Rogerio Santos-Silva

Obstructive Sleep Apnea Syndrome in the Sao Paulo Epidemiologic Sleep Study

OBJECTIVE To estimate the prevalence of Obstructive Sleep Apnea Syndrome (OSAS), using current clinical and epidemiological techniques, among the adult population of Sao Paulo, Brazil. METHODS This population-based survey used a probabilistic three-stage cluster sample of Sao Paulo inhabitants to represent the population according to gender, age (20-80 years), and socio-economic status. Face-to-face interviews and in-lab full-night polysomnographies using a nasal cannula were performed. The prevalence of OSAS was determined according to the criteria of the most recent International Classification of Sleep Disorders (ICDS-2) from American Academy of Sleep Medicine (2005). RESULTS A total of 1042 volunteers underwent polysomnography (refusal rate=5.4%). The mean age+/-SD was 42+/-14 years; 55% were women and 60% had a body mass index>25 kg/m(2). OSAS was observed in 32.8% of the participants (95% CI, 29.6-36.3). A multivariate logistic regression model identified several independent and strong associations for the presence of OSAS: men had greater association than women (OR=4.1; 95% CI, 2.9-5.8; P<0.001) and obese individuals (OR=10.5; 95% CI, 7.1-15.7; P<0.001) than individuals of normal weight. The adjusted association factor increased with age, reaching OR=34.5 (95% CI, 18.5-64.2; P<0.001) for 60-80 year olds when compared to the 20-29 year old group. Low socio-economic status was a protective factor for men (OR=0.4), but was an associated factor for women (OR=2.4). Self-reported menopause explained this increased association (age adjusted OR=2.1; 95% CI, 1.4-3.9; P<0.001), and it was more frequent in the lowest class (43.1%) than either middle class (26.1%) or upper class (27.8%) women. CONCLUSIONS This study is the first apnea survey of a large metropolitan area in South America identifying a higher prevalence of OSAS than found in other epidemiological studies. This can be explained by the use of the probabilistic sampling process achieving a very low polysomnography refusal rate, the use of current techniques and clinical criteria, inclusion of older groups, and the higher prevalence of obesity in the studied population.

Sao Paulo Epidemiologic Sleep Study: rationale, design, sampling, and procedures.

OBJECTIVES To present the rational design, sampling, and procedures utilized in an Epidemiologic Sleep Study carried out in 2007 to establish the epidemiologic profile of sleep disorders in the adult population of a large metropolitan city, Sao Paulo, Brazil. METHODS A population-based survey adopting a probabilistic three-stage cluster sample of Sao Paulo was used to represent the population according to gender, age (20-80 years), and socioeconomic class. Questionnaires, actigraphy, polysomnography (PSG), and blood samples were collected to investigate associations between sleep patterns and disturbances according to social-demographic status, activity/rest cycle, physical activity habits, mood disturbances, memory complaints, sexual dysfunction in males, drug addiction, genetic markers, and anthropometric, clinical, biochemical, hematological, endocrine, immunologic, and inflammatory indicators. RESULTS A total of 1101 questionnaires were administered at home. A total of 156 volunteers were substituted, who were equivalent to the remaining sample in terms of age, gender, and socioeconomic class. A total of 1042 volunteers underwent PSG recordings at a Sleep Institute, and the refusal rate was 5.4%. CONCLUSION The Sao Paulo Sleep Study is a pioneering investigation, incorporating and integrating up-to-date methodologies for understanding sleep profiles and sleep disorders in large populations. This study will provide reliable information for the planning of health policies and programs aimed to control such disorders and their consequences in the city of Sao Paulo and similar urban environments.

Association between body mass index and sleep duration assessed by objective methods in a representative sample of the adult population

INTRODUCTION Sleep duration has been associated with overweight individuals in many epidemiological studies; however, few studies have assessed sleep using objective methods. Our study was designed to evaluate the association between body mass index (BMI) and sleep duration measured by actigraphy (Acti), polysomnography (PSG) and the Pittsburgh sleep quality index questionnaire (PSQIO). Furthermore, we evaluated other biochemical and polysomnographic parameters. METHODS A representative sample of 1042 individuals from Sao Paulo, Brazil, including both genders (20-80 yrs), participated in our protocol. Weight and other anthropometric parameters were measured at the onset of the study. Sleep duration was calculated by Acti, PSG, and the PSQIQ. The population was sorted by sleep duration, body, slow wave sleep (SWS) and REM sleep (REMS) duration subsets. In addition, other biochemical and polysomnographic parameters were analyzed. Differences between population subsets were analyzed by one-way analysis of variance (ANOVA). Linear regression analysis was performed between sleep and anthropometric parameters. RESULTS Shorter sleep duration was associated with higher BMI and waist and neck circumference when measured by Acti and PSG (p<0.05). Lower leptin levels were associated with short sleep in normal-weight (BMI>18 and ⩽25) individuals (p<0.01). The association between short sleep duration Acti and higher BMI was present when apnea-hypopnea index (AHI) was less than 15 (p=0.049). Shorter REMS and SWS also were associated with higher BMI (p<0.01). Normal-weight individuals tended to sleep longer, have higher sleep efficiency and longer SWS and REMS than obese individuals (Acti, PSG; p=0.05). Sleep duration was negatively correlated with BMI (Acti, PSG; p<0.05). Short SWS and REMS were associated with higher cardiovascular risk factors (p<0.05). CONCLUSION Shorter sleep, SWS, and REMS duration were associated with higher BMI, central adiposity measurements, and cardiovascular risk factors when measured by objective methods.

Prevalence of erectile dysfunction complaints associated with sleep disturbances in Sao Paulo, Brazil: A population-based survey

INTRODUCTION The aims of this study were to estimate the prevalence of erectile dysfunction (ED) complaints in a population-based sample from Sao Paulo and to determine the associations of ED prevalence with sleep disturbances, testosterone levels, age, body mass index (BMI), socioeconomic factors and selected medical history indicators. METHODS The Epidemiologic Sleep Study (EPISONO) is a population-based study of sleep and risk factors for sleep disturbances in Brazils largest city, Sao Paolo. This study adopted a probabilistic three-stage cluster sampling approach for the city of Sao Paulo. Questionnaires that covered medical conditions and sexual and erection complaints were administered and polysomnographies and fasting blood samples were collected. The patient cohort of the current study of ED consisted of 467 men, aged 20-80 years at the time of their enrollment in EPISONO. The percentage of men who participated in EPISONO but refused to participate in our study was 2.3%. RESULTS The prevalence of ED complaints in the study cohort was 17.08% overall. ED complaints ranged from 7.3% in younger men (20-29 years old) to 63.25% in older men (>50years old) (adjusted odds ratio [OR]=21.65). The logistic regression model showed that both reduced time spent in REM sleep and fragmented sleep had significant effects as risk factors for ED complaints. Obesity (OR=1.8), low testosterone levels (OR=4.28), low quality of life (OR=4.4), an apnea-hypopnea index over 15 (OR=2.75), and obstructive sleep apnea syndrome (OR=2.13) were also significantly associated with a higher risk of ED complaints. CONCLUSION EPISONO study indicates that ED complaints are relatively common phenomena, especially among older men. Adequate sleep patterns and normal or high levels of testosterone, which serve as markers for sexual motivation, may be protective against ED. The prevalence of sleep apnea showed a strong impact on erectile function and subsequently negatively affects sexual activity.

Increasing trends of sleep complaints in the city of Sao Paulo, Brazil

OBJECTIVE The aim of this study was to compare the prevalence of sleep habits and complaints and to estimate the secular trends through three population-based surveys carried out in 1987, 1995, and 2007 in the general adult population of the city of Sao Paulo, Brazil. METHODS Surveys were performed using the same three-stage cluster-sampling technique in three consecutive decades to obtain representative samples of the inhabitants of Sao Paulo with respect to gender, age (20-80 years), and socio-economic status. Sample sizes were 1000 volunteers in 1987 and 1995 surveys and 1101 in a 2007 survey. In each survey, the UNIFESP Sleep Questionnaire was administered face-to-face in each household selected. RESULTS For 1987, 1995, and 2007, respectively, difficulty initiating sleep (weighted frequency %; 95% CI) [(13.9; 11.9-16.2), (19.15; 16.8-21.6), and (25.0; 22.5-27.8)], difficulty maintaining sleep [(15.8; 13.7-18.2), (27.6; 24.9-30.4), and (36.5; 33.5-39.5)], and early morning awakening [(10.6; 8.8-12.7), (14.2; 12.2-16.5), and (26.7; 24-29.6)] increased in the general population over time, mostly in women. Habitual snoring was the most commonly reported complaint across decades and was more prevalent in men. There was no statistically significant difference in snoring complaints between 1987 (21.5; 19.1-24.2) and 1995 (19.0; 16.7-21.6), but a significant increase was noted in 2007 (41.7; 38.6-44.8). Nightmares, bruxism, leg cramps, and somnambulism complaints were significantly higher in 2007 compared to 1987 and 1995. All were more frequent in women. CONCLUSIONS This is the first study comparing sleep complaints in probabilistic population-based samples from the same metropolitan area, using the same methodology across three consecutive decades. Clear trends of increasing sleep complaints were observed, which increased faster between 1995 and 2007 than from 1987 to 1995. These secular trends should be considered a relevant public health issue and support the need for development of health care and educational strategies to supply the populations increased need for information on sleep disorders and their consequences.

Relationship between physical activity and depression and anxiety symptoms: A population study

BACKGROUND There are few studies evaluating the association between practice of physical activity and mood in a population sample. This study evaluated the frequency of symptoms of depression and anxiety in the population of the city of Sao Paulo and their association with the report of practice of regular physical activity. METHODS This survey was conducted with the adult population of Sao Paulo between July and December of 2007. The sample was composed of 1042 volunteers (both genders) with a mean age of 41.9±14.4 years. The volunteers were evaluated using the Beck Depression Inventory, the Beck Anxiety Inventory, and two simple questions designed to evaluate and classify physical activity. Socioeconomic status was also determined according to Brazils Economic Classification Criterion. RESULTS People who do not engage in physical activity are two times more likely to exhibit symptoms of depression (PR: 2.1) and anxiety (PR: 2.5) compared with those who regularly practice physical activity and a higher prevalence of symptoms for anxiety (9.8%) and depression (10.9%) was observed among those claiming to not practice regular physical activity and 63.2% related did not practice any physical activity regularly. CONCLUSION Altogether, these results suggest that people who do not practice physical activity have a higher chance of exhibiting symptoms of depression and anxiety when compared to those who perform physical activity regularly. In this sense, regular physical activity must be encouraged, and this incentive should be routine in both current and future public health policies. Although the methodology in the present study does not allow assigning a relation of cause and effect, we observed associations between symptoms of depression, anxiety and physical activity.

Consequences of obstructive sleep apnea on metabolic profile: A Population-Based Survey†

Epidemiologic studies that control for potential confounders are needed to assess the independent associations of obstructive sleep apnea (OSA) with metabolic abnormalities. The aim of our study was to evaluate the associations of OSA with metabolic abnormalities among the adult population of Sao Paulo, Brazil.

Effects of aging on sleep structure throughout adulthood: a population-based study

OBJECTIVE Although many studies have shown the evolution of sleep parameters across the lifespan, not many have included a representative sample of the general population. The objective of this study was to describe age-related changes in sleep structure, sleep respiratory parameters and periodic limb movements of the adult population of São Paulo. METHODS We selected a representative sample of the city of São Paulo, Brazil that included both genders and an age range of 20-80 years. Pregnant and lactating women, people with physical or mental impairments that prevent self-care and people who work every night were not included. This sample included 1024 individuals who were submitted to polysomnography and structured interviews. We subdivided our sample into five-year age groups. One-way analysis of variance was used to compare age groups. Pearson product-moment was used to evaluate correlation between age and sleep parameters. RESULTS Total sleep time, sleep efficiency, percentage of rapid eye movement (REM) sleep and slow wave sleep showed a significant age-related decrease (P<0.05). WASO (night-time spent awake after sleep onset), arousal index, sleep latency, REM sleep latency, and the percentage of stages 1 and 2 showed a significant increase (P<0.05). Furthermore, apnea-hypopnea index increased and oxygen saturation decreased with age. The reduction in the percentage of REM sleep significantly correlated with age in women, whereas the reduction in the percentage of slow wave sleep correlated with age in men. The periodic limb movement (PLM) index increased with age in men and women. CONCLUSIONS Sleep structure and duration underwent significant alterations throughout the aging process in the general population. There was an important correlation between age, sleep respiratory parameters and PLM index. In addition, men and women showed similar trends but with different effect sizes.

Adenosine Deaminase Polymorphism Affects Sleep EEG Spectral Power in a Large Epidemiological Sample

Slow wave oscillations in the electroencephalogram (EEG) during sleep may reflect both sleep need and intensity, which are implied in homeostatic regulation. Adenosine is strongly implicated in sleep homeostasis, and a single nucleotide polymorphism in the adenosine deaminase gene (ADA G22A) has been associated with deeper and more efficient sleep. The present study verified the association between the ADA G22A polymorphism and changes in sleep EEG spectral power (from C3-A2, C4-A1, O1-A2, and O2-A1 derivations) in the Epidemiologic Sleep Study (EPISONO) sample from São Paulo, Brazil. Eight-hundred individuals were subjected to full-night polysomnography and ADA G22A genotyping. Spectral analysis of the EEG was carried out in all individuals using fast Fourier transformation of the signals from each EEG electrode. The genotype groups were compared in the whole sample and in a subsample of 120 individuals matched according to ADA genotype for age, gender, body mass index, caffeine intake status, presence of sleep disturbance, and sleep-disturbing medication. When compared with homozygous GG genotype carriers, A allele carriers showed higher delta spectral power in Stage 1 and Stages 3+4 of sleep, and increased theta spectral power in Stages 1, 2 and REM sleep. These changes were seen both in the whole sample and in the matched subset. The higher EEG spectral power indicates that the sleep of individuals carrying the A allele may be more intense. Therefore, this polymorphism may be an important source of variation in sleep homeostasis in humans, through modulation of specific components of the sleep EEG.

Does the reproductive cycle influence sleep patterns in women with sleep complaints

Objective The aim of the present study was to investigate how prominent gynecological factors (regular/irregular menstrual cycle, premenstrual complaints, or menopause) can influence both subjective and objective sleep data. Methods A total of 931 women who sought clinical assistance because of a sleep complaint were included in the investigation. All subjects filled out a sleep and gynecological questionnaire prior to undergoing a polysomnography (PSG) recording. Results Premenopausal women with an irregular menstrual cycle were more likely to report sleep difficulties (related to falling sleep and insomnia symptoms) than those with a regular cycle (odds ratio 2.1; 95% confidence interval 1.2–3.5). These women showed increased light sleep stages and awakenings. Premenstrual complaints were reported by a higher percentage of women with periodic leg movement, lower time in saturation under 90%, and higher sleep efficiency. A lower percentage of women who took hormonal contraceptives reported snoring, had fewer arousals and longer REM latency compared to those not taking hormonal contraceptives. Menopausal women with hot flushes had more restless leg complaints. Awake time was shorter in hormone therapy users compared with non-users. Women with menopause are more likely to have an apnea–hypoapnea index greater than 5/h. Conclusion The present findings suggest that gynecological status is associated with subjective sleep quality and objective sleep parameters in women with sleep complaints.