Benefitting From Bicultural Communication: Cleveland Clinic's Hispanic Sleep Disorders Center

Cinthya Pena Orbea, MD

Most adults need 7 to 9 hours of sleep each night, but some subpopulations in the US struggle to achieve this. One such group is Latino adults, who makeup 19% of the general population, with 1 in 3 sleeping less than 7 hours.1 Over the years, the documented evidence regarding the prevalence of sleep disorders among Hispanic patients has grown significantly, with conditions like obstructive sleep apnea among the most frequent.

In early August 2024, Cleveland Clinic opened a new sleep disorders clinic at its Lutheran Hospital in efforts to meet the unique needs of Hispanic patients in the community. Still relatively new, the clinic is primarily directed by Cinthya Pena Orbea, MD, a sleep disorders specialist, with assistance from other internists, nurse practitioners, and primary care physicians.

The new clinic lies within Cleveland Clinic’s Sleep Disorder Center, part of the Cleveland Clinic system, which spans across 23 hospitals, 276 outpatient facilities, and a 173-acre main campus in downtown Cleveland, Ohio. Although not relatively massive in size, the clinic will provide key bilingual and bicultural services, allowing Hispanic patients to better connect with physicians and understand the appropriate treatment course for their sleep disorder. As of 2022, nearly 50,000 people identified as Hispanic living in Cleveland, making up roughly 13.1% of the city’s population.

Literature on the relationship between Hispanic individuals and the medical workforce consistently highlights significant levels of distrust, often driven by a variety of cultural, historical, and systemic factors.^2,3 Language differences can be a major barrier, as many Hispanic patients report feeling misunderstood or disregarded due to the lack of Spanish-speaking healthcare providers or interpreters. Miscommunication between patients and clinicians can often lead to incorrect diagnoses, inadequate treatment, or a perceived lack of empathy, which fuels distrust.

"If the patient prefers Spanish language, that’s something that should be available at the Hispanic clinic, even from the check in," Pena Orbea told NeurologyLive®. "We have people at the front desk that are Hispanic, so they are able to communicate easily. That is from the check-in and questions they may have at the visit and post-treatment, which is very important. This is why we have been working with different durable medical equipment companies to ensure that even the service there is provided in Spanish."

Pena Orbea added that previously, the materials provided to patients, whether during consultation or throughout the treatment process, were only in English. Now, Hispanic patients entering the clinic will have access to all paperwork in Spanish, which may ultimately help facilitate better interactions and care for this group.

The poor sleep habits experienced by Hispanics have been well documented in recent years. Data from the Hispanic Community Health study/Study of Latinos found that up to 14% of Hispanics/Latinx may have obstructive sleep apnea, a sleep disorder related to increased heart disease, hypertension, diabetes, and depression. A 2012 study showed that more than 75% of Hispanic/Latinx participants screened had high risk for sleep-disordered breathing, and over 65% had insomnia symptoms.⁴

Some of the sleep issues seen in this community start at an early age and continue into adulthood. The TuCASA (Tucson Children’s Assessment of Sleep Apnea) study, a notable trial published in 2015, found a significant difference in sleep duration between elementary school-aged Hispanic and Caucasian children, and that Hispanic children tend to have a consistently later bedtime than Caucasian children.⁵ Short sleep duration, commonly observed within the Hispanic population, is associated with poor school performance, behavioral problems, obesity, and hypertension. It is believed that short sleep duration seen in Hispanic children may contribute to health disparities.

Leonor Osorio, DO

"We deal with diabetes, hypertension, pain, and a gamut of all diseases. Sleep has a very important role. If you don’t sleep, your high blood pressure is uncontrolled, your blood sugars are uncontrolled as well," Leonor Osorio, DO, a staff member at the clinic, told NeurologyLive.

Osorio, who’s been with the Cleveland Clinic since 2001, says that a lot of the sleep disorders seen in this patient community are from depression and anxiety, but that patients rarely will talk about their condition. "Sometimes in our culture, it’s like you’re [not supposed] to talk about it. It’s not in vogue or in mode to go to a psychologist to ask for help, especially for men. There’s still some of that machismo of, 'I need to be the provider,' but mental health affects us all."

In one of the first and largest studies to examine the cumulative effect of multiple and disparate stressors on sleep in more than 5000 Hispanic/Latino adults from diverse background groups, results showed that both chronic psychosocial stress and understudied sociocultural stressors, namely ethnic discrimination and acculturation stress, were associated with self-reported poor sleep. The analysis, published in 2017, also revealed that increases in chronic stress were associated with greater insomnia symptoms, whereas increases in ethnic discrimination and acculturation stress were most consistently associated with greater daytime sleepiness symptoms, and increases in the prevalence of short sleep duration (< 7 h) as well as long sleep duration (> 9 h) after adjustment for important confounders, including affective bias.⁶

"It doesn’t matter what race you are or how much money you make, [mental health affects all]," she added. "With the COVID-19 pandemic, that kind of exploded [the conversation] about mental health. A lot of us were not able—with the political climate, the world climate—to sleep as well."

Authors from that 2017 study stressed that there should be efforts directed towards developing and refining psychosocial and behavioral interventions to reduce stress and improve poor sleep among Hispanics. For example, they noted that cognitive behavioral interventions for insomnia, considered a first-line treatment, could be tailored for Hispanics/Latinos who struggle with coping with sociocultural stressors such as acculturation stress and ethnic discrimination.

In addition to sleep disorders related to anxiety and depression, Osorio noted that a lot of presenting Hispanic patients struggle with obesity, mainly influenced by the types of foods eaten within Hispanic culture.

"In some of the cultures, like Puerto Rican culture, there’s a lot of fried food, a lot of starchy food," she said. "It’s delicious, but something that shouldn’t be indulged every day."

Health-related behaviors, such as changes in diet, have been shown to influence sleep patterns. From a macronutrient perspective, the excessive intake of saturated fats and sugar alongside low levels of fiber intake appears to be associated with less restorative sleep.⁷ Likewise, the insufficient intake of proteins and carbohydrates could also lead to a decrease duration of sleep.

Among Hispanic individuals, research has shown that the underconsumption of certain foods like vegetables, fruits, diary, lean means, and legumes, as well as the overconsumption of others, such as sugary soft drinks and sweets, were both associated with a higher risk of suffering from a sleeping disorder. In 2022, a cross-sectional study of nearly 900 Spanish university students revealed a noteworthy rate of bad sleepers (51.6%) and students whose diet needed modifications (82.2%). Within that study, investigators found a strong correlation between dietary habits and sleep quality.⁸

Educating patients on appropriate sleeping habits, as well as better dietary practices, is one of the key pieces to this clinic. Coming into the clinic, many patients are still trying to understand their condition, how it may relate to other comorbidities, and why it’s impacting quality of life.

"I truly try to focus on how much of their condition, whether it’s sleep apnea, insomnia, or sleep deprivation, is associated with their chronic condition. I also focus on quality of life and safety, because in many cases a lot of patients are driving, working in factories, or taking care of babies while they are sleepy," Pena Orbea said. "That’s one part. The other is the importance of treatment, and how that can impact or perhaps even motivate them to make a change and improve on their goals.”

"We understand we have a lot of people from Mexico, South America, Central America, etc. We give ideas for substitutions for certain foods and decreasing the amount of food to ultimately reduce weight," Osorio added. "Also, educating patients about CPAP usage. Some get diagnosed and don’t want to use a machine. [Sometimes] just trying to tell them that there are smaller machines that don’t make noise and different types of masks, that can be life-saving because the risk of untreated obstructive sleep apnea [can lead to] stroke, heart attack, and death.”

Osorio and Pena Orbea noted that a lot of the small details of the clinic truly make it what it is. At times, presenting patients may come into the clinic with their entire family aside them, which may normally be frowned upon at other institutions. The clinic welcomes families to be by the patient’s side, especially if they are trying to learn more about better cooking practices and ways to improve their sleep. Osorio noted that to them, it takes a village to raise a child and a village to keep people healthy.

While it may be overlooked in other institutions, the small changes to the clinic are some that have the greatest impacts on presenting patients. In the clinic, staff members are cognizant of sitting close with patients, ensuring they feel respected and validated. Even asking more pertinent questions about how patients’ families are doing, as well as having a greater background knowledge of Hispanic culture and heritage are aspects the clinic stresses to its members.

"It’s these little nuances that make patients come back," Osorio told NeurologyLive. "Because you can have one visit with a patient, but if you don’t build that trust, they won’t stay here."

A lot of the sleep issues among Hispanics are often unrecognized, says Pena Orbea. Major studies like the Hispanic Community Health Study/Study of Latinos (HCHS/SOL) and the Multi-Ethnic Study of Atherosclerosis have shed light on these issues. In the HCHS/SOL, which consists of more than 16,000 Hispanic patients, many participants showed signs of sleep-breathing disorders without being aware of their condition. The study also highlighted that a very small percentage of participants (less than 2%) reported receiving a formal diagnosis of sleep apnea from a physician, indicating a large burden of undiagnosed sleep apnea within this community.⁹

"I recently saw a patient who had been snoring his whole life, and I asked him, ‘why are you coming to the clinic now?’ He told me, ‘well, because my cardiologist told me.’ He thought the snoring was normal, that it was something that comes with aging," Pena Orbea said. "He never thought that this was something else. That has been a pattern [we’ve seen at the clinic]."

Going forward, the clinic is making a concerted effort to better understand the sleep disparities seen in Hispanics, including research on sociodemographic and economic factors, as well as referral patterns. Led by Pena Orbea, some of the initiatives will focus on trying to understand the needs of these patients, using qualitative data. In addition, the clinic will also study some of the barriers of why patients don’t get screened, as well as some of the potential genetic differences in specific Latin countries which may ultimately lead to more personalized treatment strategies.

REFERENCES
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2. 5 facts about Hispanic Americans and Health Care. Pew Research Center. October 30, 2023. Accessed October 10, 2024. https://www.pewresearch.org/short-reads/2023/10/30/5-facts-about-hispanic-americans-and-health-care/
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8. Ramon-Arbues E, Granada-Lopez JM, Martinez-Abadia B, et al. The association between diet and sleep quality among Spanish University Students. Nutrients. 2022;14(16):3291. doi:10.3390/nu14163291
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