Online screening for obstructive sleep apnea in adult non-obese individuals in the society the importance of application of modern technology in mass screening

INTRODUCTION

Obstructive sleep apnea (OSA) is a potentially serious sleep order which is being proven to be an important etiological factor for multiple diseases. Obesity is most commonly associated with OSA.¹ Many prevalence studies have been conducted worldwide in different population groups. Very few studies have been conducted in India and no study has laid emphasis on prevalence of OSA in non-obese individuals.² STOP-Bang questionnaire is considered to be the most validated screening tool for OSA for various population groups.³ In this survey we have used modified STOP-Bang questionnaire which requires relatively less time for response. Also this study was conducted with the help of online survey which made the response time much lesser. A sample of 600 non-obese individuals was screened and results were analysed.

Aim of the present study was to study the prevalence of OSA in non-obese adult individuals using modified STOP-BANG questionnaire through online surveys and to evaluate the importance of internet and modern technology in the mass screening of OSA.

METHODS

This was a prospective study conducted during the period from January 2018 to February 2018.

Selection criteria

All individuals between 20-60 years of age were included in the study and individuals with body mass index >30 km/m² were excluded.

Method of data collection

STOP-BANG questionnaire is a validated tool for screening of obstructive sleep apnea.³ Various modifications of STOP-BANG questionnaire have been made in various studies around the world according to the requirements of the study. We modified the STOP-BANG questionnaire (Stanley version) to screen non-obese individuals for OSA.

STOP-BANG questionnaire

• • S- Snoring
• • T- Tiredness
• • O- Observed apneic spells
• • P- Blood Pressure
• • B- BMI
• • A- Age
• • N- Neck circumference
• • G- Gender

Modified STOP-BANG questionnaire⁴

• • Snoring
• • Tiredness
• • Observed apneic spells
• • High BP
• • Sleep refreshing
• • Smoking/alcohol

With the changing lifestyle that includes altered food and sleep habits, more mental and less physical works people have already started acquiring obesity and related disorders. Due to lack of permission to avail leave at work places, increased transport time every day, the cooperation from the society to participate in the screening trials is becoming very difficult. And for the same reasons practical difficulties are encountered by the persons who conduct the study. Online surveys would reduce the time and money spent for mass screening of the society. Thus the participants can take part in the survey without affecting their work.

Hence we decided to use internet as a medium to conduct the survey. The questionnaire was uploaded in the survey monkey website in the investigator’s account. The link of the survey was sent to the candidates. Candidates willing to take part in the survey can click on the link which will take them to the questionnaire. After completing the survey, the candidates should click the submit button and the responses will be sent to the investigators account. The settings were made such that a survey can’t be taken up more than once from a device. The survey can be taken up using a desktop computer, laptop, smartphones. The investigator will get all the responses from an individual and can analyse and access everyone’s responses. The link was sent to as many individuals as possible.

The body mass index (BMI) was calculated from the data provided by the candidates and obese individuals were excluded from the study. The responses of the remaining non-obese individuals were then analysed using IBM. SPSS statistics software 23.0 version.

RESULTS

Among the 640 individuals participated in the survey 600 belonged to the non-obese category. 21% belonged to less than 25 years of age. 34% belonged to 26-35 years of age. 36-45 age groups contained 19%. 17% and 9% of the individuals belonged to 46-55 age groups and greater than 55 years of age respectively (Figure 1).

Among the individuals participated in the study 18% reported that they would snore loudly during sleep (Figure 2). 26% of the study population experienced day time tiredness (Figure 3). 6% of the individuals reported to have choking spells during night (Figure 4). 19% of the study population reported that their sleep is not refreshing (Figure 5). 59% were females and 41% were males (Figure 6). While 7% of the individuals had the habit of smoking cigarettes, 10% had the habit of consuming alcohol (Figure 7). Varying proportions of study individuals were found to be affected by hypertension, diabetes mellitus and thyroid disorders.

Of the 6 questions in the questionnaire a positive response to 3 or more questions was considered to be in high risk group. In our study 14% of the study population belonged to the high risk group (Figure 8). As expected age and gender had a significant association with the high-risk group.

DISCUSSION

There is increasing evidence that sleep abnormalities in general and sleep-disordered breathing, such as snoring, have deleterious effects beyond the neuro-cognitive realm.⁵ The prevalence of OSA in USA, Australia and China are approximately 26%, 18%, 17% respectively.⁶ The prevalence in India ranges from 15% to 29%.⁷ Prevalence studies have been conducted in Tamil Nadu and relation between OSA and obesity, thyroid disorders have been studied. 40% is the prevalence found to be associated with metabolic abnormalities.⁸ No studies have been conducted to study the prevalence of OSA in non-obese individuals.⁹ This study shows that 14% of the non-obese individuals are at high risk of developing OSA. The next phase of the study will progress in the direction of conducting polysomnography for the high-risk patients.

The major highlights of this study will be the use of the modern technology to conduct a survey for more than 600 persons within a week. With smart phones being available to almost everyone now-a-days they can be used for many such purposes. Another highlight will be studying the prevalence of OSA among non-obese individuals. With OSA being one of the major causes of many co-morbid conditions it is essential to screen as early as possible. Though obesity is commonly associated with OSA syndrome it should be borne in mind that it is also prevalent in non-obese individuals. This study substantiates the same.

Limitations

This study has certain limitations. Smartphones and access to internet is not completely available to everyone in our place. Hence risk groups in those population groups can’t be screened by this method. The height and weight measurements given by the individuals may not be absolutely accurate.

CONCLUSION

STOP-BANG questionnaire is a very useful tool in screening OSA syndrome and this questionnaire has been modified by various experts worldwide who are involved in sleep medicine according to the needs. This modified version is useful in the screening of OSA in the individuals of the society. OSA a does occur in non-obese individuals and early diagnosis and treatment is therefore essential since the manifestations are hidden when compared to that of obese population. Internet and associated technology can be made use in such mass screening activities as it reduces the time and money spent and increases the compliance.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

REFERENCES

1. 1. Young T, Palta M, Dempsey J, Skatrud J, Weber S, Badr S. The occurrence of sleep-disordered breathing among middle-aged adults. N Engl J Med. 1993;328(17):1230-5.
2. 2. Gozal D, Capdevila OS, Kheirandish-Gozal L. Metabolic alterations and systemic inflammation in obstructive sleep apnea among non-obese and obese pre-pubertal children. Am J Respir Crit Care Med. 2008;177(10):1142-9.
3. 3. Nagappa M, Liao P, Wong J, Auckley D, Ramachandran SK, Memtsoudis S, et al.Validation of the STOP-BANG Questionnaire as a Screening Tool for Obstructive Sleep Apnea among Different Populations: A Systematic Review and Meta-Analysis. PLoS One. 2015;10(12):e0143697.
4. 4. Ozturk NAA, Dilektasl AG, Cetinoglu ED, Ursavas A, Karadag M. Diagnostic Accuracy of a Modified STOP-BANG Questionnaire with National Anthropometric Obesity Indexes. Turk Thorac J. 2019;20(2):103-7.
5. 5. Joshi SR. Metabolic syndrome-emerging clusters of the Indian phenotype. J Assoc Physicians India. 2003;51:445-6.
6. 6. Bixler EO, Vgontzas AN, Ten Have T, Tyson K, Kales A. Effects of age on sleep apnea in men: I. Prevalence and severity. Am J Respir Crit Care Med. 1998;157(1):144-8.
7. 7. Bixler EO, Vgontzas AN, Lin HM, Ten Have T, Rein J, Vela-Bueno A, et al. Prevalence of sleep-disordered breathing in women: effects of gender. Am J Respir Crit Care Med. 2001;163(3.1):608-13.
8. 8. Udwadia ZF, Doshi AV, Lonkar SG, Singh CI. Prevalence of sleep-disordered breathing and sleep apnea in middle-aged urban Indian men. Am J Respir Crit Care Med. 2004;169(2):168-73.
9. 9. Elmasry A, Janson C, Lindberg E, Gislason T, Tageldin MA, Boman G. The role of habitual snoring and obesity in the development of diabetes: a 10-year follow-up study in a male population. J Intern Med. 2000; 248(1):13-20.