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Obesity Without Sleep Apnea Is Associated with Daytime Sleepiness

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Obesity Without Sleep Apnea Is Associated with Daytime Sleepiness ORIGINAL INVESTIGATION Obesity Without Sleep Apnea Is Associated With Daytime Sleepiness Alexandros N. Vgontzas, MD; Edward O. Bixler, PhD; Tjiauw-Ling Tan, MD; Deborah Kantner, BS; Louis F. Martin, MD; Anthony Kales, MD Background: Daytime sleepiness and fatigue is a fre- onset of sleep, and total wake time were significantly quent complaint of obese patients even among those who lower, whereas the percentage of sleep time was signifi- do not demonstrate sleep apnea. cantly higher in obese patients compared with controls. In contrast, during the nighttime testing, obese patients Objective: To assess in the sleep laboratory whether obese compared with controls demonstrated significantly higher patients without sleep apnea are sleepier during the day wake time after onset of sleep, total wake time, and lower compared with healthy controls with normal weight. percentage of sleep time. An analysis of the relation be- tween nighttime and daytime sleep suggested that day- Methods: Our sample consisted of 73 obese patients time sleepiness in obese patients is a result of a circa- without sleep apnea, upper airway resistance syn- dian abnormality rather than just being secondary to drome, or hypoventilation syndrome who were consecu- nighttime sleep disturbance. tively referred for treatment of their obesity and 45 con- trols matched for age. All patients and healthy controls Conclusions: Daytime sleepiness is a morbid charac- were monitored in the sleep laboratory for 8 hours at night teristic of obese patients with a potentially significant im- and at 2 daytime naps, each for 1 hour the following day. pact on their lives and public safety. Daytime sleepiness in individuals with obesity appears to be related to a meta- Results: Obese patients compared with controls were bolic and/or circadian abnormality of the disorder. sleepier during the day and their nighttime sleep was dis- turbed. During both naps, sleep latency, wake time after Arch Intern Med. 1998;158:1333-1337 N 1988 TO 1991, 33.4% of US adults RESULTS aged 20 years or older were esti- mated to be overweight (at least an NIGHTTIME SLEEP increase of 24% for men and 20% for women above ideal body Compared with controls, obese patients Iweight).1 Obesity is associated with signifi- demonstrated a significantly higher cant mortality and morbidity, including dia- WTASO (82.4 ± 6.9 vs 46.1 ± 6.1 min- betes, cerebral and cardiovascular disorders, utes; P,.01) and TWT (117.3 ± 8.8 vs 72.3 and obstructive sleep apnea.2,3 In a large ± 7.2 minutes; P,.01) and a significantly group of severely or morbidly obese patients, lower percentage of sleep time (75.5% ± 40% of men and 3% of women demonstrated 1.8% vs 84.9% ± 1.5%; P,.01) (Table 1). obstructivesleepapneasevereenoughtowar- Also, the percentage of WTASO during the rant therapeutic intervention.4 sleep period was higher in obese patients Daytime sleepiness and fatigue is a fre- compared with controls (18.9% ± 1.7% vs quent complaint of obese people even 10.7% ± 1.4%; P,.01). In addition, com- among those who do not demonstrate sleep pared with controls, obese patients dem- apnea or any degree of sleep disordered onstrated a significantly higher percent- From the Sleep Research breathing.4 However, to our knowledge, no age of stage 1 sleep (10.3% ± 0.8% vs 7.3% and Treatment Center and study has assessed objectively the degree of ± 0.7%; P,.01) and a significantly lower Department of Psychiatry daytime sleepiness in obese patients with- (Drs Vgontzas, Bixler, Tan, and Kales and Ms Kantner) and out sleep apnea. The aim of our study was University Weight Management to assess in the sleep laboratory whether obese patients without sleep apnea are This article is also available on our Center (Dr Martin), Web site: www.ama-assn.org/internal. Pennsylvania State University sleepier during the day compared with College of Medicine, Hershey. healthy controls with normal weight. ARCH INTERN MED/ VOL 158, JUNE 22, 1998 1333 ©1998 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/30/2021 PATIENTS, SUBJECTS, a complaint of daytime sleepiness or fatigue and their poly- somnographic study demonstrated loud snoring, waking AND METHODS up at night because of snoring or gasping, and frequent brief electrophysiologic semiarousals that appeared to be re- PATIENTS AND SUBJECTS lated to snoring were excluded from the study.5 Finally, obese patients who were diagnosed as having a primary dis- Seventy-three patients, 7 men (9.6%) and 66 women (90.4%) order of excessive daytime sleepiness, ie, narcolepsy or id- (6 of them postmenopausal [9.1%]), with a diagnosis of obe- iopathic hypersomnia, were excluded from the study. sity (body mass index [BMI, a measure of weight in kilo- The controls consisted of 28 women (62.2%) grams divided by the square of the height in meters] $27.8, (3[10.7%] of them postmenopausal) and 17 men (37.8%) mean ± SE, 45.4 ± 1.3; range, 27.8-85.8) and 45 healthy (mean ± SE age, 41.2 ± 1.7 years; range, 17-58 years). control subjects (mean ± SE BMI, 23.5 ± 0.42; range, 18.6- The controls were selected from a large pool of subjects 30.6) participated in this study. Sixty-eight of the obese pa- by controlling for age with the obese patients (the mean tients were either severely (BMI $32) or morbidly (BMI age of the controls was not significantly different from $39) obese. Overall 91 patients were referred consecu- the mean age of the obese patients); the controls were tively to the University Weight Management Center of the selected solely based on age without knowledge of sleep Milton S. Hershey Medical Center, Hershey, Pa, for treat- laboratory findings. Control subjects were recruited ment of their obesity. Eighteen of them were excluded from from the medical and technical staff and student popula- the study because they were found to have some type of tion of the medical center as well as from friends and sleep disordered breathing or other disorder of excessive acquaintances of the medical center personnel. A careful daytime sleepiness. The mean ± SE age of these obese pa- screening process was used to ensure that the control tients was 37.4 ± 1.0 years (range, 16-55 years). A com- subjects had no sleep complaints, no major psychiatric plete medical history was recorded and a complete physi- disorders, were in good general health, and were not cal examination was performed, including neurologic using any medication. The project was approved by our assessment and a battery of clinical tests (including com- institutional review board and a written informed con- plete blood cell count, urinalysis, thyroid indexes, and elec- sent was obtained from the subjects. trocardiography). No abnormalities were detected in the clinical or laboratory assessment, including blood cell counts SLEEP LABORATORY PROCEDURES and thyroid indexes, which could have accounted for the daytime sleepiness. All the patients and control subjects were monitored us- The obese patients who demonstrated obstructive sleep ing 16-channel polygraphs (Model 78c, Grass Instrument apnea of sufficient severity to warrant therapeutic recom- Co, Quincy, Mass) in the sleep laboratory for one 8-hour mendation4 or had an apnea plus hypopnea index of 5 or nocturnal polysomnogram and for 2 daytime naps the next more events per hour of sleep were excluded from the study. day in sound-attenuated, light- and temperature- Also the patients who demonstrated symptoms and/or signs controlled rooms. The 2 nap sessions lasted 60 minutes each consistent with hypoventilation syndrome or a resting he- and began at approximately 9:00 AM and 12:30 PM.6 This moglobin oxygen saturation of less than 92% were ex- test provides a quantitative assessment of pathologic diur- cluded from the study. In addition, obese patients who had nal sleepiness and has been suggested as an alternative to percentage of REM sleep (16.7% ± 0.9% vs 19.7% ± 0.9%; between these 2 groups during the second nap (18.7 ± 1.6 P,.01). The amount of REM sleep was significantly de- vs 27.6 ± 2.8 minutes; P,.01) (Table 3). creased in the first and second third of the night in obese patients compared with controls. Furthermore, REM la- AMOUNT AND STRUCTURE OF DAYTIME SLEEP tency and REM interval were significantly increased in obese patients compared with controls. During both naps, obese patients compared with con- trols slept more. Specifically, during the first nap obese DAYTIME SLEEP patients had significantly lower WTASO (4.7 ± 0.6 vs 8.6 ± 1.4 minutes; P,.01) and TWT (18.5 ± 1.4 vs 30.4 ± In the morning nap, 72 (100%) of 72 obese patients and 2.6 minutes; P,.01) and a significantly higher percent- 41 (28.1%) of 146 controls had some sleep. In the after- age of sleep time (69.3% ± 2.8% vs 49.4 ± 4.4; P,.01) noon nap, 62 (100%) of 62 obese patients and 37 (80.4%) (Table 2). Also, the percentage of WTASO during the sleep of 46 controls had some sleep. The percentage of obese period was lower in obese patients compared with healthy patients compared with healthy controls who slept dur- controls (10.3% ± 1.4% vs 21.0% ± 3.4%; P,.01). Dur- ing the 2 naps was significantly higher (for both, P,.01). ing the second nap, obese patients had a significantly lower TWT (26.9 ± 1.8 vs 35.0 ± 2.7 minutes; P,.01) and a PROPENSITY TO FALL ASLEEP (SLEEP LATENCY) significantly higher percentage of sleep time (55.1% ± 3.0% vs 41.5 ± 4.4; P,.01) (Table 3). Also, the percentage of During both naps obese patients fell asleep significantly WTASO during the sleep period was lower in obese pa- faster than healthy controls.
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