Healthinequalitiesinthe Diagnosisandtreatmentof Obstructivesleepapneain Childrenandadults

Health Inequalities in the
D i a g n o s i s an d Tre a t m e n t o f
O b s t r u c t i v e Sl e e p A p n e a i n
C h i l d ren an d A d u l t s
Javier J.M. Howard, MD, MPHa,1, Robson Capasso, MD
a,1
,
Stacey L. Ishman, MD, MPHb,*
KEYWORDS
Obstructive sleep apnea Inequalities Disparities Socioeconomic Gender
Race Ethnicity
KEY POINTS
The prevalence of obstructive sleep apnea (OSA) is increasing in the United States, with
disadvantaged populations disproportionately affected.
Biological sex influences OSA prevalence; estrogen may be protective, while testosterone
may contribute to OSA development.
There are significant disparities in OSA diagnosis and treatment based on gender, race,
and socioeconomic status.
Health literacy and cultural norms affect the recognition and management of OSA, contrib-
uting to inequities in care.
Future research should address the gaps in understanding OSA in diverse populations
and develop inclusive diagnostic strategies.
INTRODUCTION
In the United States, the prevalence of obstructive sleep apnea (OSA) is growing across
the board in tandem with the obesity epidemic.1,2 There is a growing body of evidence
asserting that disadvantaged populations are disproportionately impacted by OSA,
much like a myriad of other chronic diseases. We seek to characterize the English-
language literature exploring the health inequities in the diagnosis and treatment of
OSA across the lifespan.
Funding: This work was not funded.

a
Department of Otolaryngology, Head and Neck Surgery, Stanford University, Palo Alto, CA,
USA; b Division of Otolaryngology – Head and Neck Surgery, University of Wisconsin School of
Medicine and Public Health, Madison, WI, USA
1
Present address: 801 Welch Road, Palo Alto, CA 94304.
* Corresponding author. University of Wisconsin School of Medicine and Public Health, K4/719
Clinical Science Center, 600 Highland Avenue, Madison, WI 53792.
E-mail address: [email protected]
Otolaryngol Clin N Am 57 (2024) 353–362

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354 Howard et al
SEX
With regards to biological sex, the evidence to date illustrates that estrogen likely
plays a protective role against OSA development.1,3–5 Explanations from animal and
in vitro studies demonstrate estrogen receptor up regulation in the genioglossus mus-
cle, which they hypothesize may be protective on the fatigability of the muscle when
exposed to intermittent hypoxia.4 A handful of small human case series support this
hypothesis along with larger scale population of data. An even smaller number of
weak studies support the theory that testosterone may play a role in the pathogenesis
of OSA.6,7 Epidemiologic assessments report that men have a 2:1 or 3:1 predomi-
nance of OSA when matched with their premenopausal peers, but the relationship
is 1:1 when they are compared to postmenopausal matches.1,8,9 Of note, the preva-
lence and severity of OSA increases with age in both sexes.
In children, the data are quite limited. Because many studies rely on caregiver report
of subjective sleep disordered breathing (SDB) symptoms for prevalence estimates,
there is concern that these data are faulty with arguments for both over and underes-
timation. Similar to the data reported in adults, the symptom profiles of male and fe-
male children with OSA are influenced by social and cultural perceptions as to what
constitutes normal age and sex-associated behaviors (snoring, hyperactivity, etc.).
Additionally, the sample populations for these studies are often heterogenous, with
unbalanced sex and age distributions that include both pre and postpubescent chil-
dren. This last factor is considered critical as it has been widely theorized that differ-
ences in OSA prevalence between sexes likely emerge with puberty-related hormonal
changes. The available evidence also suggests that boys have higher rates of SDB
than girls, obese children have higher rates than those who are nonobese, and Black
American children have higher prevalence rates than those who are not.10
Moreover, cultural norms and perceptions are also drivers of health inequities be-
tween men and women. The “classic presentation” of a patient with OSA was devel-
oped based on the presenting characteristics of middle-aged White men. Often,
women presenting with OSA are described as having “more vague” symptoms than
their male counterparts, including symptoms that overlap significantly with other com-
mon conditions like insomnia, hypothyroidism, and depression.11–13 Of note, women
with OSA are less likely to present with witnessed apneas (as hypopneas are more
commonly prevalent in women) and typically report consuming less caffeine than
men with OSA.12 These factors may contribute to delayed diagnosis, misdiagnosis,
or underdiagnosis of OSA in women. This is supported by the fact that women tend
to be diagnosed with OSA at a later age, with more central obesity, and at a higher
body mass index (BMI) than men; despite this, the AHI at the time of diagnosis is lower
for women than men.14,15
Overall, evidence from the United States shows that women are less likely to be
diagnosed with OSA than their male counterparts. This is in keeping with the Wiscon-
sin cohort study estimates that approximately only 7% of women and 18% of men
with at least moderate OSA hold a formal diagnosis.16 Among those individuals found
to have mild OSA on polysomnography, only 2% of women and 10% of men had a
diagnosis.
With regards to the treatment of OSA, very little evidence exists illustrating differ-
ences by biological sex. While the rates of diagnosis of OSA clearly differ between
the sexes, it is unclear whether there are any differences in the prescription of OSA treat-
ment. The literature regarding continuous positive airway pressure (CPAP) compliance
by sex is mixed with some studies showing higher, equal, and lower compliance rates in
men than women, depending on the study.17–22 There is no literature assessing
Health Inequalities in Obstructive Sleep Apnea 355
differences in the prescription or compliance of oral appliance therapy by sex for OSA
treatment.
Of the few studies that report the sex breakdown of patients who have undergone
surgical management for OSA, the available evidence alludes to a vast disparity in sur-
gical care delivered. A large, national database study examining individuals undergo-
ing either soft tissue or skeletal surgery for OSA found that men were significantly more
likely than women to undergo surgery.23 Similarly, data regarding implantation of new
technology like hypoglossal nerve stimulation therapy suggests that women are also
being left behind at even higher rates, as men constitute the vast majority of individuals
who have been implanted.24–26 The only treatment that seems to favor access for
women is based on a single large national database study that reported that patients
undergoing jaw surgery for OSA are more likely to be women.27
GENDER IDENTITY AND EXPRESSION
There is currently no literature specifically reporting or examining the clinical presen-

tation, diagnosis, or treatment of OSA in individuals who are gender nonbinary or non-
conforming. There is, however, a recent administrative claims database study that
reporting higher rates of all sleep disorders in gender nonconforming youth, and 3
times the odds of OSA in transgender youth as compared to their cisgender peers.
Gender affirming therapy (GAT) is associated with reduced odds of other sleep disor-
ders; however, there was no difference seen in the odds of OSA in transgender youth
using GAT.28
SEXUAL ORIENTATION
Given that one of the common ways that people present with concern for OSA is
based on bed partner concerns or brought up by the patient’s bed partner during
health care visits, the role of sexual orientation should not be overlooked. There is
currently a paucity of information examining differences in the clinical presentation
or diagnosis and management of patients who are sexual minorities. However, the
2019 next generation health study, a national longitudinal cohort study of US adoles-
cents found that sexual minority female individuals reportedly significantly more self-
reported daytime sleepiness and snoring than their heterosexual peers.29 They also
noted that these symptoms tended to be associated with overweight status and
increased depressive symptoms, which suggests that the overall health status of sex-
ual minority female individuals may be worse than in sexual majority female individ-
uals.29 There were no other studies identified by these authors that examined sleep
health disparities among sexual minorities highlighting this an area that deserves
further study.
RACE AND ETHNICITY
While race and ethnicity are frequently used in medical research, there is no formal
agreement regarding their definitions that has resulted in confusion, misuse of the
terms, and a lack of clarity regarding their use. Moreover, race is a social construct,
without any biological basis, which has been historically defined primarily based on
physical characteristics. Alternatively, ethnicity, while also considered a social
construct, is typically defined as a set of cultural factors including ancestry, nationality,
language, cuisine, and religion that specific communities share.30 With regards to the
definition and reporting of race and ethnicity in scientific literature broadly, there is an
immense degree of inconsistency.31 Unfortunately, the otolaryngology and sleep
356 Howard et al
research to date are wrought with these same issues, as the majority of studies fail to
report race or ethnicity at all.32 For those studies that did report results based on race
and ethnicity, the existing English-language literature on health inequities will be sum-
marized here.
With regards to the prevalence of OSA based on race and ethnicity, most available
data compare White and Black populations within the United States, with fewer exam-
ining Latinx and Asian populations. In addition, there is almost no data that include
indigenous American populations or other American ethnic groups.
Most of the American literature demonstrates that Black Americans have a higher
prevalence and severity of OSA than Whites across the lifespan.33,34 However, this
paradigm has been challenged recently, with growing evidence reflecting no signifi-
cant difference in the prevalence or severity of OSA between adult Black and White
populations.35–38 Broadly, it is reported that Black Americans have significantly worse
sleep quality and duration, as well as increased daytime sleepiness when compared to
their White peers.35 This asserts that a broader disparity in sleep health exists and war-
rants further study for a multidisciplinary approach to eliminating that disparity.
Studies looking at differences in diagnosis among children report that Black
children’s caregivers are more likely to present with concerns about OSA than White
children’s caregivers.39 This may be the result of a variety of factors including environ-
mental issues like poorer neighborhood air quality, or bed-sharing.
Black adults are reported to underreport all sleep problems including the use of
sleep medicine, difficulty falling and/or staying asleep, early morning awakening or
waking feeling tired, and napping.40 Despite that, Black adults were noted to be
younger and have a higher BMI than their White peers at the time of diagnosis.41
There are mixed data whether or not Blacks have more severe OSA at the time of
diagnosis.41,42
Studies reporting on OSA prevalence in Latinx adults date back to the early 1990s
with several reports noting that Latinx adults having significantly higher rates of OSA
diagnosis and worse disease severity of OSA than non-Hispanic white populations;
however, a majority of the more recent cohort studies have not found a difference in
OSA prevalence among Latinx adults.36,38,43,44 One study did, however, report a
higher prevalence of severe OSA (apnea hypopnea index [AHI] >30) in Latinx adults
when compared to non-Hispanic White Americans after adjusting for age and
gender.35 Latinx women with OSA were more likely to present with concurrent psy-
chogenic insomnia, while White women with OSA were more likely to present with
sleep maintenance insomnia.13
Reports of prevalence in Latinx children are scant. A single 2004 study found that Lat-
inx children presented with greater caregiver-reported snoring, excessive sleepiness,
witnessed apneas, and parent-reported learning difficulties than their White peers.45
Assessment of Asian American adults reports that they have a higher prevalence
and severity of OSA relative to White American populations.46,47 This may, however,
vary based on nationality or ethnicity. In one large cohort study, Chinese Americans
were found to have a higher odds of OSA in every severity category than White Amer-
icans, but had significantly lower odds of having a formal diagnosis of OSA.35 Chinese
individuals also tend to have a more severe OSA phenotype at a lower BMI than White
adults, which may be due to craniofacial skeletal restriction.48,49 Japanese Americans,
on the other hand, are reported to have a lower prevalence and reduced severity of
OSA than White Americans.35,50
Overall, Asian American adults tend to underreport sleep problems.47 There is scant
existing evidence on the differences in OSA symptoms reported between Asian and
White children’s caregivers.10,51
Very little-or-no data have been published comparing OSA prevalence or diagnosis
for indigenous Americans, Pacific Islanders, or other ethnicities within the United
States.
BEHAVIORAL AND SOCIOCULTURAL
Limitations in health literacy play a significant role in the disparities in the diagnosis
and management of OSA.52 It is well known that patients and families with low health
literacy face barriers all along the health care continuum: with greater difficulty locating
providers and more challenges communicating with providers once they have suc-
cessfully located one than families with high health literacy. Even informational bro-
chures in the waiting room can miss the mark with more than 40% of low health
literacy patients requiring assistance interpreting National Sleep Foundation and
American Academy of Sleep Medicine brochures.53 Often, standardized screening
and diagnosis methods do not effectively identify patients with OSA, with some
studies showing that more than half of adults reporting difficulty completing the
Epworth Sleepiness Scale.54
SOCIOECONOMIC STATUS
Children with lower socioeconomic status (SES) are less likely to follow up with an
otolaryngologist and ultimately to receive treatment for OSA.51,55 For those children
with lower SES who undergo treatment for OSA, they are more likely than their higher
SES peers to have postoperative complications.56
In adults, those with higher SES have a higher likelihood of receiving treatment for
OSA and are up to twice as likely to be compliant with CPAP therapy as their lower
SES peers.57–59 Patients of the highest income brackets are also most likely to un-
dergo surgical treatment for OSA when compared to those in lower income
brackets.23
ENVIRONMENT AND GEOGRAPHY
There are few publications regarding the impact of environmental factors, despite
well-known importance of environment on health—most frequently and notably on
lower SES populations.60 Data from the National Health and Nutrition Examination
Survey found a correlation between living in households with pets or mildew smell
with having higher rates of self-reported OSA symptoms.61
Evidence supports that there can be delays in the diagnosis and management of
OSA in both urban and rural children with OSA, for differing reasons. In rural popula-
tions, the physical distance from providers and facilities like sleep laboratories may
play a key role. There is evidence that longer driving times are associated with lower
odds of polysomnography (PSG) before surgical management of OSA in Canadian
children.62 Children residing in inner-city, urban settings are more likely to have public
insurance—and experience significantly longer intervals from initial evaluation to PSG
than those with private insurance; they are also reported to be twice as likely to be lost
to follow up and to have delayed time to treatment of those with OSA.63,64
Infrastructural limitations can often be a rate-limiting step for patients who are con-
nected to health care resources. It can take months to undergo formal polysomnog-
raphy after referral, with longer wait times reported in underserved communities.65
Research in urban Black adult populations suggests that home sleep testing could
play a key role in reducing these barriers, but more research is needed to assess
the impact on clinical outcomes.66
358 Howard et al
SUMMARY AND FUTURE DIRECTIONS
There are significant inequalities in the diagnosis and treatment of patients with OSA
and research in this area is inadequate, thus limiting our ability to fully understand the
health care needs and fixes that are required to address them. Characterizing where
these inequalities exist and then further examining the reasons behind those inequal-
ities requires thoughtful and meticulous efforts by researchers and clinicians. Shifting
the paradigm toward improved inclusiveness and reporting requires engagement of
stakeholders representing the various identities and backgrounds of those suffering
from OSA in the development of newly tailored educational materials, screening tools,
and diagnostic approaches.
In particular, there are glaring gaps in our understanding of OSA as it manifests in
certain communities like indigenous Americans, Pacific Islanders, and sexual minor-
ities. The accurate and consistent reporting of demographic data like sex, sexual
orientation, race, ethnicity, and gender identity is critical for the identification of health
disparities in all groups: as we cannot intervene on issues that we do not know exist.
Further efforts to diversify the pipeline to academic medicine, and more specifically
otolaryngology, are likely critical to alleviating these inequities—as the perspectives
of individuals from underrepresented groups are paramount in efforts to bring the dis-
parities seen in patients from their communities to light.
CLINICS CARE POINTS
When evaluating and managing sleep apnea patients, individual patient factors must be
taken into account even outside of anatomy and physiology including culture,
environment, behavioral, and psychosocial factors
It is important to acknowlege that historically, most of the research on obstructive sleep
apnea diagnosis and management has been based on overwhelmingly white, male
populations
Targeted efforts to engage diverse communities into the sleep care continuum are needed
DISCLOSURE
There was no funding for this work. Dr S.L. Ishman has consulted for Ethicon and has
grant funding from NIDCR and NHLBI from the NIH. Dr R. Capasso serves on the Sci-
entific Advisory Board for Invicta Medical.
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Health Inequalities in the

Funding: This work was not funded.

Otolaryngol Clin N Am 57 (2024) 353–362

GENDER IDENTITY AND EXPRESSION

There is currently no literature specifically reporting or examining the clinical presen-

RACE AND ETHNICITY

BEHAVIORAL AND SOCIOCULTURAL

ENVIRONMENT AND GEOGRAPHY

SUMMARY AND FUTURE DIRECTIONS

CLINICS CARE POINTS

5. Shahar E, Redline S, Young T, et al. Hormone replacement therapy and sleep-

59. Simon-Tuval T, Reuveni H, Greenberg-Dotan S, et al. Low socioeconomic status is

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