Sleep Apnea 101: Why Sleep Apnea Is So Often Missed — And What You Can Do About It
By Glenye Cain Oakford
A leading sleep neurologist, Dr. Hrayr Attarian explains why sleep apnea goes undiagnosed — especially in women, thin people, and East Asian populations — and how patients can advocate for themselves.
Sleep apnea affects millions of people, but it is one of the most frequently missed diagnoses in medicine. The reasons are more complex than many patients realize, and they go far beyond body weight or loud snoring.
Dr. Hrayr Attarian, Professor of Neurology at Northwestern University Feinberg School of Medicine and Medical Director of the Northwestern Medicine Center for Sleep Health in Chicago, Illinois, points to some overlapping reasons that contribute to misdiagnoses. For a start, the most obvious symptoms like snoring and frequent, very brief awakenings, happen at night while patients and their bed partners are asleep.
"People generally don't think about sleep. Doctors don't think about sleep to ask, and patients don't generally volunteer information about their sleep symptoms unless they become really, really bad," Dr. Attarian said. "Bed partners are notoriously poor reporters of sleep apnea symptoms. I mean, I'm a sleep doctor, and I did not know my wife had sleep apnea."
Second, sleep apnea presents very differently depending on who has it.
"Sleep apnea is a prevalent disorder that affects anybody from six months to 106 years, so looking for it in just a specific age population is not appropriate," said Dr. Attarian. "You also have to be careful about different groups of people: women present symptoms differently from men, and a lot of thin people have sleep apnea."
Dr. Attarian explains what patients should know.
1. Women are frequently underdiagnosed with sleep apnea.
Women make up more than half the world's population — and they are disproportionately missed.
"Women have been under-diagnosed with sleep apnea both because they present with different symptoms and because there's also a lot of gender bias," Dr. Attarian explained. "It's not unusual for a woman to go to a primary care doctor with sleepiness and be diagnosed with depression, because, in their mind, you have to be a middle-aged or older fat man to have sleep apnea, which is not true."
Women are more likely to report insomnia and fatigue — not the classic picture of falling asleep at the wheel or during meetings.
"Between gender bias and a doctor not knowing the exact symptomatic presentation in women, a lot of those cases are missed," he said.
2. Thin people can have sleep apnea.
Dr. Attarian mentions a recent large study published in Lancet Respiratory Medicine that found that about 38% of people with sleep apnea were not heavy, which reveals that weight is only part of the picture.
"Weight is one factor. It's a huge factor, and I'm not discounting that," Dr. Attarian said. "There's also the factor of genetics, because in a genetically relatively uniform population, like in Iceland, they have identified specific genes that affect collapsibility of the airway. A third factor is reproductive hormonal balance."
And that applies to both men and women.
"Testosterone increases the risk," Dr. Attarian explained. "A lot of guys who are bodybuilders and take anabolic steroids, which are testosterone-like, end up having sleep apnea. A lot of people who are women, when they go through menopause and there's a decline in estrogen, the smooth muscles become more collapsible.
"So there are endocrine reasons, anatomical reasons, weight, muscular function due to genetics," he continued. "It's a disorder that has multiple risk factors and pathophysiologic co-mechanisms."
At least some weight-loss data reinforces this. In GLP-1 clinical trials using Zepbound®, even though the entire cohort lost weight after a year, Dr. Attarian notes, only 43% had their sleep apnea resolved. "We see the same with bariatric surgery," Dr. Attarian explained. "After weight loss, we only see sleep apnea cure in about 60% of patients." That means a significant portion do not.
3. Sleep apnea often is underdiagnosed in East Asian patients.
"The third population in whom sleep apnea often gets under diagnosed are East Asians. People from China, Korea, and Japan tend not to be heavy when they have sleep apnea, and they often get missed," Dr. Attarian said.
The underlying cause is largely anatomical, he explained. Specific facial structures common in East Asian populations can narrow the airway independently of body weight.
4. Misinformation about CPAP keeping patients from getting diagnosed.
"People think that if they complain of snoring and sleep apnea, they are going to get a CPAP, this huge mask with hoses and stuff," Dr. Attarian said. "And that's not necessarily true. So they don't want to complain because they don't want to go there, because there's so much misinformation out there between social media and the internet and incorrect news," he said.
The reality is that treatment options have expanded beyond CPAP, and modern CPAP equipment is far less cumbersome than some of the images circulating on social media.
5. What should I do if I think I have sleep apnea?
Start with your primary care doctor, Dr. Attarian advises. Go in with a list of your specific symptoms and ask for a referral to a sleep specialist or a sleep study, which might be available as a home sleep test.
Use reliable sources. The Alliance of Sleep Apnea Partners (ASAP) is a trusted starting point for patients. Dr. Attarian also recommends the American Academy of Sleep Medicine and the National Sleep Foundation.
Understand the stakes. Dr. Attarian is direct about the risks of leaving OSA untreated.
"It's important to understand the impact of untreated sleep apnea on overall health, risk for stroke, heart attack, etc.," he said. "A lot of people may say, 'I don't care if I die. I'm not going to use this CPAP machine.' Fine, but you may not die. You may end up with a stroke and be severely disabled."
Consider a consumer sleep tracker — but understand their limitations. Dr. Attarian acknowledged that the Apple Watch, Samsung smartwatch, Oura ring, and Garmin devices can be potentially helpful screening tools. These wearable devices can't provide a diagnosis for sleep apnea, but if they flag abnormal breathing, take it seriously, Dr. Attarian said.
6. How can I advocate for myself if I'm not being heard?
If you feel that your doctor isn't responding to your concerns about sleep apnea symptoms, consider bringing in some data from your wearable device.
"There's also a free app called SnoreLab," Dr. Attarian said. "You can record yourself and present that."
SnoreLab records snoring volume and patterns. The free version lets you play back recordings; the paid version analyzes patterns and gives you a risk level.
If you're still not getting traction with the doctor, Dr. Attarian said, "A lot of the sleep clinics, including ours, don't require a referral physician" so you can book an appointment directly.
If you think you might have sleep apnea, do advocate for yourself and seek a diagnosis. If you feel you have been dismissed, misdiagnosed, or told your symptoms don't fit the profile — keep pushing. Sleep apnea doesn't look the same in everyone.
Dr. Hrayr Attarian is Professor of Neurology at Northwestern University Feinberg School of Medicine and Medical Director of the Northwestern Medicine’s Centers of Sleep Health. He specializes in sleep and circadian rhythm disorders. His primary clinical focus is diagnosing and treating sleep disorders, particularly those with comorbid neurological illnesses.
The Sleep Apnea 101 series is supported Eli Lilly and Company.
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