratios of 1047 adults (386 women, 661
men) with OSA, defined as respiratory disturbance
index (RDI) more than 5, and found that women
with OSA were older than men and had a higher BMI
and waist-to-hip ratio; OSA severity was higher in
men than women (mean RDI 42 vs. 30 per hour,
respectively) despite a lower BMI and age in
the men; neck circumference was only weakly
correlated with severity of OSA, and there were no
significant sex influences on this trait; waist-to-
hip ratio predicted OSA severity in men more than
in women; no single anthropometric measure
predicted OSA severity and the predictive value
of anthropometric values of OSA severity was at
best modest.
A recent prospective case series observational
study evaluated relationships between severity of
OSA and measures of regional obesity in 96 adults
KEY POINTS
The prevalence of SDB is more than two times higher in
men compared with premenopausal women despite
similar age and lower weight.
Women have less severe apnea at all ages, when
compared with age-matched men.
Consider using WHO obesity criteria to compare OSA
in different ethnicities and populations for the most
effective use of BMI.
The menopausal transition significantly increases a
woman’s risk for OSA.
Residence in a neighborhood of severe socioeconomic
disadvantage increases the odds for an individual
having OSA.
Obstructive sleep apnea syndromes Ralls and Grigg-Damberger
1070-5287 ß2012 Wolters Kluwer Health | Lippincott Williams & Wilkins www.co-pulmonarymedicine.com 569
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
(60 men, 36 women) referred for OSA to the
researchers’ sleep center [14]. OSA severity was based
on AHI from an in-laboratory overnight PSG. Dual-
energy absorptiometry was used to measure percent-
age of fat and lean tissue. Multivariate regression
models for men and women were developed. The
percentage of fat in the neck region and BMI
together explained 33% of the variance in AHI in
women. The percentage of fat in the abdominal
region and neck-to-waist ratio together accounted
for 37% of the AHI variance in men.
A retrospective study determined cutoff point
values for anthropometric indexes in 499 patients
with OSA (AHI 5). BMI, waist circumference
and neck circumference were statistically higher
in the patients with OSA compared with controls
[15]. Risk coefficients for neck circumference,
waist circumference and BMI were 5.5, 4.5 and
2.2, respectively. Cutoff point values for anthropo-
metric obesity indexes as a predictor of OSA were
as follows: a BMI more than 27.8 kg/m
2
in a male
and more than 28.9 kg/m
2
in a woman; neck circum-
ference more than 40 cm in a male, and more
than 36 cm in a woman; and waist circumference
more than 105 cm in a male and more than 101 cm
in a woman.
Certain craniofacial measurements (facial depth,
mandibular plane angle and vertical growth index)
correlated with AHI in male, but not female, children
with OSA [16]. Using multivariate analyses, a retro-
spective cross-sectional study identified male sex
and retropalatal Mu
¨ller grade as risk factors for the
presence and severity of OSA in nonobese snoring
Chinese patients [17].
Sex hormone status affects the risk for
obstructive sleep apnea in women
The menopausal transition significantly increases
a woman’s risk for OSA [18]. Using multivariable
logistic regression, the odds ratio (OR) for having
AHI 15 or more among 589 women enrolled
in the Wisconsin Sleep Cohort Study was 1.1 when
perimenopausal and 3.5 after menopause, inde-
pendent of multiple known confounding factors
[18]. The risk for OSA at menopause is reduced by
hormone replacement therapy: one study found the
prevalence of symptomatic OSA in postmenopausal
women with and without HRT was 0.6 vs. 2.7% [19].
An experimental study in female rats showed
that chronic intermittent hypoxia reduced the
contractile properties of the genioglossus muscle,
ovariectomy exacerbated this effect and estrogen
replacement partially reversed the effect [20].
Hormone replacement therapy in menopausal
women may improve upper airway patency.
Rising levels of estrogen and progesterone
in women during pregnancy increase the risk for
snoring and OSA [21]. Snoring, rhinitis, nasal
vasodilation and tissue edema in pregnant women
may be due to increased levels of estrogen and
progesterone [21]. Accumulating data suggest that
snoring and OSA during pregnancy increases the
risk for gestational hypertension and preeclampsia
[22]. A recent prospective study found PSG-
confirmed OSA (AHI >5) in 53% of 34 pregnant
women with gestational hypertension, compared
with 12% in 26 women with uncomplicated preg-
nancies [23]. Most of the women with gestational
hypertension and OSA were obese. More research is
needed to unravel the relationships between obesity
and OSA in pregnancy.
Polycystic ovarian syndrome (PCOS) is associ-
ated with increased production of androgens,
disordered gonadotropin secretion, visceral obesity,
insulin resistance and metabolic syndrome in pre-
menopausal women. Androgen hormones (such as
testosterone) may depress respiration and increase
the risk of snoring and OSA. Obese women with
PCOS are at increased risk for OSA [24]. One study
found the prevalence of OSA in PCOS was seven-fold
higher than that in controls. OSA in women with
PCOS increases the risks for glucose intolerance,
insulin resistance and type-2 diabetes.
Roles of race/ethnicity and residential
socioeconomics on obstructive sleep apnea
Sleep researchers continue to tackle the thorny
subject of whether race and ethnicity impact
the prevalence and severity of OSA in adults and
children. The Multiethnic Study of Atherosclerosis
was designed to compare the prevalence of OSA
among 211 Hispanic and 246 white Americans
and 978 Japanese [25]. The majority of the race/
ethnic difference in OSA prevalence was explained
by BMI and obesity. OSA was estimated by recording
a single-channel airflow monitor and sleep-
disordered breathing (SDB) defined as an RDI of
15 or more. The prevalence of OSA was higher
among Hispanics (37%) and whites (33%) than
among Japanese (18%) but best corresponded with
differences in BMI. BMI and SDB were strongly
and similarly associated in Americans and Japanese.
The authors argued that the majority of the race/
ethnic difference in the prevalence of SDB was
explained by a difference in the BMI distribution.
A retrospective study in Sa
˜o Paulo, Brazil (a city
with the largest community of Japanese descend-
ants outside Japan) examined the strength of BMI
to determine OSA risk in male patients who were
diagnosed with OSA [26]. Of the 2290 patients who
Sleep and respiratory neurobiology
570 www.co-pulmonarymedicine.com Volume 18 Number 6 November 2012
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
underwent sleep studies during the period of
retrospective review, 586 individuals remained
after various exclusions. Similar proportions of both
groups met diagnostic criteria for OSA (AHI 5),
leaving 520 patients (54 Japanese and 466 whites)
who were subjected to further analysis. SDB severity
and comorbidities were also similar between
the Japanese descendants and white adults with
OSA, but the Japanese overall had a lower BMI
than white patients (mean 27.1 vs. 29.4 kg/m
2
,
respectively, P<0.001), suggesting that an ethnicity
factor other than BMI added to the severity of OSA
in Japanese individuals.
Multiple linear regression revealed that age,
BMI, neck circumference, Epworth sleepiness
scale, ethnicity and percentage rapid eye movement
sleep were independent predictors for AHI. How-
ever, ethnicity had a less significant impact on
OSA severity when WHO criteria for obesity were
used. WHO criteria define obesity in white men
as 30 kg/m
2
or more, but call for a threshold of
25 kg/m
2
or more in Japanese men. Substituting a
categorical variable for obesity, using WHO criteria,
in the multivariate regression indicated that
presence or absence of obesity was the controlling
factor rather than BMI per se (P<0.001). The
authors concluded that ethnicity was not associated
with OSA severity when the ethnic difference in
defining obesity was respected.
Another cross-sectional study compared 280
African–American and white men and women
[27
&
]. Multiple linear regression analysis was
used to establish whether race predicted AHI when
controlling for age, sex and BMI. Neither race nor
age predicted the AHI score, but a higher BMI was
associated with a higher AHI. Men had higher
AHI scores than women. Race was not a predictor
of OSA severity after controlling for age, sex and
especially BMI.
A study of 364 New Zealanders (ages 30–
59 years) evaluated whether OSA was more common
in the Maori [28]. After controlling for sex and age,
Maori were 4.3 times more likely to have an RDI
of 15 or more. However, ethnicity was not an inde-
pendent risk factor after they controlled for BMI and
neck circumference. Body habitus better explained
the higher prevalence of OSA in Maori.
Another study evaluated differences in cranio-
facial structures and obesity in 150 adults with OSA
(74 white and 76 Chinese) [29]. The Chinese had
more severe OSA than the white patients (AHI 35 vs.
25 per hour). They also had more craniofacial bony
restriction, including a shorter cranial base and
maxilla and mandible length, even after correcting
for differences in body height. When matched for
OSA severity (n¼52), Chinese patients had more
craniofacial bony restriction, but white patients
were more overweight (BMI 30.7 vs. 28.4 kg/m
2
)
and had a larger neck circumference (40.8 vs.
39.1 cm); however, the ratios of BMI to the mandible
or maxilla size were similar. The authors concluded
that craniofacial factors and obesity contribute
differentially to OSA in white and Chinese patients.
For the same degree of OSA severity, whites were
more overweight, whereas Chinese exhibited more
craniofacial bony restriction.
Obstructive sleep apnea more common in
African–American urban children
Studies in the prevalence of OSA in white and
African–American children living in Cleveland have
found that the prevalence of snoring and sleep
apnea is much greater among African – American
children [30,31]. Other risk factors for OSA in
children are obesity [32–34], asthma [35,36], pre-
mature birth [30,31,37
&&
], and lower socioeconomic
status [38].
A recent cross-sectional study of 346 children
aged 2–6 years found that the OR for snoring was
2.5 times greater in African–American children and
2.3 times higher in Hispanics compared with white
children, using parent-identified ethnicity [37
&&
].
On multivariate analysis, only African–American
race and prematurity were associated with snoring,
whereas male sex was associated with SDB. Upper
airway dynamic function was measured during
sleep in 56 normal nonobese African–American
and white children, ages 8–18 years [39]. No signifi-
cant differences were found between the groups
of African–American and white children. Upper
airway collapsibility was similar in these two groups.
Differences in upper airway characteristics and neu-
romuscular function cannot explain the increased
prevalence of OSA in African–American children.
Residential socioeconomics and lower
socioeconomic status as a risk factor for
obstructive sleep apnea
Lower socioeconomic status and neighborhood
disadvantage may better explain OSA being more
common among African–American children [31,38,
40
&&
]. A cross-sectional analysis of 843 children
(ages 8–11, 51% male, 36% African–American)
found residence in a neighborhood of severe socio-
economic disadvantage increased the odds for OSA
by 3.4 times after adjusting for African–American
ethnicity, premature birth and obesity [38].
A recent study from Montreal compared
residential census tract metrics among 436 children
aged 2–8 years, hypothesizing that the 300 with no
Obstructive sleep apnea syndromes Ralls and Grigg-Damberger
1070-5287 ß2012 Wolters Kluwer Health | Lippincott Williams & Wilkins www.co-pulmonarymedicine.com 571
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
OSA would come from more disadvantaged neigh-
borhoods [40
&&
]. Compared with the no OSA group,
the OSA group lived in census tracts with lower
median family incomes, higher proportions of
children living below the Canadian low-income
cutoff (indicating poverty), higher proportions
of single-parent families, and greater population
densities. The highest probability of having OSA
was seen in children referred from the most dis-
advantaged census tracts and these children prim-
arily suffered from moderate-to-severe OSA. Group
differences remained significant when adjusted for
age, race/ethnicity and obesity.
Impact of sex, ethnic and neighborhood
socioeconomics on continuous positive
airway pressure requirements and adherence
in adults
Continuous positive airway pressure (CPAP) require-
ments may differ between men and women with
OSA. A recent retrospective study found CPAP
pressures were higher in men than women (12.7
vs. 10.2 cm water, respectively) in 95 adult patients
(59% women) with OSA who underwent CPAP
titration during an overnight PSG [41]. The women
had a higher average BMI than the men (mean 48.5
vs. 42.1). Despite a similar level of severity of OSA,
CPAP requirements were significantly higher in the
men compared with the women (12.7 vs. 10.2 cm
water). It is believed that differences in CPAP
pressure requirements between women and men
may be due to sex-specific differences in pharyngeal
collapsibility.
A particularly interesting study systematically
evaluated ethnic differences in CPAP adherence in
126 consecutive New Zealand patients with severe
OSA (mean AHI 58 per hour), 20% of whom were
Maori [42
&
]. Using multivariate logistic regression,
they found no significant relationships between
adherence and subjective sleepiness, health literacy
or self-efficacy. A multivariate logistic model found
failing to complete tertiary education and high levels
of individual socioeconomic deprivation predicted
average CPAP adherence in an individual would
not reach 4 h or more per night (OR 0.25 and 0.10,
respectively). The overall model explained approxi-
mately 23% of the variance in adherence. The authors
argue the disparity in CPAP compliance between
Maori and non-Maori can be explained in part by
lower education levels and socioeconomic status.
CONCLUSION
Men have a higher prevalence for OSA than women
and require higher CPAP pressures for treatment
despite similar severity of OSA. Menopause,
pregnancy and PCOS increase the risk for OSA in
women. Obesity, craniofacial structure, lower
socioeconomic status and neighborhood dis-
advantage may better explain ethnic/racial differ-
ences in the prevalence and severity of OSA. Neck
fat and BMI influence AHI severity in women,
whereas abdominal fat and waist-to-hip ratio do
so in men. Evaluation of ethnic differences in
prevalence of OSA should use WHO definitions
of obesity. Ethnicity is not significantly asso-
ciated with OSA severity when WHO criteria for
obesity are used. For each specific age range, women
have less severe apnea throughout the adult
lifespan.
Acknowledgements
None.
Conflicts of interest
There are no conflicts of interest.
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Obstructive sleep apnea syndromes Ralls and Grigg-Damberger
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