A validation study on three screening questionnaires for obstructive sleep apnea in a Korean community sample

The Association of Serum Uric Acid with Risk of Obstructive Sleep Apnea: The Korean National Health and Nutrition Examination Survey 2019-2021

Upper airway collapse and apneas in obstructive sleep apnea (OSA) induce intermittent hypercapnia and hypoxia, eventually contributing to excessive uric acid production. This study aimed to evaluate the association between hyperuricemia and OSA in the general population via analysis of the eighth KNHANES dataset (2019-2021). OSA risk was identified via the STOP-Bang questionnaire, with a score ≥3 indicating high risk. Among 11,981 total participants, 4572 (38.2%) had a high OSA risk. Participants with a high OSA risk had higher uric acid levels compared to those with a low risk (5.5 ± 1.4 mg/dL vs. 4.8 ± 1.2 mg/dL, p < 0.001). Serum uric acid levels were positively correlated with STOP-Bang score (r: 0.317, p < 0.001). Multivariate analysis revealed that hyperuricemia was associated with a high OSA risk after adjusting for confounders (odds ratio: 1.30, 95%CI: 1.11-1.53, p = 0.001). Therefore, serum uric acid levels are significantly higher in those with a high OSA risk and correlate with the risk of OSA. Further, hyperuricemia is an independently associated risk factor for high OSA risk. More research is warranted to evaluate the long-term clinical outcomes of hyperuricemia in OSA and to determine whether treatment targeting hyperuricemia is effective in the clinical course of OSA.

Associations between obstructive sleep apnea and dental pain and chewing discomfort in Korean adults: a nationwide cross-sectional study

Obstructive sleep apnea (OSA) may be linked with oral health issues. This study evaluated the associations between OSA, dental pain, and chewing discomfort. Big data from a nationwide survey involving 6984 participants aged ≥ 40 years were analyzed. The STOP-Bang questionnaire was used to assess the OSA risk, categorizing the participants into low-, intermediate-, and high-risk groups. The associations of OSA risk with dental pain and chewing discomfort were evaluated using multivariate logistic regression analyses (α = 0.05). Results revealed that 50.33%, 37.50%, and 12.17% of the population belonged to the low-, intermediate-, and high-risk groups, respectively. After adjusting for covariates, a significant association emerged between OSA risk and dental pain, with adjusted odds ratios (95% confidence intervals) of 1 (reference), 1.208 (1.003-1.455), and 1.472 (1.131-1.916) for the low-, intermediate-, and high-risk groups, respectively (p = 0.0156). The adjusted odds ratio for chewing discomfort in the high-risk OSA group was 1.307 (0.977-1.748), although not significantly different from that of the low-risk group (p > 0.05). A high risk of OSA was associated with 1.472-fold increased risk of dental pain compared to those at low risk, implicating OSA as a potential risk indicator of poor oral health.

Obstructive sleep apnea related to mental health, health-related quality of life and multimorbidity: A nationwide survey of a representative sample in Republic of Korea

OBJECTIVES

This study assessed the effects of obstructive sleep apnea (OSA) on mental health, health-related quality of life (HRQoL), and multimorbidity in Korean adults.

METHODS

The study included 8030 participants from the Korea National Health and Nutrition Examination Survey Ⅷ (2019-2020). The risk of OSA was assessed using STOP-BANG questionnaire. Depression was measured using the Patient Health Questionnaire-9 (PHQ-9), and stress was measured using a questionnaire. HRQoL was determined by EuroQol 5-dimension (EQ-5D) and Health-related Quality of Life Instrument with 8 Items (HINT-8) scores. Multimorbidity was defined as the presence of 2 or more chronic diseases. A complex sample multivariate logistic regression analysis was conducted.

RESULTS

Participants with a high OSA risk were more likely to a have high PHQ-9 score (OR 4.31, 95% confidence interval [CI] 2.80-6.65), total depression (OR 4.07, 95% CI 2.67-6.19) stress (OR 2.33, 95% CI 1.85-2.95), lower EQ-5D (OR 2.88, 95% CI 2.00-4.15) and HINT-8 scores (OR 2.87, 95% CI 1.65-4.98), and multimorbidity (OR 2.62, 95% CI 2.01-3.41) than participants with low OSA risk. High OSA risk was significantly associated with all EQ-5D and HINT-8 items.

CONCLUSIONS

This study adds to the few population-based studies showing associations between mental health, HRQoL, and multimorbidity using nationwide data. OSA prevention might be helpful for good mental health, improving HRQoL, and comorbidity burdens. The results provide novel insights regarding the association between sleep apnea and multimorbidity.

Sleep duration, weekend catch-up sleep, and risk of obstructive sleep apnea in relation to handgrip strength

PURPOSE

This cross-sectional study aimed to evaluate whether weekday sleep duration, weekend catch-up sleep, and risk of obstructive sleep apnea are individually and in combination associated with handgrip strength.

METHODS

Data from the Korea National Health and Nutrition Examination Survey 2019, including weekday sleep duration, weekend catch-up sleep, STOP-BANG scores, relative handgrip strength (handgrip strength divided by body mass index), and confounding factors (sociodemographic factors, health behaviors, and health and nutritional status), were evaluated in 3678 Korean adults aged 40 to 80 years. Adequate (vs. inadequate) sleep parameters were defined as weekday sleep duration (6-7 vs. ≤ 5 or ≥ 8 h), weekend catch-up sleep (presence vs. absence), and risk of obstructive sleep apnea (low vs. high based on STOP-BANG scores). Sex-specific quintiles of relative handgrip strength were categorized as high (highest 5th quintile) or low (lower 1^st to 4^th quintiles). A complex-sample logistic regression analysis was performed.

RESULTS

After adjusting for other sleep parameters and confounding variables, each adequate sleep parameter individually and collectively was associated with high relative handgrip strength (adjusted odds ratios [95% confidence interval], 1.43 [1.09, 1.89] for 6-7 h weekday sleep duration; 1.44 [1.10, 1.90] for low risk of obstructive sleep apnea; 1.72 [1.23, 2.40] for any two parameters; 1.81 [1.18, 2.79] for all parameters). The combination of adequate weekend catch-up sleep and obstructive sleep apnea risk had the highest odds ratio for high relative handgrip strength (2.36 [1.45, 3.83]).

CONCLUSIONS

Adequate weekday sleep duration, weekend catch-up sleep, and low obstructive sleep apnea risk were individually and in combination associated with high handgrip strength.

Relationship between obstructive sleep apnea, insulin resistance, and metabolic syndrome: a nationwide population-based survey

We aimed to identify the association between obstructive sleep apnea (OSA), insulin resistance (IR), and metabolic syndrome (MetS) in a nationwide population-based sample. A total of 7,900 adults with information on the STOP-Bang score and MetS (3,341 men and 4,469 women) were identified from the dataset of the Korea National Health and Nutrition Examination Survey 2019-2020. The association between OSA, IR, MetS, and its components was estimated using complex sample logistic regression analysis with adjustments for age, body mass index, residence, smoking status, alcohol consumption, household income, education, and the presence of diabetes. Participants with a high OSA score were more likely to have IR (odds ratio [OR] 2.78, 95% confidence interval [CI] 1.96-3.95 in men and OR 2.64, 95% CI 0.55-12.80 in women), MetS (OR 6.05, 95% CI 4.23-8.69 in men and OR 4.20, 95% CI 1.23-15.70 in women), and components of MetS, compared to individuals with a low OSA score. Compared to premenopausal women, postmenopausal women had a more intense association between OSA and IR (OR 1.78, 95% CI 0.13-24.43 for premenopausal women and OR 3.64, 95% CI 0.60-22.28 for postmenopausal women) and MetS (OR 2.58, 95% CI 0.23-29.55 for premenopausal women and OR 5.36, 95% CI 1.42-20.21 for postmenopausal women). OSA was associated with abdominal obesity and hypertension in premenopausal women, while all components of MetS were associated with OSA in postmenopausal women. Further studies are necessary to elucidate the underlying mechanisms of these findings.

Obstructive Sleep Apnea Is Associated With Late-Onset Preeclampsia in Overweight Pregnant Women in Korea

BACKGROUND

Obstructive sleep apnea (OSA) is closely related to maternal obesity in pregnant women, and the association increases with later pregnancy. Obesity and OSA are risk factors of pregnancy-related complications, including gestational hypertension, gestational diabetes mellitus (GDM), and fetal morbidities. We aimed to determine the prevalence of OSA and to assess the impact of OSA on pregnancy-related disorders in overweight pregnant women.

METHODS

Eligible participants who were overweight [body mass index (BMI) ≥ 23 kg/m²] in gestational age 30 weeks or more, assessed OSA using a portable polysomnography at home. Clinical data were collected from pregnant women and their babies.

RESULTS

The average age of 51 participants was 34.5 years (27-44 years). The number of primipara was 25 (49%) and that of multipara was 26 (51%). Eight cases of GDM (15.7%) and five cases of preeclampsia (9.8%) were reported, and six patients (11.8%) experienced preterm delivery. In results of polysomnography, 14 patients (27.5%) were diagnosed as OSA. Apnea-hypopnea index moderately correlated with BMI (r = 0.515, P < 0.001). The BMI (P < 0.005) and preeclampsia rate (P < 0.017) were higher in the OSA group compared to the control group. Odds ratios (ORs) adjusting age, BMI, parity, and abortion history were calculated. The presence of OSA increased OR of preeclampsia (OR, 13.1; 95% confidence interval, 1.1-171.3). The majority of preeclampsia patients (4/5, 80%) underwent preterm delivery.

CONCLUSION

OSA is an important risk factor for preeclampsia, resulting in preterm delivery. For overweight pregnant women, an OSA evaluation should be mandatory.

Protocol for a randomized controlled trial evaluating the effect of Hibiscus syriacus L. flower extract on sleep quality

Introduction

Hibiscus syriacus L. flower (HSF) is a food ingredient commonly used for tea, and previous animal studies have reported its sleep-promoting effect. This study aims to test the potential of HSF extract as functional food that improves sleep in humans.

Methods and analysis

Eighty participants with sleep disturbances who meet the inclusion/exclusion criteria will be enrolled in this study. Since the effect of HSF extract on sleep is considered to be that of a functional food rather than a medicine, participants with severe insomnia will be excluded from the study. The enrolled participants will be randomly assigned to the HSF extract or placebo groups in a 1:1 ratio. The HSF extract and placebo capsules will look identical, and participants, investigators, and outcome assessors will be blinded to the allocation. Four capsules of HSF extract or placebo will be orally administered 30-60 min before bedtime for 4 weeks. The primary outcome of this study will be the change in the Pittsburgh Sleep Quality Index (PSQI) global score from the baseline after 4 weeks. The subjective and objective changes in the participants' sleep will be evaluated using the Insomnia Severity Index (ISI), Epworth Sleep Scale (ESS), sleep diary, and polysomnography (PSG). The occurrence of adverse events will be closely monitored.

Discussion

The results of this trial will provide data on the efficacy and safety of HSF extract in enhancing sleep quality. Based on the results, the potential of HSF extract as a functional food that improves sleep in humans will be evaluated, and the findings of the trial will be submitted to the Korean Ministry of Food and Drug Safety for consideration as a new functional ingredient that may help to improve sleep quality.

Clinical trial registration

: Clinical Research Information Service: KCT0007314; Registered 19 May 2022, https://cris.nih.go.kr/cris/search/detailSearch.do/21497.

Impact of high-risk of obstructive sleep apnea on chronic cough: data from the Korea National Health and Nutrition Examination Survey

Background

Chronic cough is an extremely common clinical symptom of various diseases. However, the relationship between obstructive sleep apnea (OSA) and chronic cough in the general population has not been sufficiently studied.

Methods

Using the 2019 Korean National Health and Nutrition Examination Survey data, we identified a group at high-risk of OSA via the STOP-Bang questionnaire and determined the association between OSA and chronic cough by a regression model.

Results

Of the eligible 4,217 participants, 97.1% and 2.9% were classified into the non-chronic cough and chronic cough groups, respectively. The chronic cough group had higher STOP-Bang scores than those of the group without chronic cough (2.32 ± 1.38 vs. 2.80 ± 1.39; P < 0.001). In the group at high-risk of OSA, 40.4% and 52.0% of participants scored ≥ 3 in STOP-Bang, depending on the absence or presence of chronic cough (P = 0.012), respectively. Chronic cough independently correlated with impaired lung function (forced expiratory volume in one second ≥ 50–<80% predicted value, P = 0.001; <50, P < 0.001), low household income (P = 0.015), and a group at high-risk of OSA (STOP-Bang score 3–4, P = 0.004; 5–8, P < 0.001). Obesity I had a protective role against the occurrence of chronic cough (P = 0.023).

Conclusion

A high-risk for OSA is a significant risk factor for chronic cough. OSA should be considered when evaluating chronic cough patients.

Obstructive sleep apnea risk and hearing impairment among occupational noise-exposed male workers

This study aimed to investigate the association between obstructive sleep apnea (OSA) risk and hearing impairment among workers exposed to occupational noise. A cross-sectional study was conducted among 607 healthy male workers at a tire-manufacturing factory. The subjects underwent audiometric testing, and their OSA risk was examined based on the STOP-Bang questionnaire. Hearing impairment was defined as a hearing threshold >25 dB hearing level (HL) in any frequency of 1, 2, 3 and 4 kHz in either ear. High OSA risk was defined as a STOP-bang score of ≥3. Hearing thresholds at 1, 2, 3 and 4 kHz in both ears were significantly higher among workers with high OSA risk than among those with low OSA risk after adjusting for confounders. Multiple logistic regression analysis examining the association of OSA risk and STOP-Bang score with hearing impairment revealed an odds ratio of 1.738 (95% confidence interval [CI] 1.113-2.713, p = 0.015) and 1.256 (95% CI 1.031-1.529, p = 0.023), respectively, after adjusting for confounders. In addition, when the hearing impairment was reclassified into high- and low-frequency hearing impairment, a statistically significant OR was seen for high-frequency hearing impairment. In conclusion, high OSA risk was associated with hearing impairment in occupational noise-exposed workers, especially in the high-frequency range of 3 and 4 kHz. More efforts are required to improve the management of OSA and its risk factors to preserve hearing in occupational noise-exposed workers.

The mediation effect of depression and alcohol use disorders on the association between post-traumatic stress disorder and obstructive sleep apnea risk in 51,149 Korean firefighters: PTSD and OSA in Korean firefighters

BACKGROUND

Post-traumatic stress disorder (PTSD) is shown to be linked to a higher risk of obstructive sleep apnea (OSA). Firefighters are at high risk for PTSD given the increased exposure to trauma.  However, the relationship between PTSD and OSA remains unclear in firefighters. Moreover, alcohol use disorders (AUDs) and depression - also common in firefighters - show a high comorbidity rate with both PTSD and OSA. The purpose of this study was to investigate the association of PTSD, depression, and AUDs with OSA in a national sample of Korean firefighters.

METHODS

A total of 51,149 Korean firefighters completed self-reported questionnaires, assessing the severity of PTSD, OSA, depression, and alcohol misuse. Multivariable logistic regression and mediation analyses were performed.

RESULTS

PTSD, depression, and AUDs were significantly associated with OSA. In the mediation analyses, PTSD had both direct and indirect effects mediated by depression and AUDs on OSA. Depression had both direct and indirect effects on OSA, with the latter mediated by AUDs.

LIMITATIONS

First, high-risk of OSA was measured using the Berlin Questionnaire. Second, other medical comorbidities or mediation use were not considered. Third, self-report questionnaires were used for assessment, which are prone to subjectivity and recollection bias. Finally, the majority of the study population were male and all Korean, limiting generalizability.

CONCLUSIONS

PTSD had both direct and indirect effects on OSA, mediated by depression and AUDs. In patients with both PTSD and OSA, depression and AUD symptoms should be screened routinely.

Obstructive sleep apnea in airline pilots during daytime sleep following overnight flights

To identify the vulnerability of recovery sleep, this study investigated the occurrence of obstructive sleep apnea during daytime sleep following overnight flights in healthy airline pilots. We conducted daytime polysomnography following a long-haul night-time flight in 103 pilots. The following variables were assessed: apnea-hypopnea index, respiratory disturbance index and oxygen desaturation index. Moderate-to-severe obstructive sleep apnea was defined as an apnea-hypopnea index ≥15. Seventy-three pilots (70.9%) with no known history of obstructive sleep apnea presented with moderate-to-severe obstructive sleep apnea. Pilots showed high mean apnea-hypopnea, respiratory disturbance and oxygen desaturation indices. The body mass index, Berlin questionnaire score and cumulative flight time contributed to these indices, with both body mass index and cumulative flight time remaining significant at an apnea-hypopnea index ≥15. We found that pilots are vulnerable to obstructive sleep apnea during daytime sleep after night-time flights, which may deteriorate their health, increase fatigue and impair overall flight safety. Further research is needed to ensure flight safety, as daytime recovery sleep is unavoidable for night-time flight pilots. The pilots' normal and recovery sleep patterns should both be studied to develop an effective sleep management protocol.

Diagnostic performance of the STOP-Bang questionnaire as a screening tool for obstructive sleep apnea in different ethnic groups

STUDY OBJECTIVES

The STOP-Bang questionnaire is a concise and easy screening tool for obstructive sleep apnea (OSA). Using modified body mass index (BMI), we assessed the diagnostic performance of the STOP-Bang questionnaire in predicting OSA in ethnically different groups of patients undergoing surgery.

METHODS

This was a multicenter prospective cohort study involving patients with cardiovascular risk factors who were undergoing major noncardiac surgery. Patients underwent home sleep apnea testing. All patients completed the STOP-Bang questionnaire. The predictive parameters of STOP-Bang scores were calculated against the apnea-hypopnea index.

RESULTS

From 4 ethnic groups 1,205 patients (666 Chinese, 161 Indian, 195 Malay, and 183 Caucasian) were included in the study. The mean BMI ranged from 25 ± 4 to 30 ± 6 kg/m² and mean age ranged from 64 ± 8 to 71 ± 10 years. For the Chinese and Indian patients, diagnostic parameters are presented using BMI threshold of 27.5 kg/m² with the area under curve to predict moderate-to-severe OSA being 0.709 (0.665-0.753) and 0.722 (0.635-0.808), respectively. For the Malay and Caucasian, diagnostic parameters are presented using BMI threshold of 35 kg/m² with the area under curve for predicting moderate-to-severe OSA being 0.645 (0.572-0.720) and 0.657 (0.578-0.736), respectively. Balancing the sensitivity and specificity, the optimal STOP-Bang thresholds for the Chinese, Indian, Malay, and Caucasian groups were determined to be 4 or greater.

CONCLUSIONS

For predicting moderate-to-severe OSA, we recommend BMI threshold of 27.5 kg/m² for Chinese and Indian patients and 35 kg/m² for Malay and Caucasian patients. The optimal STOP-Bang threshold for the Chinese, Indian, Malay and Caucasian groups is 4 or greater.

CLINICAL TRIAL REGISTRATION

Registry: ClinicalTrials.gov; Name: Postoperative Vascular Events in Unrecognized Obstructive Sleep Apnea; URL: https://clinicaltrials.gov/ct2/show/study/NCT01494181; Identifier: NCT01494181.

Validation of the STOP-Bang questionnaire for screening of obstructive sleep apnea in the general population and commercial drivers: a systematic review and meta-analysis

Purpose

Obstructive sleep apnea (OSA) is a critical occupational health concern, but is often undiagnosed in the general population and commercial drivers. The STOP-Bang questionnaire is a simple, reliable tool to screen for OSA, which could improve public health in a cost-effective manner. The objective of this systematic review and meta-analysis is to assess the validity of the STOP-Bang questionnaire to detect OSA in these key populations.

Methods

We searched MEDLINE, Embase, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, PsycINFO, Journals @ Ovid, Web of Science, Scopus, and CINAHL for relevant articles from 2008 to March 2020. The quality of studies was appraised using Cochrane Methods criteria. To calculate pooled predictive parameters, we created 2 × 2 contingency tables and performed random-effects meta-analyses.

Results

Of 3871 citations, five studies that evaluated STOP-Bang in the general population (n = 8585) and two in commercial drivers (n = 185) were included. In the general population, prevalence of all OSA (AHI ≥ 5), moderate-to-severe OSA (AHI ≥ 15), and severe OSA (AHI ≥ 30) was 57.6%, 21.3%, and 7.8% respectively. In commercial drivers, the prevalence of moderate-to-severe OSA was 37.3%. The trends of high sensitivity and negative predictive value of a STOP-Bang score ≥ 3 illustrates that the questionnaire helps detect and rule out clinically significant OSA in the general population and commercial drivers.

Conclusion

This meta-analysis demonstrates that the STOP-Bang questionnaire is a valid and effective screening tool for OSA in the general population and commercial drivers.

Trial registration

PROSPERO No. CRD42020200379; 08/22/2020

Supplementary Information

The online version contains supplementary material available at 10.1007/s11325-021-02299-y.

Association of Snoring with Prediabetes and Type 2 Diabetes Mellitus: The Cardiovascular and Metabolic Diseases Etiology Research Center Cohort

BACKGROUND

Evidence suggests that habitual snoring is an independent risk factor for poor glycemic health. We examined the associations between snoring with prediabetes and diabetes in Korean population.

METHODS

Self-reported snoring characteristics were collected from 3,948 middle-aged adults without prior cardiovascular diseases. Multivariable linear regression assessed the association of snoring intensity, frequency, disruptiveness, and disrupted breathing with fasting glucose and glycosylated hemoglobin (HbA1c) level. Then, multinomial regression evaluated how increasing snoring symptoms are associated with the risk for prediabetes and diabetes, adjusting for socioeconomic and behavioral risk factors of diabetes, obesity, hypertension, and other sleep variables.

RESULTS

Higher snoring intensity and frequency were positively associated with fasting glucose and HbA1c levels. Participants presenting the most severe snoring were at 1.84 times higher risk (95% confidence interval [CI], 1.09 to 2.29) for prediabetes and 2.24 times higher risk (95% CI, 1.84 to 2.95) for diabetes, compared to non-snorers. Such graded association was also observed amongst the most frequent snorers with higher risk for prediabetes (odds ratio [OR], 1.78; 95% CI, 1.29 to 2.22) and diabetes (OR, 2.03; 95% CI, 1.45 to 2.85). Disruptive snoring (OR, 1.60; 95% CI, 1.12 to 2.28) and near-daily disruptive breathing (OR, 2.18; 95% CI, 1.02 to 4.19) were associated with higher odds for diabetes. Such findings remained robust after additional adjustment for sleep duration, excessive daytime sleepiness, unwakefulness, and sleep-deprived driving.

CONCLUSION

Snoring is associated with impaired glucose metabolism even in otherwise metabolically healthy adults. Habitual snorers may require lifestyle modifications and pharmacological treatment to improve glycemic profile.

Prediction of cardiopulmonary events using the STOP-Bang questionnaire in patients undergoing bronchoscopy with moderate sedation

The objective was to evaluate the prevalence of patients at a high risk of having OSA by using a screening questionnaire and to investigate whether the questionnaire can predict patients who are at risk of cardiopulmonary events occurring during a bronchoscopy under sedation. We prospectively enrolled consecutive adult patients who underwent flexible bronchoscopies under moderate sedation. The snoring, tiredness, observed apnea, high blood pressure-body mass index, age, neck circumference and gender (STOP-Bang) questionnaire was used to identify patients at a high (score ≥ 3 of 8) or low risk (score < 3 of 8) of having OSA. The cardiopulmonary events included hypoxemia and hypotension. Multivariable logistic regression was performed with variables selected by the least absolute shrinkage and selection operator. The prevalence of a STOP-Bang score of ≥ 3 was 67.2% (195/290), and 36.9% (107/290) experienced cardiopulmonary events. The multivariable analysis adjusting for chronic obstructive pulmonary disease, chronic kidney disease, baseline SpO₂, and procedure time revealed that a STOP-Bang score of ≥ 3 was significantly associated with cardiopulmonary events in a subgroup of patients without a history of cerebrovascular disease (adjusted odds ratio, 1.94; 95% confidence interval, 1.06-3.54). The STOP-Bang questionnaire can predict cardiopulmonary events occurring during this procedure.Trial registration: NCT03325153.