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Prevalence of Sleep-disordered Breathing and

Sleep Apnea in Middle-aged Urban Indian Men


Zarir F. Udwadia, Amita V. Doshi, Sharmila G. Lonkar, and Chandrajeet I. Singh

Department of Chest Medicine, P. D. Hinduja National Hospital and Medical Research Centre, Veer Savarkar Marg, Mahim, Mumbai, India

No data are available on the prevalence of sleep-disordered breathing METHODS


(SDB) and obstructive sleep apnea–hypopnea syndrome (OSAHS) in
Indians. We conducted a two-phase cross-sectional prevalence study Sample
for the same in healthy urban Indian males (35–65 years) coming to This investigation was based on a random sample of healthy Indian
our hospital in Bombay for a routine health check. We also investigated males residing in Bombay. The males were aged 35–65 years and were
its risk factors and evaluated the significance of the most commonly coming for a health check to our hospital between December 1999 to
asked questions that best correlated with the presence of OSAHS. In December 2000. All of these patients were asymptomatic and came for
the first phase, 658 subjects (94%) returned completed questionnaires a health check as part of their employment policy or for insurance
regarding their sleep habits and associated medical conditions. In the reasons. A two-stage sampling scheme designed to optimize the study’s
second phase, 250 of these underwent an overnight home sleep study. precision by oversampling subjects more likely to have SDB was used
The estimated prevalence of SDB (apnea–hypopnea index of 5 or to construct a cohort representing a wide range of SDB. The exclusion
more) was 19.5%, and that of OSAHS (SDB with daytime hypersomno- criteria were recent myocardial infarction (one subject) and recent
lence) was 7.5%. Multiple stepwise logistic regression determined upper-airway surgery (two subjects).
body mass index, neck girth, and history of diabetes mellitus as the
Procedure
principal covariates of SDB. The presence of snoring, nocturnal chok-
ing, unrefreshing sleep, recurrent awakening from sleep, daytime hyp- In the first stage, subjects were given questionnaires by trained inter-
ersomnolence, and daytime fatigue was each statistically significant viewers. These included questions on presence of snoring, its intensity,
for identifying patients with OSAHS. The higher prevalence of OSAHS the presence of choking/witnessed breathing pauses during sleep, recur-
in urban Indian men is striking and may have major public health rent awakenings from sleep, EDS, prior medical history, medication
use, alcohol consumption, and smoking history. Habitual snoring was
implications in a developing country.
defined as snoring more than 5 days/week. Daytime hypersomnolence
Keywords: epidemiology; sleep study; India (synonymous with EDS) was defined as sleepiness at least 3 or more
days/week during the past 3 months in one or more of the following:
Obstructive sleep apnea–hypopnea syndrome (OSAHS) is a po- after awakening, during free time, at work or driving, or during daytime
in general. A limited physical examination was performed in which the
tentially disabling condition characterized by excessive daytime
height, weight, neck, waist and hip girth, and blood pressure were
sleepiness (EDS), disruptive snoring, repeated episodes of upper measured. Subjects were considered hypertensive if they were currently
airway obstruction during sleep, and nocturnal hypoxemia. Undi- receiving antihypertensive medication or if their systolic blood pressure
agnosed OSAHS represents a major public health hazard. Various was 160 mm Hg or more or diastolic blood pressure was 95 mm Hg or
global epidemiologic studies have demonstrated the prevalence of more. All questionnaire respondents were briefed about our study in
OSAHS to vary from 0.3–5.1% (1–8). These prevalence estimates, a face-to-face interview and were told that they would be contacted
however, are based on data from predominantly white populations later.
and may not be applicable to other racial groups. Major etiologic In the second stage, data of the questionnaire were analyzed, and
factors such as obesity (5, 6, 9) and craniofacial anatomic predispo- the respondents were divided as per their snoring habits into habitual
sition (9–11) are both genetically and environmentally influenced, snorers and nonsnorers. Because most patients with sleep apnea snore
habitually and loudly, we invited by phone 100% of the habitual snorers
and it is therefore pertinent to determine the prevalence of sleep
and 25% of randomly chosen nonsnorers for a home sleep study to
apnea in different populations. yield a cohort with adequate variance in SDB. A technician trained in
There are no data on prevalence of sleep-disordered breath- sleep medicine visited the respondent’s house to attach the limited
ing (SDB) and OSAHS in the Indian population, and hence, we polysomnography (PSG) machine (Compumedics P series, 10-channel
conducted a two-stage study to estimate this in healthy urban system). This machine recorded continuous polygraphic recordings for
Indian males between 35–65 years coming for a routine health electrocardiography, nasal and oral airflow (thermisters), tracheal
check to the P. D. Hinduja National Hospital and Medical Re- sounds, thoracic and abdominal effort (by inductance plethysmo-
search Centre in Bombay, India. We also investigated the risk graphy), limb movement, body position, and oxyhemoglobin level
factors for SDB and OSAHS and evaluated the significance of (pulse oxymeter). The technician stayed until the patient seemed to
the most clinically relevant questions used to diagnose SDB and have slept and noted this time. The awakening time was noted by the
patient himself and reported to the technician when he returned to
OSAHS.
disconnect the leads. The polysomnographic records were manually
scored by a doctor specialized in sleep medicine. An abnormal breathing
event was defined as a complete cessation of airflow for 10 seconds or
more (apnea) or a discernible 50% reduction in respiratory airflow
(Received in original form February 24, 2003; accepted in final form October 31, 2003) accompanied by a decrease of 4% or more in oxyhemoglobin saturation
(hypopnea). The apnea–hypopnea index (AHI) was defined as total
Correspondence and requests for reprints should be addressed to Zarir F. Udwadia,
number of apneas and hypopneas divided by the number of hours of
M.D., F.R.C.P., F.C.C.P., Department of Chest Medicine, P. D. Hinduja National
Hospital and Medical Research Centre, Veer Savarkar Marg, Mahim, Mumbai
sleep. SDB was defined as an AHI of 5 or more and OSAHS as SDB
400002, Maharashtra, India. E-mail: zfu@vsnl.com with daytime hypersomnolence.
This article has an online supplement, which is accessible from this issue’s table Statistical Analysis
of contents online at www.atsjournals.org
Am J Respir Crit Care Med Vol 169. pp 168–173, 2004
Descriptive statistics of all continuous variables were calculated as
Originally Published in Press as DOI: 10.1164/rccm.200302-265OC on November 6, 2003 means and standard deviation, whereas categoric data were expressed
Internet address: www.atsjournals.org as percentages. A comparison between groups was done using Student’s
Udwadia, Doshi, Lonkar, et al.: Sleep Apnea in Urban Indian Men 169

t test for continuous variables, and chi-square test or Fisher’s exact test Prevalence of SDB and OSAHS
was used for discrete variables. The odds ratios and 95% confidence
intervals (CIs) for continuous variables were estimated for the increased A wide range of SDB ranging from apnea–hypopnea scores of
risk of SDB associated with an increase of 1 SD in the mean value of 0–73 was found among the 250 subjects who underwent limited
specific risk factor. All statistical tests were two-sided and were per- PSG. Of these, 93 subjects (87 snorers and 6 nonsnorers), 61
formed at a 5% level of significance (p ⬍ 0.05). The interactions among subjects (all snorers), and 45 subjects (44 snorers and 1 non-
the variables were first examined using correlation coefficient. The snorer) had AHIs of 5 or more, 10 or more, and 15 or more,
variables that were found to be significant were included in multiple respectively. When the mean age and BMI of sample subjects
logistic regression analysis (12). Stepwise logistic regression determined who underwent PSG were compared with those who did not
the most affected risk factors of SDB. All analyses were done with have PSG in the respective snoring groups, no significant differ-
SPSS version 10.0 for Windows.
ence was found. Thus, the prevalence rate of SDB in the PSG
Calculation of Prevalence group of snorers (58%, 95% CI, 50–66%) and nonsnorers (6%,
95% CI, 1–11%) was considered representative of the corre-
The mean age and body mass index (BMI) of subjects who had PSG
were compared with those who did not have PSG in the respective
sponding questionnaire respondents group, and results were ex-
snoring category. If no significant difference was found, the prevalence trapolated (13). Thus, the prevalence of SDB in our population
rate of SDB in the PSG group of snorers or nonsnorers would be was 19.5%.
considered representative of the corresponding questionnaire respon- Forty subjects (39 snorers and 1 nonsnorer) had EDS along
dents group (13). If a significant difference was found between the PSG with an AHI of 5 or more, making the prevalence of OSAHS
and no-PSG groups, a conservative estimate would be adopted, treating in healthy Indian males between 35–65 years 7.5%. The preva-
the SDB subjects documented by PSG as the only subjects with SDB lence of SDB and OSAHS at various cutoff points of AHI is
in the entire corresponding questionnaire group. depicted in Figure 1.
The prevalence of SDB at apnea–hypopnea scores of 5 or
RESULTS more, 10 or more, and 15 or more was extrapolated from the
A flow chart of the study population is available in Figure E1 cohort to the general population (Table 2). The maximum preva-
lence of SDB was seen in the age group 45–54 years. However,
in the online supplement. In the first stage, 658 of 700 men
age was not a significant risk factor, and no significant difference
returned the questionnaire, giving a response rate of 94%. Of
was seen among the three age groups.
these, 171 (26%) were snorers and 487 (74%) were nonsnorers.
In the second stage, all of the snorers (n ⫽ 171) and 25% of Factors Associated with SDB and OSAHS
nonsnorers (n ⫽ 122) were contacted to undergo a home sleep
The significant correlates of SDB in the PSG subjects with the
study (total n ⫽ 293). Of these, 151 (88.3%) snorers and 103
odds ratios are shown in Table 3. The variables, which were
(84.4%) nonsnorers agreed (total n ⫽ 254), giving a participation
significantly affected, were included in a multiple logistic regres-
rate of 87%. Subjects who agreed to the home sleep study and
sion. Stepwise logistic regression selected and retained BMI,
those who refused the home sleep study in snorers and nonsnor-
neck girth, and history of diabetes mellitus as principal covariates
ers showed similar frequencies with regard to their responses to
for SDB. Age-adjusted odds ratio for BMI was 3.47 (95% CI,
all questionnaire items on sleep characteristics, body habitus,
2.23–9.96), for neck girth was 3.85 (95% CI, 1.72–10.11), and for
and age. However, of these, four sleep studies were excluded
history of diabetes mellitus was 2.03 (95% CI, 1.11–2.83).
(one in a snorer and three in nonsnorers), as they were unable
Table 4 shows the odds ratio estimating the increased risk of
to sleep with leads attached and hence disconnected them within
SDB as against specific questions regarding sleep characteristics
1–3 hours. Thus, 250 sleep studies (150 in snorers and 100 in
of the patient. A history of snoring, EDS, nocturnal choking,
nonsnorers) were included in the final analysis.
unrefreshing sleep, recurrent awakening from sleep, and daytime
The demographic profile of the snorers and nonsnorers who
fatigue was each significantly associated with SDB and OSAHS
returned completed questionnaires is given in Table 1. The snorers
with high odds ratio.
had a significantly higher weight, BMI, neck girth, waist girth, and
hip girth as compared with nonsnorers. Habitual snoring was
DISCUSSION
seen in 26% of the study population, nocturnal choking/witnessed
apneas in 5%, and daytime hypersomnolence in 22% of the study A number of epidemiologic studies have been performed to
population. The mean age of the sample was 47.84 years, and the evaluate the prevalence of OSAHS in various ethnic and racial
mean BMI was 24.56. The mean Epworth score of snorers was groups. However, most of these studies are Western studies
8.39 ⫾ 4.67, and that of nonsnorers was 6.05 ⫾ 3.67.

TABLE 1. DEMOGRAPHIC PROFILE AS PER SNORING STATUS


OF THE QUESTIONNAIRE RESPONDENTS
Snorers Nonsnorers Total
Variables (n ⫽ 171) (n ⫽ 487 ) (n ⫽ 658)

Age, years 48.35 ⫾ 7.35 47.67 ⫾ 7.55 47.84 ⫾ 7.5


Weight, kg* 82.45 ⫾ 15.54 70.03 ⫾ 11.38 73.26 ⫾ 13.64
BMI, kg/m2* 27.87 ⫾ 4.98 23.4 ⫾ 3.56 24.56 ⫾ 4.31
Neck girth, inches* 16.21 ⫾ 1.23 15.31 ⫾ 1.01 15.54 ⫾ 1.14
Waist girth, inches* 40.21 ⫾ 4.98 37.24 ⫾ 3.87 38.01 ⫾ 4.43
Hip girth, inches* 42.33 ⫾ 4.17 39.82 ⫾ 3.15 40.47 ⫾ 3.68
Waist:hip ratio 0.95 ⫾ 0.04 0.94 ⫾ 0.06 0.94 ⫾ 0.05
Figure 1. Prevalence rate of sleep-disordered breathing (SDB) and ob-
Definition of abbreviation: BMI ⫽ body mass index. structive sleep apnea–hypopnea syndrome (OSAHS) in 658 question-
Data presented as mean ⫾ SD. naire respondents using various cut-off points of apnea–hypopnea index
* Comparison between snorers and nonsnorers, p ⬍ 0.05. (AHI). EDS ⫽ excessive daytime sleepiness.
170 AMERICAN JOURNAL OF RESPIRATORY AND CRITICAL CARE MEDICINE VOL 169 2004

TABLE 2. AGE-SPECIFIC PREVALENCE RATES OF SDB (95% CONFIDENCE INTERVAL) AT


DIFFERENT SCORES OF APNEA–HYPOPNEA INDEX BASED ON POLYSOMNOGRAPHY RESULTS
FOR THE TOTAL SAMPLE OF 658 QUESTIONNAIRE RESPONDENTS
Prevalence Rate, % (95% CI )
Subjects (n ⫽ 658)
Age, years n (% ) AHI ⭓ 5 AHI ⭓ 10 AHI ⭓ 15

35–44 246 (37.4) 17.2 (12.5–21.9) 8.5 (5.0–11.9) 4.7 (2.1–7.3)


45–54 265 (40.3) 21.9 (16.9–26.9) 21.9 (16.9–26.9) 21.9 (16.9–26.9)
55–65 147 (22.3) 19.4 (13.0–25.8) 10.2 (5.3–15.1) 8.6 (4.1–13.2)
Total 658 (100) 19.5 (16.5–22.5) 11.1 (8.7–13.5) 8.4 (6.2–10.5)

Definition of abbreviations: AHI ⫽ apnea–hypopnea index; CI ⫽ confidence interval.

performed in predominantly white populations and may not be that this is the first epidemiologic study evaluating the prevalence
applicable to other racial groups. Therefore, the global impor- of OSAHS from this country. Sleep medicine has been slow to
tance and impact of this disease remain poorly understood. At develop in India, there being no more than 40 sleep laboratories
present, data from studies in nonwhite groups are too sparse in a country of one billion. High costs of equipment, large patient
to even determine with confidence whether prevalence differs workloads in hospitals, and methodologic difficulties have proba-
worldwide (14). bly been factors that have discouraged other epidemiology stud-
An important Asian study was conducted by Ip and col- ies from India. We have attempted to redress this imbalance
leagues (15), who investigated the prevalence of OSAHS in with this study.
Chinese office workers from Hong Kong. Her figures of 4% Our study is strengthened by the very high response rate of
OSAHS were similar to those from Western studies despite 94%. This study confirms the wide prevalence of OSAHS in
obesity, a strong risk factor for OSAHS, being relatively uncom- the urban Indian population. Our prevalence rates of 7.5% for
mon in Asian countries. She postulated that craniofacial features OSAHS are among the highest prevalence rates reported from
that compromise the upper airways could exist in her population epidemiologic studies across the globe and are higher than most
and account for the high OHAHS prevalence. When 75 skulls Western and other Asian studies. The exact causes for this higher
of Indian origin were compared with 98 of Tuscan origin, cepha- prevalence are unclear, but it is possible that Indian facial and
lometry showed differences in mandibular length and the antero- anthropometric characteristics might be responsible.
posterior dimensions of the nasopharynx-pharyngeal tubercle to India is too vast and diverse a country and huge gulfs exist
posterior nasal spine in the Indian skulls, pointing to the possible between urban and rural populations (70% of Indians live in
presence of an osteogenic etiology of OSAHS (16). Another villages, many remote and inaccessible). Our study population
study by Li and colleagues (17) showed that when compared represents urban Indian males. It also represents males that are
with white men, Far East Asian men were less obese but had a better educated and employed, have higher incomes, and are
greater severity of OSAHS. A crucial conclusion from these of better socioeconomic class and status than an impoverished
studies is that predictive equations for the presence of OSAHS Indian villager. These more affluent males are therefore more
developed from populations of obese, white subjects and based likely to be westernized and perhaps have a higher prevalence
on weight or facial measurements are unlikely to be accurate of diabetes, hypertension and ischemic heart disease than rural
for Asian population, and the prevalence of OSAHS in different Indians. Also, urban Indian males are significantly more obese
ethnic groups may vary considerably and should be studied (BMI of 24) than their rural counterparts (BMI of 20) (18).
individually. Thus, the prevalence rates of our study would be representative
No data are available on the prevalence of this condition of urban males of better socioeconomic status (and may be
from the Indian subcontinent, and a Medline search confirms higher than for rural Indian men). Women were not included

TABLE 3. CORRELATES AND ODDS RATIO (UNADJUSTED) OF SLEEP-DISORDERED BREATHING


BASED ON DEMOGRAPHIC, ANTHROPOMETRIC, AND QUESTIONNAIRE DATA

AHI ⬍ 5 AHI ⭓ 5
Variables (n ⫽ 157) (n ⫽ 93) p Value Odds Ratio for SDB 95% CI

Age, years 47.80 ⫾ 7.49 48.28 ⫾ 7.49 NS 1.12 0.58–2.18


Weight, kg* 77.61 ⫾ 13.34 89.44 ⫾ 16.88 0.0001 8.78 4.16–18.5
BMI, kg/m2* 26.69 ⫾ 4.05 30.76 ⫾ 5.30 0.005 5.70 2.86–11.4
Neck girth, inches* 15.29 ⫾ 1.08 16.37 ⫾ 1.43 0.012 5.34 2.01–14.2
Waist girth, inches* 39.80 ⫾ 4.86 43.21 ⫾ 5.47 0.013 6.24 2.94–13.2
Hip girth, inches* 41.98 ⫾ 3.55 45.10 ⫾ 4.70 0.002 5.58 2.67–11.6
Waist:hip ratio 0.95 ⫾ 0.01 0.96 ⫾ 0.01 NS 1.52 0.68–3.39
Hypertension* 27 (17) 36 (39) 0.017 1.21 1.02–1.66
Diabetes* 11 (7) 28 (30) 0.003 2.68 1.45–3.68
Habitual drinking* 9 (6) 18 (19) 0.001 3.95 1.69–9.21
Smoking 21 (13) 14 (15) NS 1.15 0.55–2.38

Definition of abbreviations: AHI ⫽ apnea–hypopnea index; BMI ⫽ body mass index; CI ⫽ confidence interval; NS ⫽ not significant;
SDB ⫽ sleep-disordered breathing.
Data presented as mean ⫾ SD or n (%).
Odds ratio estimated for increase of 1 SD over mean for parameters expressed as mean ⫾ SD.
* Comparison between an AHI of ⬍ 5 and an AHI of ⭓ 5, p ⬍ 0.05.
Udwadia, Doshi, Lonkar, et al.: Sleep Apnea in Urban Indian Men 171

TABLE 4. ODDS RATIO (UNADJUSTED) FOR SLEEP-DISORDERED BREATHING AND


SLEEP-RELATED HISTORY
Parameter % in AHI ⭓ 5 % in AHI ⬍ 5 Odds Ratio 95% CI for Odds Ratio p Value

Snoring 94 40 19.4 9.36–40.3 ⬍ 0.001


EDS 43 24 2.67 1.92–3.84 ⬍ 0.050
Nocturnal choking 24 1 24.6 8.39–71.8 ⬍ 0.001
RAS 10 1 8.94 2.4–33.3 ⬍ 0.050
Unrefreshing sleep 30 2 22.9 9.07–58.0 ⬍ 0.001
Daytime fatigue 29 7 5.12 2.55–10.3 ⬍ 0.001

Definition of abbreviations: AHI ⫽ apnea–hypopnea index; CI ⫽ confidence interval; EDS ⫽ excessive daytime sleepiness;
RAS ⫽ recurrent awakening from sleep.

in our study because our point of inclusion was subjects having colleagues (30) used the criteria of AHI of 10 or more and
company checks for employment or insurance reasons; fewer found the prevalence of OSAHS to be 1%. In a sample of male
women than men are sent for such checks in India, and they population using a definition of OSAHS as an AHI of 10 or
would have therefore been underrepresented. Another practical more plus daytime hypersomnolence, hypertension, or other
reason for excluding women was bearing in mind Indian social cardiovascular complications, Bixler and coworkers (31) found
norms: most Indian women would have been reluctant to allow a prevalence of 3.3%. Using an AHI of 10 or more with EDS
a male technician to enter their house for a night study. as definition of OSAHS, Duran and coworkers (26) found a
The results of a prevalence study are influenced by the charac- prevalence of 3.2% in Spain. Stradling and Crosby (32) used the
teristic of the study population. Because the prevalence found definition of an AHI of 20 or more with symptoms and found
in the study group can only be generalized to a population with the prevalence of OSAHS in the United Kingdom to be 0.3%.
similar characteristics, the study group must be representative of The prevalence of OSAHS seen in our study was higher and
the total population. Unfortunately, there are no studies stating was 7.5%, 6.1%, and 5.4% using AHI cut-offs of 5 or more, 10
national average BMI for Indians. Dhurandhar and Kulkarni or more, and 15 or more with EDS, respectively.
(19) studied a population from various sections of society from The correlation between age and SDB has been studied by
Bombay and found the mean BMI of adult males to be 23.9 ⫾ different investigators with dissimilar results, with suggestion of
3.8. The mean BMI of our study population was 24.56 ⫾ 4.3 a rise in prevalence of SDB with age (5, 26, 31, 33). Age was
(statistically no significant difference). Because BMI was an im- not found to be a significant risk factor in our study, and no
portant predictor of SDB, our population would be fairly repre- such trend in the prevalence of SDB with increasing age was
sentative of adult urban Indian males. seen. The highest prevalence was seen in the age group 45–54
We used home sleep studies for the diagnosis of OSAHS in years, but it was not significantly higher than the prevalence in
our study population. Although the proposed gold standard for the other two age groups. The lack of a continuous increase in
the diagnosis of OSAHS is in-patient overnight PSG (20), as the prevalence of SDB with increasing age in our study suggests
recommended by American (21) and Australasian (22) guide- that age is not a strong risk factor for SDB over the middle
lines, it is unclear whether such complex and expensive investiga- decades of life.
tion is appropriate, especially in a developing country. A number Obesity is a significant risk factor for SDB in white popula-
of studies (23–25) have shown that domiciary use of a portable tions (5–8). In this study, a higher BMI was a risk factor for
respiratory device can be a cost-effective yet accurate way to SDB in Indian subjects as well. To assess further the impact of
diagnose OSAHS. The diagnostic usefulness of the home sleep obesity on SDB in our population, the relative risks of having
study is supported by its acceptable sensitivity and specificity. SDB in relation to measure of body habitus were calculated.
Our findings of habitual snoring in 26% of population, noctur- On comparing the odds ratios in our subjects with those reported
nal choking in 5%, and daytime hypersomnolence in 22% are in the Wisconsin study (5) and the study of Ip and colleagues
consistent with those found by the others (26, 27) and indicate (15), the risks of having SDB due to an increase in any index
that the symptoms of OSAHS are common in the general popula- of adiposity was much higher in our population (Table 3). An
tion. The definition of OSAHS is arbitrary, and it has been epidemic of obesity is sweeping across India (34), and it could
suggested that an AHI of 5 or more is a low cut-off value, be projected that the number of cases of OSAHS will increase
especially for older people (28, 29), and many studies have used over the next few decades. However, it is worth stating that 46%
higher cut-off values for AHI. Young and coworkers in their of our subjects with SDB had a BMI of less than 30, the Western
Wisconsin study (5) found the prevalence of OSAHS to be 4%, cut-off for obesity (35), whereas 27% of subjects with SDB had
2.3%, and 1.4% using AHI cut-offs of 5 or more, 10 or more, a BMI of less than 27, which is the cut-off point for obesity
and 15 or more with moderate to severe daytime sleepiness. Ip in Asians (36). These observations suggest that a significant
and colleagues (15) found the prevalence of OSAHS in Hong percentage of our subjects were not obese by Western or Asian
Kong as 4%, 3.2%, and 3.1% at an AHI of 5 or more, 10 or standards but still had SDB. This leads us to postulate that other
more, and 15 or more, respectively. Gislason and colleagues (3) craniofacial risk factors for SDB, such as pharyngeal narrowing,
found the prevalence of OSAHS in Sweden to be 1.4% and retrognathia or micrognathia, and pharyngeal collapsibility,
0.9% with an AHI of 5 or more and 10 or more, respectively. might assume greater pathogenic significance in Indian subjects
Cirignotta and colleagues (4) found the prevalence of OSAHS and may be responsible for our higher prevalence.
to be 5.1% and 3.3% in Italy using an AHI cut-off of 5 or more The importance of a larger neck girth in producing upper
and 10 or more, respectively, but only 0.5% of these had severe airway incompetence during sleep has been documented in pa-
symptomatic OSAHS requiring treatment. Bearpark and col- tients with sleep apnea in a number of studies (13, 32, 37, 38),
leagues (6) found the prevalence of OSAHS in Australia to be and the mechanism is presumably external compression of the
3.1% using an AHI of 5 or more with sleepiness. Franceschi and pharynx by superficially located fat masses. In agreement with
172 AMERICAN JOURNAL OF RESPIRATORY AND CRITICAL CARE MEDICINE VOL 169 2004

these findings, our study also showed neck girth to be an important awakening from sleep, unrefreshing sleep, and daytime fatigue
predictor of SDB and found that the risk of SDB is 5.34 times should always be elicited while evaluating a patient with possible
higher for subjects with a neck girth of 17 inches (mean ⫹ SD) OSAHS. The application of these easily identifiable predictive
or more—the mean being 15.7 and the SD being 1.33 for 250 factors would assist in appropriate referral and prioritization for
subjects with PSG. PSG. With the high prevalence of OSAHS and limited funds,
A significant association of SDB with diabetes mellitus was this might be useful for better utilization of resources.
found in our study after adjusting for demographics (age) and
Conflict of Interest Statement : Z.F.U. has no declared conflict of interest; A.V.D.
anthropometric variables (including BMI and neck girth). A has no declared conflict of interest; S.G.L. has no declared conflict of interest;
number of studies have shown that SDB may be causally associ- C.I.S. has no declared conflict of interest.
ated with metabolic derangements such as glucose intolerance
and insulin resistance (39–41). The association of diabetes and Acknowledgment : The authors thank their statisticians, Ms. Nikita Agnihotri and
Mr. Suresh Bowalekar, for helping with statistical analysis; PFT technicians Ms.
OSA has been evaluated in a sample of 116 age-stratified men Lalita Angne and Ms. Mangal Walkar for distributing and collecting the question-
with hypertension selected from subjects in a population-based naires from health check patients; Professor Mary Ip from Hong Kong and Professor
study in Sweden. It was shown that although obesity was the John Stradling from Oxford for their constructive advice; and the Research and
Ethical Committee of Hinduja Hospital for supporting this study.
main risk factor for diabetes mellitus, coexistent severe OSA
may add to the risk independently (42). Also recent studies by
Ip and colleagues (43) and Punjabi and colleagues (44) have References
shown that SDB is independently associated with glucose intoler- 1. Lavie P. Incidence of sleep apnea in a presumably healthy working
ance and insulin resistance. Collectively, the effects of elevated population. Sleep 1983;6:312–318.
sympathetic activity, the alterations in glucocorticoid regulation 2. Berry DT, Webb WB Block AJ, Switzer DA. Sleep-disordered breathing
and its concomitants in a subclinical population. Sleep 1986;9:478–483.
induced by sleep loss, and recurrent intermittent hypoxemia 3. Gislason T, Almqvist M, Eriksson G, Taube A, Boman G. Prevalence
associated with SDB may facilitate the development of glucose of sleep apnea syndrome among Swedish men: an epidemiological
intolerance and insulin resistance. However, in our study, we study. J Clin Epidemiol 1988;41:571–576.
did not measure blood sugar or insulin levels and considered 4. Cirignotta F, D’Alessandro R, Partinen M, Zucconi M, Cristina E, Ge-
diabetes to be present when the respondent gave that history rardi R, Cacciatore FM, Luugaresi E. Prevalence of every night snoring
in the questionnaire. and obstructive sleep apneas among 30–69-year-old men in Bologna,
In contrast to a systematic review in which no firm evidence Italy. Acta Psychiatr Scand 1989;79:366–372.
5. Young T, Palta M, Dempsey J. Skatrud J, Weber S, Badr S. Occurrence
for the contribution of OSAHS to hypertension was demonstrated of sleep disordered breathing among middle-aged adults. N Engl J
(45), it has been recently shown that SDB and hypertension are Med 1993;328:1230–1235.
clearly linked (46–48). In our study, although an association of 6. Bearpark H, Elliott L, Grunstein R, Cullen S, Schneider H, Althaus W,
SDB with hypertension was significant, multiple logistic regression Sullivan C. Snoring and sleep apnea: a population study in Australian
analysis did not select hypertension as a principle covariate. men. Am J Respir Crit Care Med 1995;151:1459–1465.
Another objective of our study was to evaluate the signifi- 7. Oslon LG, King MT, Hensley MJ, Saunders NA. A community study of
cance of common symptoms that are known to be associated snoring and sleep-disordered breathing: prevalence. Am J Respir Crit
Care Med 1995;152:711–716.
with SDB and OSAHS. We found that a positive history of 8. Ohayon M, Guillemenault C, Priest RG, Caulet M. Snoring and breathing
snoring, EDS, nocturnal choking, recurrent awakening from pauses during sleep: telephone interview survey of a UK population
sleep, unrefreshing sleep, and daytime fatigue were each signifi- sample. BMJ 1997;314:860–863.
cantly associated with SDB and OSAHS with high odds ratio and 9. Ferguson KA, Takashi O, Lowe AA, Ryan F, Fleetham J. The relation-
must be elicited while evaluating patients with possible OSAHS. ship between obesity and craniofacial structure in obstructive sleep
The limitations of our study are that it only represents preva- apnea. Chest 1995;108:375–381.
lence rates in urban Indian male population, and these rates 10. Hudgel DW. Mechanisms of obstructive sleep apnea. Chest 1992;101:
541–549.
cannot be generalized to the rural Indian population or to Indian
11. Mathur R, Douglas NJ. Family studies in patients with the sleep apnea-
women. Also, lack of EEG defined sleep may have caused an hypopnea syndrome. Ann Intern Med 1995;122:174–178.
underestimation of AHI. The strengths of this study are that 12. Hosmer DW, Lemeshow S. Applied logistic regression. New York: John
this is the only study to date investigating the prevalence of SDB Wiley; 1989.
and OSAHS in India. The study is also strengthened by the high 13. Keenan SP, Ferguson KA, Chan-Yeung M, Fleetham JA. Prevalence of
response rate of 94%, and thus, overestimation of prevalence sleep disordered breathing in a population of Canadian grainworkers.
due to participation by subjects with self-perception of sleep Can Respir J 1998;5:184–190.
14. Young T, Peppard PE, Gottlieb DJ. Epidemiology of obstructive sleep
disorders would be unlikely.
apnea: a population health perspective. Am J Respir Crit Care Med
In summary, we found that the prevalence of SDB was 19.5%, 2002;165:1217–1239.
and that of OSAHS was 7.5% in healthy urban Indian males 15. Ip MS, Lam B, Lauder IJ, Tsang K, Chung K, Mok Y, Lam W. A
between 35–65 years of age. The findings of this study and the community study of sleep-disordered breathing in middle-aged Chi-
high prevalence rates in middle-aged urban Indian men might nese men in Hong Kong. Chest 2001;119:62–69.
have important public health implications in a developing coun- 16. Hilloowala RA, Trent B, Gunel E, Pifer RG. Proposed cephalometric
try with limited health resources. Indian men in this age group diagnosis for osteogenic obstructive sleep apnea (OSA): the mandibu-
lar/pharyngeal ratio. Cranio 1999;17:280–288.
have among the highest rates of ischemic heart disease and
17. Li KK, Powell NB, Kushida C, Rikey RW, Guilleminault C. A compari-
hypertension worldwide (49). When compared with whites, son of Asian and white patients with obstructive sleep apnea syndrome.
blacks, Hispanics, and other Asians, coronary artery disease Laryngoscope 1999;109:1937–1940.
rates among Indians worldwide are two to four times higher at 18. Enas EA. Coronary artery disease epidemic in Indians: a cause for alarm
all ages (18). India also has among the largest number of individu- and call for action. J Indian Med Assoc 2000;98:697–702.
als with diabetes (approximately 25 million) (50). The potential 19. Dhurandhar NV, Kulkarni PR. Prevalence of obesity in Bombay. Int J
impact of undetected and uncontrolled OSAHS on the pre- Obes Relat Metab Disord 1992;16:367–375.
20. Douglas NJ, Thomas S, Jan MA. Clinical value of polysomnography.
viously mentioned populations might be considerable (51, 52) Lancet 1992;339:347–350.
and worthy of further study. In our study, BMI, neck girth, and 21. Phillipson EA, Remmers JE. American Thoracic Society Consensus Con-
a history of diabetes mellitus were significantly associated with ference on indications and standards for cardiopulmonary sleep stud-
SDB, and a history of snoring, EDS, nocturnal choking, recurrent ies. Am Rev Respir Dis 1989;139:559–568.
Udwadia, Doshi, Lonkar, et al.: Sleep Apnea in Urban Indian Men 173

22. McAvoy RD. Guidelines for respiratory sleep studies. Sydney: Thoracic 38. Flemons WW, Whitelaw WA, Brant R, Remmers JE. Likelihood ratios
Society of Australia and New Zealand; 1988. for a sleep apnea clinical prediction rule. Am J Respir Crit Care Med
23. Orr WC, Eiken T, Pegram V, Jones R, Rundell OH. A laboratory valida- 1994;150:1279–1285.
tion study of a portable system for remote recording of sleep related 39. Stoohs RA, Facchini F, Guilleminault C. Insulin resistance and sleep
respiratory disorders. Chest 1994;105:160–162. disordered breathing in healthy humans. Am J Respir Crit Care Med
24. Man GC, Kang BV. Validation of a portable sleep apnea monitoring 1996;154:170–174.
device. Chest 1995;108:388–393. 40. Wilcox I, McNamara SG, Collins FL, Grunstein RR, Sullivan CE. “Syn-
25. Whittle AT, Finch SP, Mortimore IL, MacKay TW, Douglas NJ. Use drome Z”: the interaction of sleep apnoea, vascular risk factors and
of home sleep studies for diagnosis of the sleep apnoea/hypopnoea heart disease. Thorax 1998;53:S25–S28.
syndrome. Thorax 1997;52:1068–1073. 41. Kiely JL, McNicholas WT. Cardiovascular risk factors in patients with
26. Duran J, Esnaola S, Rubio R, Iztueta A. Obstructive sleep apnea- obstructive sleep apnoea syndrome. Eur Respir J 2000;16:128–133.
hypopnea and related clinical features in a population-based sample of 42. Elmasry A, Lindberg E, Berne C, Janson C, Gislason T, Tageldin MA,
subjects aged 30 to 70 yr. Am J Respir Crit Care Med 2001;163:685–689. Bowman G. Sleep-disordered breathing and glucose metabolism in
27. Carmelli D, Bliwise DL, Swan GE, Reed T. Genetic factors in self- hypertensive men: a population-based study. J Intern Med 2001;249:
reported snoring and excessive daytime sleepiness: a twin study. Am 153–161.
J Respir Crit Care Med 2001;164:1910–1913. 43. Ip MS, Lam B, Ng MM, Lam WK, Tsang KW, Lam KS. Obstructive
28. Phillips BA, Berry DTR, Lipke-Molby TC. Sleep disordered breathing sleep apnea is independently associated with insulin resistance. Am J
in healthy, aged persons: fifth and final year follow-up. Chest 1996; Respir Crit Care Med 2002;165:670–676.
110:654–658. 44. Punjabi NM, Sorkin JD, Katzel LI, Goldberg AP, Schwartz AR, Smith
29. Ancoli-Israel S, Kripke DF, Klauber MR, Fell R, Stepnowsky C, Estline PL. Sleep-disordered breathing and insulin resistance in middle-aged
and overweight men. Am J Respir Crit Care Med 2002;165:677–682.
E, Khazani N, Chinn A. Morbidity, mortality and sleep-disordered
45. Wright J, Johns R, Watt I, Melville A, Sheldon T. The health effects of
breathing in community dwelling elderly. Sleep 1996;19:277–282.
obstructive sleep apnea and the effectiveness of continuous positive
30. Franceschi M, Zamproni P, Crippa D, Smirne S. Excessive daytime sleepi-
airway pressure: a systematic review of the research evidence. BMJ
ness: a 1-year study in an unselected in-patient population. Sleep 1982;5:
1997;314:851–860.
239–247.
46. Young T, Peppard P, Palta M, Hla KM, Finn L, Morgan B, Skatrud J.
31. Bixler EO, Vgontzas AN, Ten Have T, Tyson K, Kales A. Effects of
Population-based study of sleep-disordered breathing as a risk factor
age on sleep apnea in men: I: prevalence and severity. Am J Respir
for hypertension. Arch Intern Med 1997;157:1746–1752.
Crit Care Med 1998;157:144–148. 47. Lavie P, Herer P, Hofstein V. Obstructive sleep apnea as a risk factor
32. Stradling JR, Crosby JH. Predictors and prevalence of obstructive sleep for hypertension: population study. BMJ 2000;320:479–482.
apnea and snoring in 1,001 middle-aged men. Thorax 1991;46:85–90. 48. Nieto FJ, Young TB, Lind BK, Shahar E, Samet JM, Redline S, D’Agos-
33. Ancoli Israel S, Kripke DF, Klauber MR, Mason WJ, Fell R, Kaplan tino RB, Newman AB, Lebowitz MD, Pickering TG. Association of
O. Sleep-disordered breathing in community dwelling elderly. Sleep sleep-disordered breathing, sleep apnea, and hypertension in a large
1991;14:486–495. community based study: Sleep Heart Health Study. JAMA 2000;283:
34. Zargar AH, Masoodi SR, Laway BA, Khan AK, Wani AI, Bashir MI, 1829–1836.
Akhtar S. Prevalence of obesity in adults: an epidemiological study 49. Ramachandran A, Sathyamurthy I, Snehalatha C, Satyavani K, Sivasana-
from Kashmir Valley of Indian Subcontinent. J Assoc Physicians India kari S, Misra J, Girinath MR, Viswanathan V. Risk variables for coro-
2000;48:1170–1174. nary artery disease in Asian Indians. Am J Cardiol 2001;87:267–271.
35. Garrow JS. Obesity. In: Weatherall DJ, Leadingham JGG, Warrell DA, 50. Iyer SR. Type 2 diabetes express highway, where is the “U” turn?
editors. Oxford textbook of medicine, 3rd ed. Oxford, UK: Oxford J Assoc Physicians India 2003;51:495–500.
University Press; 1996. p. 1304–1314. 51. Shahar E, Whitney CW, Redline S, Lee ET, Newman AB, Javier Nieto F,
36. International Diabetes Institute, World Health Organization. The Asia- O’Connor GT, Boland LL, Schwartz JE, Samet JM. Sleep-disordered
Pacific perspective: redefining obesity and its treatment. Melbourne, breathing and cardiovascular disease: cross-sectional results of the
Australia: Health Communications Australia Pty Ltd.; 2000;15–21. Sleep Heart Health Study. Am J Respir Crit Care Med 2001;163:19–25.
37. Katz I, Stradling J, Slutsky AS, Zamel N, Hoffstein V. Do patients 52. Mooe T, Franklin KA, Holmstrom K, Rabben T, Wiklund U. Sleep-
with obstructive sleep apnea have thick necks? Am Rev Respir Dis disordered breathing and coronary artery disease: long-term prognosis.
1990;141:1228–1231. Am J Respir Crit Care Med 2001;164:1910–1913.