Investigating Obstructive Sleep Apnea (OSA) in African and Latin Americans from Chicago - ICJS - International Collegiate Journal of Science

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Abstract

Obstructive sleep apnea (OSA) is a significant sleep disorder affecting millions of Americans. With only ⅕ of Americans affected by obstructive sleep apnea receiving diagnosis and treatment, there is a need for more research and intervention.¹ The purpose of this literature review is to provide a thorough overview of the history, epidemiology, social determinants of health, clinical symptoms, existing interventions, and possible future interventions for OSA. Drawing on 24 scholarly articles from PubMed and Google Scholar, the literature review investigates gaps in existing research and interventions related to the diagnosis and treatment of OSA within Chicago, Illinois and identifies the limits of current interventions. The Black and Hispanic minority populations in Chicago are at most risk of developing OSA and going untreated. These marginalized populations tend to have disproportionately high rates of OSA due to factors such as BMI, way of life, access to healthcare, and lack of education. It is necessary to implement more effective public health interventions that educate these populations on the widespread symptoms of the condition. We have used information from the literature review to develop a plan of action for OSA education and treatment in Chicago, which we outline in this article.

Keywords: obstructive sleep apnea, sleep health, sleep disorder, health implications, Chicago

Introduction

Obstructive sleep apnea (OSA) is one of the most common medical conditions, with an estimated prevalence rate of 20 percent² in the United States, and 14 percent globally²¹. Still, the vast majority of the population (80% or over 23 million individuals) believed to have clinically significant OSA are undiagnosed³. OSA refers to the temporary cessation of or large reduction in breathing (apnea) while sleeping⁴. OSA can be caused by repetitive bouts of upper airway obstruction during sleep as a result of the narrowing of respiratory passages⁵. It is one of the most common sleep-related breathing disorders, and can significantly reduce quality of life⁶. Sleep apnea was only officially recognized as a disorder in the twentieth century. However, the condition has been around for far longer, and recorded cases of likely sleep apnea symptoms go back 2,000 years⁷.

Some factors that might contribute to an individual suffering from OSA include obesity, thickened lateral pharyngeal walls, nasal congestion, an enlarged uvula, and/or facial malformations. The prevalence of OSA is particularly high among African Americans and Hispanic individuals, which can be attributed to these population’s distinct craniofacial structures, genetics, and higher rates of obesity⁸. OSA is a necessary issue to address because of its extraordinarily high prevalence and rates of diagnosis. In fact, the estimated economic cost of undiagnosed sleep apnea in the U.S. was nearly $150 billion in 2015. This estimate considers both the effects of comorbidities (e.g. high blood pressure, diabetes, vehicle accidents) and indirect factors like decreased workplace productivity due to reduced quality of life⁹.

To effectively address OSA and ensure that Americans can access equitable healthcare, decrease the economic cost of undiagnosis, and improve quality of life, better public education about the condition is imperative, especially in its early stages. This will improve the timeliness and success of interventions. In this literature review, we outline the epidemiology of OSA, describe the factors that contribute to individuals developing OSA, identify which populations are disproportionately affected, analyze existing public health efforts, and discuss future solutions to address this prevalent issue.

Methods

Using 30 sources, including peer-reviewed articles, government reports, and other scholarly sources on PubMed and Google Scholar, we conducted a literature review to identify the gaps in prior research and limitations of current interventions that prevent certain communities from receiving effective OSA interventions. This literature review considers data specifically related to causes and risk factors for OSA, populations most affected, the prevalence of OSA, and current interventions. We also interviewed 2 stakeholders who are sleep health professionals over Zoom for information on how we can implement our plan of action. We analyzed and interpreted data about at-risk populations and interventional gaps by transforming it into a plan of action which holistically addresses these concerns.

Literature Review

According to the National Aging Council, roughly 39 million Americans have been diagnosed with OSA¹⁰. The rate at which OSA was diagnosed increased dramatically from about 108,000 cases in 1990 to over 1.3 million in 1998, a 12-fold increase, and continued to surge from 2000 to 2010 with an additional increase of over 700,000 cases due to increasing prevalence of risk factors such as obesity and with better diagnosis¹¹.

The prevalence of OSA in Chicago, with large Hispanic and Black populations that are particularly at risk, is especially high. Compared to the national population, of which 13.6% is Black and 19.1% is Hispanic¹², 18% of Chicago’s population consists of Black or African American individuals and about 19% are Hispanic or Latino. Comorbidities are very common in these populations, with the reported prevalence of hypertension, obesity, and diabetes at 17.1%, 5.5%, and 35.4%, respectively, for both populations¹³. More specifically, the odds for hypertension associated with higher sleep fragmentation and poorer self-reported sleep quality are significantly higher for Black and Hispanic groups¹³. A Chicago study by the National Institutes of Health (NIH) found that Black participants had the shortest sleep duration (409.3 minutes), the lowest sleep percentage (87.6%), greatest minutes of wake after sleep onset (52.5 minutes), and sleep fragmentation (23.1%) of all study subjects. Furthermore, in Black and Hispanic participants, the level of restlessness (wake after sleep onset) was worse in those with less extensive educational background, likely because of the occupations that these individuals tend to work. The rising prevalence of sleep apnea in Chicago – the third most populous city in the nation – reflects broader trends in the United States, which has seen a 12-fold increase in the prevalence of the condition from the years 1990 to 1998¹⁴.

The Socioecological Model

The socioecological model, which illustrates that health behaviours are affected by the interaction between the characteristics of the individual, and their social and political environments, sheds more light on the nature of health disparities surrounding OSA. There are a total of five factors that work together to make up this model. These factors are intrapersonal (abilities, knowledge, and behavior), interpersonal (friends and family), institutional (schools and workshops), community (city, county, neighborhood), and policy(Federal and state governments).

Personal

On the individual level, multiple factors can influence OSA prevalence and severity including gender, age, and body mass index. Alcohol consumption (for women in particular) and cardiovascular disease are also important factors – though OSA is generally more common in men than women¹⁵. In the population at large, the two major factors driving growth in OSA prevalence are rising obesity rates and an aging population. High BMI and old age are both major risk factors of OSA¹⁵. Additionally, there are anatomical and physiological factors that can contribute to the development of OSA, such as the size and shape of the upper airway, and one reason why obese individuals are at high risk of OSA is because they have excess soft tissue around the neck, which can collapse and block the airway during sleep. Moreover, menopausal women can experience changes in muscle tone, hence increasing the likelihood of an airway collapse or OSA¹⁹.

Interpersonal

From an interpersonal perspective, friends, family and the broader community influence the prevalence and severity of OSA. Dietary practices within one’s racial or ethnic community partly explain the occurrence of OSA²³, for example, by increasing fat intake and body weight. Another factor that contributes to OSA is genetics received from family members, which can affect an individual’s development of facial muscles, leading to genetically induced OSA. Lastly, some communities and cultures lack awareness on the significance of sleep disorders because they are not considered as something to seek treatment for.

Community

There are various community-based factors that influence OSA rates, including urbanization, socioeconomic status, healthcare access, and awareness. Black and Hispanic populations in Chicago tend to experience greater financial difficulty, which contributes to a lack of access to healthcare and low diagnosis rates. This is compounded by the fact that most communities across the US have very limited awareness on the prevalence and significance of OSA, which further contributes to higher rates of individuals going untreated for the condition.

Organizational

Many organizations such as the National Heart, Lung, and Blood Institute (NHLBI), the American Academy of Sleep Medicine (AASM), the American Sleep Apnea Association (ASAA), and organizations like Houston Sleep Solutions work to research the effects of OSA on millions of patients around America. These organizations not only research the condition but also educate Americans about OSA and the treatments patients should use to combat its effects. However, specific communities such as the Black and Hispanic communities in Chicago lack access to and understanding of the treatments needed for OSA, and may be less likely to encounter them given inequities in access to health insurance, healthcare facilities, and treatment¹⁶. These populations may also be less likely to trust medical information due to a history of discrimination and mistreatment in clinical studies – for example, the Tuskegee Syphilis study, where Black men were prohibited from medical care so doctors could observe disease progression.

Policy

The US government also works to decrease the costs of expensive sleep apnea treatments for OSA patients. For instance, Medicare, federal health insurance for people 65 and older, may cover a 3-month trial of CPAP therapy for patients diagnosed with OSA. In terms of oral treatment for sleep apnea, the Durable Medical Equipment benefit (SSA 1861(s) (6)) covers oral appliances used to treat OSA. However, despite these insurance measures, many patients from Hispanic and African American communities face issues with their healthcare providers when it comes to understanding and attaining OSA technological treatments. Oftentimes, men, minorities, and persons with a lack of health literacy (typically attributed to a lower level of education) are less likely to self-report trouble sleeping¹⁷. These issues can also be attributed to the limited access to healthcare, socioeconomic barriers, and under-appreciation of the seriousness of OSA. In order to further improve access to OSA treatments, there must be more action taken to reduce costs and address health literacy disparities within African American and Hispanic populations.

Table 1: Overview of Sleep Apnea Programs for low-resourced Black/Hispanic populations in Chicago

Stakeholder Perspectives

Dr. Jennifer Mundt, a sleep psychologist at the Feinberg School of Medicine, gave us insights about patient adherence to CPAP post diagnosis. In her work, she uses behavioral treatment to help patients overcome their claustrophobia and other anxieties about CPAP through systematic desensitization, where she has developed detailed treatment plans that gets patients to the end goal of using the CPAP treatment successfully through the night. Often when patients with sleep apnea are sent to her, she discovers that they also have insomnia, and believes that it would be beneficial to research this overlap further. She also recommends that AI tools could help improve PAP adherence.

Dr. Phyllis Zee, a professor of sleep medicine at the Feinberg School of Medicine, gave insights on ethnic groups and populations most affected by OSA in Chicago as well as across the nation. She works at the Circadian & Sleep Medical Clinic, integrating personalized treatments and digital solutions to more efficiently diagnose sleep apnea. Her work has made it possible for patients to be tested for sleep apnea from their homes using PAP machines. She also gave much insight into personalizing treatments for patients since the same treatment is not preferred by everyone. Her clinic uses AI to develop treatment plans, record data, and score studies/diagnostics. She has found digital technologies to be useful in her practice, and believes that a transition to greater adoption of digital health solutions will enhance rates of sleep apnea diagnosis.

Digital Health Solutions

The Quintuple Aim model provides a comprehensive framework for addressing healthcare challenges by focusing on improving population health, enhancing patient experience, reducing costs, improving healthcare providers’ experiences, and advancing health equity. In Chicago’s healthcare landscape, digital solutions are transforming the management of Obstructive Sleep Apnea (OSA). Innovations like CPAP, APAP, BiPAP, and the Inspire Sleep Apnea device leverage technology to customize air pressure and enhance airflow, crucial for stabilizing oxygen levels in patients. More specifically, CPAP (Continuous Positive Airway Pressure) delivers a constant set stream of air pressure while APAP (Automatic Positive Airway Pressure) automatically adjusts air pressure based on the user’s current breathing. BiPAP (Bilevel Positive Airway Pressure) has two levels of air pressure which include IPAP, or higher pressure during inhalation, and EPAP, which is lower pressure during exhalation. This is used for patients with complex sleep apnea who haven’t adhered to CPAP or APAP. The Inspire Sleep Apnea device is unlike any PAP machine because it is an implantable device that focuses less on air pressure and more on hypoglossal nerve stimulation to move the tongue forward. Artificial intelligence (AI) further refines OSA care by predicting treatment outcomes and improving therapy strategies. By aligning with this framework, digital interventions for OSA diagnosis and management can help optimize care delivery and achieve equitable health outcomes for OSA patients across diverse communities in Chicago.

Table 2: The Quintuple Aim Model and benefits of digital health measures for sleep apnea

Plan of Action

To accomplish our twelve-month plan to improve sleep apnea diagnosis and treatment for the Black and Hispanic population in Chicago, we will break our plan up into four 3-month intervals. This intervention was designed with the help of the OSA professionals we interviewed and incorporates findings from our literature review.

From January to March, we will begin conducting a health promotion program inside the Chicago Area. The program will distribute educational materials around the community, and hold assemblies where qualified sleep doctors educate the public on sleep apnea. Additionally, we plan to erect a tent to act as a diagnostic facility, and will seek approval from local health departments or apply for assistance from federal/state facilities like the CDC which can allow access to pre-designed emergency facilities (e.g. rapid-deployment shelters).

Another viable option is collaborating with the American Sleep Apnea Association and SecondWindCPAP as their partnership provides free CPAP machines to those in need, and setting up stations within public facilities like schools or gyms that are temporarily closed or underutilized. We will provide overnight sleep tests for a low or no cost to patients, encouraging them to seek further results from their healthcare providers and establish a treatment plan. Then, we will reach out to centers such as the U.S. Circadian Medical Clinic and the Community Health Initiative for Patient-centered Apnea Protocols (CHI-PAP) to provide treatments to low-resourced participants and provide recycled treatment materials to participants diagnosed with OSA. Oftentimes, quality CPAP machines go unused by customers because they have bariatric surgery, their apnea disappears, or their health plan covers a replacement. Organizations like SecondWindCPAP use qualified medical equipment companies to safely recycle the machines for re-use by those who cannot afford the price of a new machine. By using high-quality, discounted sleep apnea equipment, diagnostic costs can be reduced while allowing the diagnostic facilities to provide high-quality treatment. We will also develop a marketing campaign to convince communities to seek the services of a healthcare facility.

From April to June, we will evaluate the success of the intervention over the first few months and schedule follow-up sessions with our patients for program-related feedback. Then, we will intensify the coverage of the educational campaign through social media marketing. We also plan to create more testing centers around low-income areas in public places and strengthen our support services by setting up online and in-person support groups for people diagnosed with OSA.

From July to September, we will further evaluate and improve ongoing care using the findings from the patient sessions. Then, we will assign personalized treatment plans, possibly referring to various treatment options. Afterwards, we will hold weekly community sessions for patients with OSA and hear their opinions on the treatment and diagnostic process to gather input on the adjustments that need to be made. Afterwards, we plan to raise OSA awareness within schools and other public centers to raise awareness by offering OSA workshops and lectures. After evaluating the program by looking at the impact from the previous 6 months, using the people diagnosed, treated, and the health outcomes, we will create a long-term outreach and education program that focuses on spreading awareness of OSA and scheduling monthly checkups.

From October to December, we will use AI to evaluate the long-term sustainability program and the progress of the monthly checkups to better understand patient preference for regular checkups. After seeking more funding from partnerships, we will increase outreach to Northern Chicago, using patient data from the last six months to recommend treatments for participants who test positive for OSA. Then, we will inform clinics we listed in our interventions table about patients’ reactions to education, testing, and treatment so they can adjust their operations to fit low-income target populations. Using the data collected, we will write an article about the successes and weaknesses of the campaign and publish the article with the intent of drawing attention to the issue and allow patients to be diagnosed.

Strengths & Limitations

In Chicago, our program aims to tackle sleep apnea (OSA) from all angles. We put a lot of effort into spreading the word, finding cases, and treating people in Black and Hispanic neighborhoods across the city. We use both online tools and local community efforts to reach as many individuals as possible. This way, we hope to catch more cases and offer treatments that work well for each area.

Keeping our program sustainable is our main goal. We will do this by teaming up with partners, getting sponsors, and applying for grants from institutions. This money will help us keep our support services going and reach more people in the community. Also, using cutting-edge tech like AI makes our diagnosis and treatment faster and more accurate leading to quick and precise care. But we know there will be hurdles. We need to keep people interested for a long time, grow our services the right way, respect different cultures, think about the environment, and protect patient info. To tackle these issues, we will develop strong plans, encourage community members to help each other, hire different kinds of staff to improve our operation’s cultural awareness, provide assistance with travel and bad weather, and follow HIPAA rules.

Conclusion

Since 1965, when Henry Gastaut made the first comprehensive report of OSA¹⁸ to the present day, the prevalence of OSA has risen dramatically. There are now 6 million Americans who are diagnosed with sleep apnea¹⁹. There is a much larger population, estimated at 24 million, who are undiagnosed individuals with OSA that are not receiving treatment¹⁹. The rise in OSA can be attributed to a variety of factors, including the rising obesity epidemic in the US, which contributes to the condition by altering facial structure and through other physiological mechanisms.

Many patients with negative Social Determinants of Health (sDoH), for instance environmental factors, economic instability, and lack of healthcare access (healthcare literacy), have trouble understanding OSA and attaining treatment for it. These individuals also tend to have additional conditions such as cardiovascular issues, neurocognitive impairments, and daytime fatigue that affect their daily life. The lack of diagnosis and treatment of OSA and comorbid conditions is further exacerbated by lack of OSA awareness in underserved communities, difficulty accessing quality healthcare, and limited supply of sleep devices and treatments²⁰. In Chicago, OSA is a major occurrence due to many high risk individuals such as African Americans and Latin Americans living in the area. They are unable to receive a viable education on sleep apnea and how it can affect them in the long run.

Public health efforts focus on addressing the needs of not just individuals, but entire communities. OSA is very common and often overlooked – thus it is a condition ripe for public health intervention. OSA often leads to a variety of comorbid conditions such as cardiovascular diseases, diabetes, hypertension, and in some cases mental health problems. Designing health solutions to address OSA will help reduce the prevalence of all these conditions. . Our intervention has been made with the help of OSA professionals and their knowledge has been used to make our intervention as sustainable and effective as possible. Future interventions are needed to address the increasing rates of OSA, lack of awareness and education, and alarmingly high rates of undiagnosed populations. Moving forward, more research also needs to be conducted to explore the trends in obesity in the United States, how to decrease the economic cost of undiagnosis, and limitations in community education and awareness on OSA.