Sleep and Breathing

, Volume 9, Issue 3, pp 111–118 | Cite as

Obstructive sleep apnea and ischemic heart disease in southwestern US veterans: implications for clinical practice

  • Carol M. Baldwin
  • Iris R. Bell
  • Stefano Guerra
  • Stuart F. Quan
Original Article


This study describes associations between obstructive sleep apnea (OSA), intake of food rich in antioxidant nutrients, and ischemic heart disease (IHD) in military veterans. Subjects were male veterans (n=211), 54 to 85 years of age, and enrolled in primary care clinics at the Southern Arizona Veterans Affairs Health Care System (SAVAHCS), Tucson, AZ. Measures included the SAVAHCS Minority Vascular Center Questionnaire, the Sleep Heart Health Study Sleep Habits Questionnaire, the Arizona Food Frequency Questionnaire, height, weight, and blood pressure. Veterans with OSA were significantly more likely to be obese, to have elevated systolic blood pressure and physician-diagnosed IHD, more likely to undergo coronary angiography, and less likely to consume foods rich in cardioprotective antioxidants compared to veterans without OSA. After adjusting for confounding variables, the association between OSA and IHD remains significant [adjusted OR=2.99, confidence interval (CI)=1.07–8.42]. These data reinforce the importance of recognizing OSA within the veterans affairs health care system and suggest that early detection of OSA may improve veterans' health and well-being and reduce associated medical costs.


Cardiovascular disease Nutrient antioxidant intake Obesity Obstructive sleep apnea US military veterans 



We wish to gratefully acknowledge the SAVAHCS Health Services Research and Development staff, study staff, librarians, and in particular, the study participants who made this research possible. Sincere appreciation is extended to Margaret Kurzius-Spencer, MPH, Research Specialist Senior, University of Arizona Respiratory Center, for her critical review and revisions of the manuscript.

This study was supported by a Department of Veterans Affairs VISN 18 Minority Vascular Center grant to Dr. Baldwin and Dr. Bell and, in part, Cooperative Agreement Supplement U01HL53938-07S1 from the National Institutes of Health National Heart, Lung, and Blood Institute to Dr. Baldwin.


  1. 1.
    Young T, Palta M, Dempsey J, Skatrud J, Weber S, Badr S (1993) The occurrence of sleep-disordered breathing among middle-aged adults. N Engl J Med 29:1230–1235CrossRefGoogle Scholar
  2. 2.
    El-Ad B, Korczyn AD (1998) Disorders of excessive daytime sleepiness—an update. J Neurol Sci 153:192–202CrossRefPubMedGoogle Scholar
  3. 3.
    Ancoli-Israel S (1989) Epidemiology of sleep disorders. Clin Geriatr Med 5:347–362PubMedGoogle Scholar
  4. 4.
    Baldwin CM, Quan SF (2002) Sleep disordered breathing. Nurs Clin North Am 37:633–654CrossRefPubMedGoogle Scholar
  5. 5.
    Young T, Peppard PE, Gottlieb DJ (2002) Epidemiology of obstructive sleep apnea: a population health perspective. Am J Respir Crit Care Med 165:1217–1239CrossRefPubMedGoogle Scholar
  6. 6.
    Leger D (1994) The cost of sleep-related accidents: a report of the National Commission on Sleep Disorders Research. Sleep 17:84–93PubMedGoogle Scholar
  7. 7.
    Mitler MM, Carskadon MA, Czeisler CA, Dement WC, Dinges DF, Graeber RC (1988) Catastrophes, sleep and public policy: consensus report. Sleep 11:100–109PubMedGoogle Scholar
  8. 8.
    Young T, Blustein J, Finn L, Palta M (1997) Sleep-disordered breathing and motor vehicle accidents in a population-based sample of employed adults. Sleep 20:608–613PubMedGoogle Scholar
  9. 9.
    Baumel MJ, Maislin G, Pack AI (1997) Population and occupational screening for obstructive sleep apnea: are we there yet? Am J Respir Crit Care Med 155:9–14PubMedGoogle Scholar
  10. 10.
    Millman RP, Redline S, Carlisle CC, Assaf AR, Levinson PD (1991) Daytime hypertension in obstructive sleep apnea. Prevalence and contributing risk factors. Chest 99:861–866PubMedCrossRefGoogle Scholar
  11. 11.
    Fletcher E (1995) The relationship between systemic hypertension and obstructive sleep apnea: facts and theory. Am J Med 98:118–128CrossRefPubMedGoogle Scholar
  12. 12.
    Young T, Peppard P, Palta M, Hla M, Finn L, Morgan B, Skatrud J (1997) Population-based study of sleep-disordered breathing as a risk factor for hypertension. Arch Intern Med 157:1746–1752CrossRefPubMedGoogle Scholar
  13. 13.
    Franklin KA, Nilsson JB, Sahlin C, Naslund U (1995) Sleep apnoea and nocturnal angina. Lancet 345:1085–1087CrossRefPubMedGoogle Scholar
  14. 14.
    Hung J, Whitford EG, Parsons RW, Hillman DR (1990) Association of sleep apnoea with myocardial infarction in men. Lancet 336:261–264CrossRefPubMedGoogle Scholar
  15. 15.
    Mooe T, Rabben T, Wiklund U, Franklin KA, Eriksson P (1996) Sleep-disordered breathing in men with coronary artery disease. Chest 109:659–663PubMedCrossRefGoogle Scholar
  16. 16.
    Nieto FJ, Young TB, Lind BK, Shahar E, Samet JM, Redline S, D'Agostino RB, Newman AB, Lebowitz MD, Pickering TG (2000) Association of sleep-disordered breathing, sleep apnea, and hypertension in a large community-based study. JAMA 283:1829–1836CrossRefPubMedGoogle Scholar
  17. 17.
    Newman AB, Nieto JF, Guidry U, Lind BK, Redline S, Shahar E, Pickering TG, Quan SF (2001) Relation of sleep-disordered breathing to cardiovascular disease risk factors in the Sleep Heart Health Study. Am J Epidemiol 154:50–59CrossRefPubMedGoogle Scholar
  18. 18.
    Shahar E, Whitney CW, Redline S, Lee ET, Newman AB, Nieto FJ, O'Connor GT, Boland LL, Schwartz JE, Samet JM (2001) Sleep-disordered breathing and cardiovascular disease: cross-sectional results of the Sleep Heart Health Study. Am J Respir Crit Care Med 163:19–25PubMedGoogle Scholar
  19. 19.
    Lavie P (2003) Obstructive sleep apnea syndrome—an oxidative stress disorder. Sleep Med Rev 7:35–51CrossRefPubMedGoogle Scholar
  20. 20.
    Bunout D, Garrido A, Suazo M, Kauffman R, Venegas P, De la Maza P, Petermann M, Hirsch S (2000) Effects of supplementation with folic and antioxidant vitamins on homocysteine levels and LDL oxidation in coronary patients. Nutrition 16:107–110CrossRefPubMedGoogle Scholar
  21. 21.
    Dwyer JH (2001) Oxygenated carotenoid lutein and progression of early atherosclerosis: the Los Angeles Atherosclerosis Study. Circulation 103:2922–2927PubMedGoogle Scholar
  22. 22.
    Maxwell SR (2000) Coronary artery disease-free radical damage, antioxidant protection and the role of homocysteine. Basic Res Cardiol 95(Suppl 1):165–171CrossRefGoogle Scholar
  23. 23.
    Davidson TM, Do KL (2000) Sleep-disordered breathing: a survey of otolaryngologic practice at military hospitals. Ear Nose Throat J 79:843–844PubMedGoogle Scholar
  24. 24.
    Roccaforte WH, Burke WJ, Bayer BL, Wengel SP (1992) Validation of a telephone version of the mini-mental state examination. J Am Geriatr Soc 40:697–702PubMedGoogle Scholar
  25. 25.
    Wolf PA, D'Agostino RB, Belanger AJ, Kannel WB (1991) Probability of stroke: a risk profile from the Framingham Study. Stroke 22:312–318PubMedGoogle Scholar
  26. 26.
    Quan SF, Howard BV, Iber C, Kiley JP, Nieto FJ, O'Connor GT, Rapoport DM, Redline S, Robbins J, Samet JM, Wahl PW (1997) The Sleep Heart Health Study: design, rationale, and methods. Sleep 20:1077–1085PubMedGoogle Scholar
  27. 27.
    Martinez ME, Marshall JR, Graver E, Whitacre RC, Woolf K, Ritenbaugh C, Alberts DS (1999) Reliability and validity of a self-administered food frequency questionnaire in a chemoprevention trial of adenoma recurrence. Cancer Epidemiol Biomark Prev 8:941–946Google Scholar
  28. 28.
    Deyo RA, Diehl AK, Hazuda H, Stern MP (1985) A simple language-based acculturation scale for Mexican Americans: validation and application to health care research. Am J Publ Health 75:51–55CrossRefGoogle Scholar
  29. 29.
    Peacock MD, Morris MJ, Houghland MA, Anders GT, Blanton HM (1997) Sleep apnea–hypopnea syndrome in a sample of veterans of the Persian Gulf War. Mil Med 162:249–251PubMedGoogle Scholar
  30. 30.
    Flemons WW, Douglas NJ, Kuna ST, Rodenstein DO, Wheatley J (2004) Access to diagnosis and treatment of patients with suspected sleep apnea. Am J Respir Crit Care Med 169:668–672CrossRefPubMedGoogle Scholar
  31. 31.
    Chervin RD, Guilleminault C (1996) Obstructive sleep apnea and related disorders. Neurol Clin 14:583–609CrossRefPubMedGoogle Scholar
  32. 32.
    Smith R, Ronald J, Delaive K, Walld R, Manfreda J, Kryger MH (2002) What are obstructive sleep apnea patients being treated for prior to this diagnosis? Chest 121:164–172PubMedCrossRefGoogle Scholar
  33. 33.
    Kapur V, Blough DK, Sandblom RE, Hert R, de Maine JB, Sullivan SD, Psaty BM (1999) The medical cost of undiagnosed sleep apnea. Sleep 22:749–755PubMedGoogle Scholar
  34. 34.
    Boethel CD (2002) Sleep and the endocrine system: new associations to old diseases. Curr Opin Pulm Med 8:502–505CrossRefPubMedGoogle Scholar
  35. 35.
    Wolk R, Somers VK (2003) Cardiovascular consequences of obstructive sleep apnea. Clin Chest Med 24:195–205CrossRefPubMedGoogle Scholar
  36. 36.
    Punjabi NM, Ahmed MM, Polotsky VY, Beamer BA, O'Donnell CP (2003) Sleep-disordered breathing, glucose intolerance, and insulin resistance. Respir Physiol Neurobiol 136:167–178CrossRefPubMedGoogle Scholar
  37. 37.
    Punjabi NM, Sorkin JD, Katzel LI, Goldberg AP, Schwartz AR, Smith PL (2002) Sleep-disordered breathing and insulin resistance in middle-aged and overweight men. Am J Respir Crit Care Med 165:562–563PubMedGoogle Scholar
  38. 38.
    Carpagnano GE, Kharitonov SA, Resta O, Foschino-Barbaro MP, Gramiccioni E, Barnes PJ (2002) Increased 8-isoprostane and interleukin-6 in breath condensate of obstructive sleep apnea patients. Chest 122:1162–1167CrossRefPubMedGoogle Scholar
  39. 39.
    Shamsuzzaman AS, Gersh BJ, Somers VK (2003) Obstructive sleep apnea: implications for cardiac and vascular disease. JAMA 290:1906–1914PubMedCrossRefGoogle Scholar
  40. 40.
    Ubbink JB (1994) Vitamin nutrition status and homocysteine. Nutr Rev 52:383–387PubMedCrossRefGoogle Scholar
  41. 41.
    Baldwin CM, Bootzin RR, Schwenke DC, Quan SF (2005) Antioxidant nutrient intake and supplements as potential moderators of cognitive decline and cardiovascular disease in obstructive sleep apnea. Sleep Med Rev (in press)Google Scholar
  42. 42.
    Kazis LE, Miller DR, Clark J, Skinner K, Lee A, Rogers W, Spiro A III, Payne S, Fincke G, Selim A, Linzer M (1998) Health-related quality of life in patients served by the Department of Veterans Affairs. Arch Intern Med 158:626–632CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag 2005

Authors and Affiliations

  • Carol M. Baldwin
    • 1
    • 2
  • Iris R. Bell
    • 2
    • 3
  • Stefano Guerra
    • 4
  • Stuart F. Quan
    • 5
  1. 1.College of NursingArizona State UniversityTempeUSA
  2. 2.Southern Arizona VA Health Care SystemResearch Service LineTucsonUSA
  3. 3.Departments of Medicine, Psychology, Psychiatry, Surgery, Program in Integrative Medicine, and College of Public HealthUniversity of ArizonaTucsonUSA
  4. 4.Department of Medicine, Arizona Respiratory Center, and College of Public HealthUniversity of ArizonaTucsonUSA
  5. 5.Department of Medicine, Arizona Sleep and Respiratory Centers, and College of Public HealthUniversity of ArizonaTucsonUSA

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