Prevalence and Recognition of Obstructive Sleep Apnea in Chinese Patients With Type 2 Diabetes Mellitus

doi:10.1378/chest.10-0596

Chest

Volume 138, Issue 5, November 2010, Pages 1101-1107

https://doi.org/10.1378/chest.10-0596 Get rights and content

Background

Obstructive sleep apnea (OSA) is associated with disorders of glucose metabolism. Previous studies revealed a high prevalence of OSA among subjects with type 2 diabetes mellitus (DM). The aims of this study were to determine the prevalence of OSA and associated clinical factors in Chinese patients with DM.

Methods

All records of the DM clinic at a teaching hospital in Hong Kong were screened between January 2007 and June 2008. Inclusion criteria for patients were Chinese, aged 18 to 75 years, with type 2 DM. Patients with unstable medical illnesses, gestational diabetes, or on renal replacement therapy were excluded.

Results

Of 3,489 records screened, 1,859 subjects were eligible. A random sample of 663 (mean age, 58.2 ± 10.8; mean BMI, 26.0 ± 4.6), except six with known OSA, were invited for polysomnography (PSG). Of 165 subjects on which PSG was performed, OSA was diagnosed (apnea-hypopnea index [AHI] ≥ 5.0/h) in 89 subjects (53.9%, median Epworth Sleepiness Scale, 6 [interquartile range 3, 10]). Fifty-four (32.7%) had moderate/severe OSA (AHI ≥ 15/h). The estimated OSA prevalence in this diabetic cohort was 17.5% (24.7% in men, 10.3% in women). Regression analysis identified that AHI was associated independently with higher BMI, advanced age, male sex, and higher diastolic BP (R² = 29.6%). The adjusted OR of requiring three or more antihypertensive drugs in moderate/severe OSA was 2.48 (95% CI, 1.05–5.87). No association between glycemic control (HbA1c) and sleep was identified.

Conclusions

In conclusion, OSA is more prevalent in Chinese adults with DM than in the general population. A high index of suspicion for OSA in patients with DM is warranted, because they may not have overt daytime sleepiness.

Trial registry

ClinicalTrials.gov; No.: NCT01172093; URL: www.clinicaltrials.gov

Section snippets

Patient Recruitment

Patients with type 2 DM were recruited at the DM clinic affiliated with the Department of Medicine, the University of Hong Kong, at Queen Mary Hospital. From January 2007 to June 2008, all records of patients attending the weekly clinic were screened for eligibility. The inclusion criteria were Chinese, aged 18 to 75 years with type 2 DM, and able to give informed written consent. Patients with acute or unstable medical illnesses; hospital admission for acute coronary syndrome, congestive heart

Results

Of 3,489 outpatient records screened, 1,859 subjects with DM were eligible based on record review, and a random sample of 824 subjects was drawn (Fig 1). Six hundred sixty-three subjects responded to the sleep questionnaire. Six had known OSA, and the other 657 subjects were invited to undergo PSG, of whom 177 subjects consented. Characteristics of PSG subjects are shown in Table 1, Table 2. Subjects who underwent PSG included more men, with higher BMI and ESS compared with those who declined

Discussion

To our knowledge, this is the first prospective study on the prevalence of OSA in subjects of Asian ethnicity with diabetes. In this cohort of adult Chinese with DM, OSA was estimated to be present in 24.7% of men and 10.3% of women. More than one-half of them had moderate or severe OSA. These prevalence rates are higher than those found in the community-based data.25, 26 For patients with diabetes between 40 and 60 years old, where age-matched comparison was possible, the prevalence was higher

Acknowledgments

Author contributions: Dr D. Lam: contributed to carrying out the recruitment, patient assessment, and clinical care of subjects recruited in this study; initial drafting of the manuscript; and drafting, editing, and approving the final manuscript.

Dr Lui: contributed to carrying out the recruitment, patient assessment, and clinical care of subjects recruited in this study; initial drafting of the manuscript; and drafting, editing, and approving the final manuscript.

Dr J. Lam: contributed to

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A systematic search of four databases (PubMed, Web of Science, Scopus & Embase) was performed. Only objective measurements of 24-h movement behaviors were included in the search strategy. The explanatory variables were classified according to the levels of the socio-ecological model (i.e. intrapersonal, interpersonal and environmental). The risk of bias was assessed using the Joanna Briggs Institute appraisal checklist.
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Between July 2010 and June 2015, patients with T2D aged ≥60 years enrolled in the Hong Kong Diabetes Register completed the Insomnia Severity Index (ISI) questionnaire. Patients were considered having insomnia if they had ISI score > 14. We prospectively followed up the cohort and censored outcome through reviewing diagnoses and clinical notes entered by attending physicians in electronic medical record to identify incident cases of mild cognitive impairment and dementia.
After excluding shift workers and those with established chronic cognitive impairment at baseline, we included 986 patients with T2D in this study (58.3 % men, mean age ± standard deviation: 62.5 ± 2.6 years, disease duration of diabetes: 10.7 ± 8.2 years, HbA1c: 7.4 ± 1.3 %, insulin users: 28.7 %, insomnia: 9.1 %). After a median follow-up of 7.6 (interquartile range = 2.0) years, 41 (4.2 %) developed chronic cognitive impairment. Using Cox regression analysis, insomnia (hazard ratio, HR 2.909, p = 0.012) and HbA1c ≥ 7 % (HR 2.300, p = 0.038) were positively associated with incident chronic cognitive impairment while insulin use (HR 0.309, p = 0.028) showed negative association.
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Citation Excerpt :
Obstructive sleep apnea (OSA) is relatively common in patients with type 2 diabetes mellitus with prevalence estimates in the range of 54–86% [1,2].
Continuous glucose monitoring (CGM) provides temporal data on glycemic variability, a predictor of outcomes related to type 2 diabetes mellitus. The current study sought to determine whether CGM-derived metrics in patients with type 2 diabetes are different in moderate-to-severe versus mild obstructive sleep apnea (OSA).
In adults with type 2 diabetes, home testing was used of assess the presence of OSA. CGM data were collected for at least 7 days in those with an oxygen desaturation index (ODI) ≥ 5 events/hr. The study sample was divided into mild (ODI: 5.0–14.9 events/hr) and moderate-to-severe OSA (ODI ≥15 events/hr). Actigraphy was used to distinguish the wake and sleep periods. CGM-derived metrics were compared between the two groups using multivariable regression models.
Compared to mild OSA, patients with moderate-to-severe OSA had higher mean glucose levels during sleep (adjusted difference 8.4 mg/dL; p-value: 0.03) and wakefulness (adjusted difference 7.1 mg/dL; p-value: 0.06). Moderate-to-severe OSA patients also had lower odds for having their glucose values within the acceptable range during wakefulness than those with mild OSA (adjusted odds ratio of 0.63; p-value: 0.02). The mean amplitude of glycemic excursion and standard deviation of the rate of change in glucose values (SD-ROC) were higher in moderate-to-severe than mild OSA, but only during wakefulness. Sex modified the association between OSA severity and SD-ROC, but not the other CGM-derived metrics.
In patients with type 2 diabetes, moderate-to-severe OSA is associated with greater abnormalities in CGM-derived metrics than mild OSA with notable differences between sleep and wakefulness.
Metabolic Consequences of Obstructive Sleep Apnea
2021, Encyclopedia of Respiratory Medicine, Second Edition
The effects of OSA on metabolism are quite complex, and obesity, diabetes, nonalcoholic fatty liver disease and dyslipidemia often coexist with OSA, making it difficult to tease out the independent effects of OSA on metabolic variables. There is firm experimental evidence of a detrimental impact of OSA on adipose tissue dysfunction, with intermittent hypoxia, sympathetic hyperactivity, and oxidative stress as the most important intermediate mechanisms. Sleep fragmentation or deprivation may also contribute to the metabolic dysfunction of OSA. This work reviews the current knowledge on this topic, as well as the results of studies on the effects of CPAP treatment.
Association of parameters of nocturnal hypoxemia with diabetic microvascular complications: A cross-sectional study
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To examine the association between obstructive sleep apnea (OSA)-related nocturnal hypoxemia parameters and diabetic microvascular complications in patients with type 2 diabetes mellitus (T2DM).
A total of 463 Chinese patients with T2DM underwent overnight polysomnography, followed by diagnosis of diabetic microvascular complications including diabetic peripheral neuropathy (DPN), diabetic retinopathy (DR) and diabetic nephropathy (DN). Parameters of nocturnal hypoxemia, including apnea-hypopnea index (AHI), oxygen desaturation index (ODI), time spent with SpO₂ < 90% (T90%) or <85% (T85%), mean SpO₂ and lowest SpO₂, were recorded.
AHI was independently associated with higher odds of DPN (OR 1.19; 95% CI, 1.05–1.36; P = 0.008) after adjustment for possible confounders. Moreover, patients with severe OSA (AHI ≥ 30 events/h) had higher likelihood of having DPN than those with mild OSA (OR 2.36; 95% CI, 1.31–4.25; P = 0.004). When combining DPN, DR and DN into an overall diabetic microvascular complication index, AHI was also independently associated with higher odds of having any diabetic microvascular complication (OR 1.21; 95% CI, 1.06–1.38; P = 0.006).
The AHI may be the OSA-related index that most strongly reflects the association of OSA and diabetic microvascular complications, compared with other OSA-related hypoxemia parameters.
The association between sleep and diabetes outcomes – A systematic review
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This study aimed to systematically review the prevalence of diagnosed sleep disorders in people with diabetes and to determine the association between sleep disorders and blood glucose levels and diabetes outcomes.
We conducted a literature search in the following databases: MEDLINE (Pubmed), EMBASE, CINAHL, PsychInfo and Web of Science Citation Index. Meta-analysis (random-effects models) was conducted to estimate the prevalence of sleep disorders in people with diabetes.
Forty-one articles measured the prevalence of sleep disorders in adults with diabetes. The estimated pooled prevalence of sleep disorders in diabetes was estimated to be 52% (95% CI 42–63%). The highest pooled prevalence was observed for unspecified sleep apnea (69%; 95% CI: 59–78%), followed by obstructive sleep apnea (60%; 95% CI 39–80%), and restless leg syndrome (27%; 95% CI 20–34%). Eleven studies examined the association between sleep disorders and diabetes control and complications. The presence of comorbid sleep disorders was associated with increased diabetes outcomes.
Diagnosed sleep disorders are highly prevalent in people with diabetes. Sleep disorders are associated with diabetes outcomes, though there was considerable heterogeneity across studies.

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Drs D. Lam and Lui contributed equally to the work as co-first authors.

Funding/Support: This study was supported by the Sleep and Respiratory Fund, University of Hong Kong.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (http://www.chestpubs.org/site/misc/reprints.xhtml).

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Original ResearchSleep MedicinePrevalence and Recognition of Obstructive Sleep Apnea in Chinese Patients With Type 2 Diabetes Mellitus

Background

Methods

Results

Conclusions

Trial registry

Section snippets

Patient Recruitment

Results

Discussion

Acknowledgments

Clin Chest Med

Chest

Respir Med

Respir Med

Chest

Chest

Chest

Chest

Lancet

Lancet

Prog Cardiovasc Dis

Sleep Med Rev

Lancet

Sleep Med Rev

Diabetes Res Clin Pract

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A randomised controlled trial of nasal continuous positive airway pressure on insulin sensitivity in obstructive sleep apnoea

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Alterations in glucose disposal in sleep-disordered breathing

Am J Respir Crit Care Med

Obstructive sleep apnoea is associated with decreased insulin sensitivity in females

Eur Respir J

Original Research
Sleep Medicine
Prevalence and Recognition of Obstructive Sleep Apnea in Chinese Patients With Type 2 Diabetes Mellitus