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He J, Ruan X, Li J. Polycystic ovary syndrome in obstructive sleep apnea-hypopnea syndrome: an updated meta-analysis. Front Endocrinol (Lausanne) 2024; 15:1418933. [PMID: 39247914 PMCID: PMC11377251 DOI: 10.3389/fendo.2024.1418933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2024] [Accepted: 08/06/2024] [Indexed: 09/10/2024] Open
Abstract
Background Obstructive sleep apnea-hypopnea syndrome (OSAHS) is correlated with metabolic deterioration in patients experiencing polycystic ovary syndrome (PCOS). Women diagnosed with PCOS exhibit a heightened prevalence of OSAHS. This meta-analysis aims to assess the morbidity of OSAHS in women affected by PCOS and to examine the differences in metabolism-related indicators between OSAHS-positive and OSAHS-negative in women with PCOS. Methods A comprehensive literature analysis of OSAHS morbidity in women with PCOS was conducted, utilizing databases such as CNKI, EMBASE, PubMed, Web of Science, and Wanfang. A comparison was carried out between patients with OSAHS-positive and those with OSAHS-negative in terms of their clinical characteristics and metabolic differences. The search language included English and Chinese. The acquired data were analyzed by employing RevMan 5.2 and Stata 11.0. Continuous variables with the same units were combined and analyzed through weighted mean differences (WMDs) as effect sizes, while continuous variables with different units were combined and analyzed through standardized mean differences (SMDs) as effect sizes. A conjoint analysis was performed on the basis of I2 value, using either a fixed effect model (I2 ≤ 50%) or a random effect model (I2 > 50%). Results A total of 21 articles met the inclusion criteria for this study. The findings indicated that 20.8% of women with PCOS were found to have comorbid OSAHS. The subjects were categorized into various subgroups for meta-analysis on the basis of race, age, disease severity, body mass index (BMI), and diagnostic criteria of PCOS. The results revealed high morbidity of OSAHS in all subgroups. In addition, most metabolic indicators and parameters of metabolic syndrome were notably worse in women suffering from both PCOS and OSAHS in comparison to their counterparts solely diagnosed with PCOS. Conclusion The current literature indicates higher morbidity of OSAHS among women with PCOS, linking OSAHS with worse metabolic status and obesity in this population. Consequently, clinicians are advised to prioritize the detection and management of OSAHS in women with PCOS. Systematic Review Registration https://www.crd.york.ac.uk/PROSPERO/#myprospero PROSPERO, identifier (CRD42024528264).
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Affiliation(s)
- Jie He
- Clinical Medical College of Chengdu Medical College, Chengdu, Sichuan, China
- Department of Pulmonary and Critical Care Medicine, The First Affiliated Hospital of Chengdu Medical College, Chengdu, Sichuan, China
- Key Laboratory of Geriatric Respiratory Diseases of Sichuan Higher Education Institutes, Chengdu, Sichuan, China
| | - Xia Ruan
- Clinical Medical College of Chengdu Medical College, Chengdu, Sichuan, China
- Department of Rehabilitation, The First Affiliated Hospital of Chengdu Medical College, Chengdu, Sichuan, China
| | - Jia Li
- Clinical Medical College of Chengdu Medical College, Chengdu, Sichuan, China
- Department of Pulmonary and Critical Care Medicine, The First Affiliated Hospital of Chengdu Medical College, Chengdu, Sichuan, China
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Taimah M, Ahmad A, Al-Houqani M, Al Junaibi A, Idaghdour Y, Abdulle A, Ali R. Association between obstructive sleep apnea risk and type 2 diabetes among Emirati adults: results from the UAE healthy future study. Front Endocrinol (Lausanne) 2024; 15:1395886. [PMID: 39081790 PMCID: PMC11286458 DOI: 10.3389/fendo.2024.1395886] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Accepted: 07/01/2024] [Indexed: 08/02/2024] Open
Abstract
Introduction Obstructive sleep apnea (OSA) can have negative impacts on the health outcomes of individuals with type 2 diabetes. However, in the United Arab Emirates (UAE), there is a lack of understanding regarding the relationship between OSA and type 2 diabetes despite the significant implications it has on health. The primary objective of this study is to investigate the association between OSA risk and type 2 diabetes, associated risk factors, and gender differences in OSA symptoms among Emirati adults. Methods We conducted a cross-sectional analysis of the baseline data from the UAE Healthy Future Study (UAEHFS) collected between February 2016 and March 2023. Our sample consisted of 4578 participants aged 18-71 who completed the STOP-BANG survey, provided body measurements and blood samples. We stratified the patients according to their OSA risk and diabetes. We used univariate and multivariate logistic regression models to analyze the relationship between OSA risk and type 2 diabetes and to identify factors associated with risk for OSA and type 2 diabetes. We estimated odds ratios (ORs) with corresponding 95% confidence intervals (95% CI). Results The mean age was 27.5 years (± 8.35), and 55.81% (n=2555) were men. The overall prevalence of high risk for OSA was 16.58% and was higher in men compared to women (26.46% vs 4.10%). Women reported feeling tired more often than men (68.02% vs 48.96%). Both genders have similar rates of stop breathing and BMI ≥ 35. There was a significant association between the OSA risk and type 2 diabetes in the unadjusted model (OR=2.44; 95% CI: 1.78-3.35; p-value <0.0001) and (OR=6.44; 95% CI: 4.32-9.59; p-value < 0.0001) among those who reported intermediate and high OSA risk, respectively. After adjusting the model for education attainment, marital status, waist circumference, and smoking, the association remained significant between diabetes and OSA risk, with an OR of 1.65 (95%CI: 1.18-2.32; p-value =0.004) for intermediate OSA risk and 3.44 (95%CI: 2.23-5.33; p-value <0.0001) for high OSA risk. Conclusions This study conducted in the UAE found a significant correlation between OSA risk and type 2 diabetes. We suggest introducing routine screening of OSA for individuals with diabetes.
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Affiliation(s)
- Manal Taimah
- Public Health Research Center, New York University Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - Amar Ahmad
- Public Health Research Center, New York University Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - Mohammad Al-Houqani
- Department of Medicine, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates
| | - Abdulla Al Junaibi
- Department of Pediatrics, Zayed Military Hospital, Abu Dhabi, United Arab Emirates
| | - Youssef Idaghdour
- Public Health Research Center, New York University Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - AbdiShakur Abdulle
- Public Health Research Center, New York University Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - Raghib Ali
- Public Health Research Center, New York University Abu Dhabi, Abu Dhabi, United Arab Emirates
- MRC Epidemiology Unit, University of Cambridge, Cambridge, United Kingdom
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Makhdom EA, Maher A, Ottridge R, Nicholls M, Ali A, Cooper BG, Ajjan RA, Bellary S, Hanif W, Hanna F, Hughes D, Jayagopal V, Mahto R, Patel M, Young J, Nayak AU, Chen MZ, Kyaw-Tun J, Gonzalez S, Gouni R, Subramanian A, Adderley N, Patel S, Tahrani AA. The impact of obstructive sleep apnea treatment on microvascular complications in patients with type 2 diabetes: a feasibility randomized controlled trial. J Clin Sleep Med 2024; 20:947-957. [PMID: 38318821 PMCID: PMC11145053 DOI: 10.5664/jcsm.11020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 01/18/2024] [Accepted: 01/18/2024] [Indexed: 02/07/2024]
Abstract
STUDY OBJECTIVES Obstructive sleep apnea (OSA) is associated with an increased risk of diabetes-related complications. Hence, it is plausible that continuous positive airway pressure (CPAP) could have a favorable impact on these complications. We assessed the feasibility of conducting a randomized control trial in patients with type 2 diabetes and OSA over 2 years. METHODS We conducted an open-label multicenter feasibility randomized control trial of CPAP vs no CPAP in patients with type 2 diabetes and OSA. Patients with resting oxygen saturation < 90%, central apnea index > 15 events/h, or Epworth Sleepiness Scale ≥ 11 were excluded. OSA was diagnosed using a multichannel portable device (ApneaLink Air, ResMed). The primary outcome measures were related to feasibility and the secondary outcomes were changes in various clinical and biochemical parameters related to diabetes outcomes. RESULTS Eighty-three (40 CPAP vs 43 no CPAP) patients were randomly assigned, with a median (interquartile range) follow-up of 645 (545, 861) days. CPAP compliance was inadequate, with a median usage of approximately 3.5 hours/night. Early CPAP use predicted longer-term compliance. The adjusted analysis showed a possible favorable association between being randomly assigned to CPAP and several diabetes-related end points (chronic kidney disease, neuropathy, and quality of life). CONCLUSIONS It was feasible to recruit, randomly assign, and achieve a high follow-up rate over 2 years in patients with OSA and type 2 diabetes. CPAP compliance might improve by a run-in period before randomization. A full randomized control trial is necessary to assess the observed favorable association between CPAP and chronic kidney disease , neuropathy, and quality of life in patients with type 2 diabetes. CLINICAL TRIAL REGISTRATION Registry: ISRCTN; Name: The impact of sleep disorders in patients with type 2 diabetes; URL: https://www.isrctn.com/ISRCTN12361838; Identifier: ISRCTN12361838. CITATION Makhdom EA, Maher A, Ottridge R, et al. The impact of obstructive sleep apnea treatment on microvascular complications in patients with type 2 diabetes: a feasibility randomized controlled trial. J Clin Sleep Med. 2024;20(6):947-957.
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Affiliation(s)
- Esraa A. Makhdom
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, United Kingdom
- Department of Respiratory Care, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, United Kingdom
| | - Alisha Maher
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, United Kingdom
| | - Ryan Ottridge
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, United Kingdom
| | - Mathew Nicholls
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, United Kingdom
| | - Asad Ali
- University Hospitals Coventry and Warwickshire NHS Trust, Coventry, United Kingdom
| | - Brendan G. Cooper
- University Hospitals of Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Ramzi A. Ajjan
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, United Kingdom
| | - Srikanth Bellary
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, United Kingdom
- University Hospitals of Birmingham NHS Foundation Trust, Birmingham, United Kingdom
- Aston University, Birmingham, United Kingdom
| | - Wasim Hanif
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, United Kingdom
| | - Fahmy Hanna
- University Hospitals of North Midlands NHS Trust, Stoke on Trent, United Kingdom
| | - David Hughes
- University Hospitals of Derby & Burton NHS Trust, Derby, United Kingdom
| | | | - Rajni Mahto
- South Warwickshire NHS Foundation Trust, South Warwickshire, United Kingdom
| | - Mayank Patel
- University Hospital Southampton NHS FT, Southampton, United Kingdom
| | - James Young
- Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, United Kingdom
| | - Ananth U. Nayak
- University Hospitals of North Midlands NHS Trust, Stoke on Trent, United Kingdom
| | - Mimi Z. Chen
- St. George’s University Hospitals NHS FT, London, United Kingdom
| | - Julie Kyaw-Tun
- Calderdale and Huddersfield NHS FT, Huddersfield, United Kingdom
| | - Susana Gonzalez
- Bradford Teaching Hospitals NHS FT, Bradford, United Kingdom
| | - Ravikanth Gouni
- Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
| | - Anuradhaa Subramanian
- Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom
| | - Nicola Adderley
- Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom
| | - Smitaa Patel
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, United Kingdom
| | - Abd A. Tahrani
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, United Kingdom
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, United Kingdom
- University Hospitals of Birmingham NHS Foundation Trust, Birmingham, United Kingdom
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Abelleira R, Zamarrón C, Riveiro V, Casal A, Toubes ME, Rábade C, Ricoy J, Lama A, Rodríguez-Núñez N, Ferreiro L, Valdés L. [Diabetes and obstructive sleep apnoea: A case-control study]. Med Clin (Barc) 2024; 162:49-55. [PMID: 37798245 DOI: 10.1016/j.medcli.2023.07.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 07/19/2023] [Accepted: 07/29/2023] [Indexed: 10/07/2023]
Abstract
INTRODUCTION Obstructive sleep apnoea (OSA) and diabetes mellitus (DM) are very prevalent diseases frequently associated. Their coexistence is independently associated with an increased prevalence of cardiovascular comorbidities. As this association is underdiagnosed, it is necessary to optimise clinical suspicion by studying independent predictors of DM or prediabetes (preDM) in patients with OSA. METHOD A simple randomised case-control study, matched for sex, body mass index (BMI) and age, aimed to study the association of OSA with DM and preDM and to identify independent predictors for both diseases in people with OSA. RESULTS We included 208 cases with OSA and 208 controls without OSA. In the former, 18.8% had DM compared to only 10.1% in the latter (P=.00). Prevalence of preDM was 41.8% vs. 10.6%, respectively (P=.00). One hundred and twenty-four cases (59.6%) reported excessive daytime sleepiness (EDS) (Epworth scale, 10.5±3.1) vs. 24.5% of the control group (Epworth scale, 6.6±2.9). Apnoea-hypopnoea index (AHI) and O2 desaturation indices (IDO, CT90 and CT80) were significantly higher in the case group. The risk of MD was related to age, nocturnal hypoxaemia and EDS. The risk of pre-MD was related to BMI and AHI. CONCLUSIONS OSA is associated with DM and preDM. Age, nocturnal hypoxaemia and EDS are predictors of DM. BMI and AHI are predictors of pre-MD.
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Affiliation(s)
- Romina Abelleira
- Servicio de Neumología, Complejo Hospitalario Universitario de Santiago de Compostela, Santiago de Compostela, A Coruña, España.
| | - Carlos Zamarrón
- Servicio de Neumología, Complejo Hospitalario Universitario de Santiago de Compostela, Santiago de Compostela, A Coruña, España
| | - Vanessa Riveiro
- Servicio de Neumología, Complejo Hospitalario Universitario de Santiago de Compostela, Santiago de Compostela, A Coruña, España
| | - Ana Casal
- Servicio de Neumología, Complejo Hospitalario Universitario de Santiago de Compostela, Santiago de Compostela, A Coruña, España
| | - María E Toubes
- Servicio de Neumología, Complejo Hospitalario Universitario de Santiago de Compostela, Santiago de Compostela, A Coruña, España
| | - Carlos Rábade
- Servicio de Neumología, Complejo Hospitalario Universitario de Santiago de Compostela, Santiago de Compostela, A Coruña, España
| | - Jorge Ricoy
- Servicio de Neumología, Complejo Hospitalario Universitario de Santiago de Compostela, Santiago de Compostela, A Coruña, España
| | - Adriana Lama
- Servicio de Neumología, Complejo Hospitalario Universitario de Santiago de Compostela, Santiago de Compostela, A Coruña, España
| | - Nuria Rodríguez-Núñez
- Servicio de Neumología, Complejo Hospitalario Universitario de Santiago de Compostela, Santiago de Compostela, A Coruña, España
| | - Lucía Ferreiro
- Servicio de Neumología, Complejo Hospitalario Universitario de Santiago de Compostela, Santiago de Compostela, A Coruña, España; Grupo Interdisciplinar de Investigación en Neumología, Instituto de Investigaciones Sanitarias de Santiago (IDIS), Santiago de Compostela, A Coruña, España
| | - Luis Valdés
- Servicio de Neumología, Complejo Hospitalario Universitario de Santiago de Compostela, Santiago de Compostela, A Coruña, España; Grupo Interdisciplinar de Investigación en Neumología, Instituto de Investigaciones Sanitarias de Santiago (IDIS), Santiago de Compostela, A Coruña, España; Departamento de Medicina, Facultad de Medicina, Universidad de Santiago, Santiago de Compostela, A Coruña, España
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Worku A, Ayele E, Alemu S, Legese GL, Yimam SM, Kassaw G, Diress M, Asres MS. Obstructive sleep apnea risk and determinant factors among type 2 diabetes mellitus patients at the chronic illness clinic of the University of Gondar Comprehensive Specialized Hospital, Northwest Ethiopia. Front Endocrinol (Lausanne) 2023; 14:1151124. [PMID: 37082123 PMCID: PMC10110920 DOI: 10.3389/fendo.2023.1151124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 03/17/2023] [Indexed: 04/07/2023] Open
Abstract
IntroductionObstructive sleep apnea is a sleep complaint among type 2 diabetes mellitus patients that has a deleterious effect on health with immediate and long-term impacts. Despite its impacts, data on the magnitude and predictors of obstructive sleep apnea among type 2 diabetes mellitus patients in Ethiopia is still limited. Thus, this study was conducted to determine how common a high risk of obstructive sleep apnea is and its predictors among type 2 diabetes mellitus patients receiving follow-up care at the chronic illness follow-up clinic at the University of Gondar Comprehensive Specialized Hospital, Northwest Ethiopia, 2022.MethodsAn institution-based cross-sectional study was conducted. Interviewer-administered questionnaires and physical measurements with standard instruments were used to collect the required data. The collected data were entered into EpiData 4.6 and exported into STATA 14. Both Bivariable and multivariable binary logistic regression analyses were done to identify factors associated with a high risk of obstructive sleep apnea. Variables with a p-value ≤0.05 in the multivariable logistic regression analysis were declared as significantly associated with a high risk of obstructive sleep apnea.ResultsA total of 319 type 2 diabetes mellitus patients with a median age of 58 years participated in our current study. The overall prevalence of a high risk of obstructive sleep apnea among the study participants was 31.97% (95%CI: 27.06, 37.32). On multivariable logistic analysis, a neck circumference of ≥40 cm (AOR=4.33, 95%CI 1.37, 13.72), physical inactivity (AOR=2.29, 95%CI 1.15, 4.53), comorbid hypertension (AOR=4.52, 95%CI 2.30, 9.18), and male sex (AOR=8.01, 95%CI 3.02, 21.24) were associated with a high risk of obstructive sleep apnea.Conclusion and recommendationThe prevalence of a high risk of obstructive sleep apnea among type 2 diabetes mellitus patients remains high. A neck circumference of ≥40 cm, physical inactivity, comorbid hypertension, and male sex were significantly associated with a high risk of obstructive sleep apnea among type 2 diabetes mellitus patients. Screening and evaluation of type 2 diabetes mellitus patients for obstructive sleep apnea are recommended to avoid the negative impacts.
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Affiliation(s)
- Abebe Worku
- Department of Internal Medicine, University of Gondar, Gondar, Ethiopia
| | - Eleni Ayele
- Department of Internal Medicine, University of Gondar, Gondar, Ethiopia
| | - Shitaye Alemu
- Department of Internal Medicine, University of Gondar, Gondar, Ethiopia
| | | | - Samrawit Meles Yimam
- Internal Medicine, University of Gondar Comprehensive and Specialized Referral Hospital, Gondar, Ethiopia
| | - Getasew Kassaw
- Department of Internal Medicine, University of Gondar, Gondar, Ethiopia
| | - Mengistie Diress
- Department of Human Physiology, University of Gondar, Gondar, Ethiopia
- *Correspondence: Mengistie Diress,
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Andayeshgar B, Janatolmakan M, Soroush A, Azizi SM, Khatony A. The prevalence of obstructive sleep apnea in patients with type 2 diabetes: a systematic review and meta-analysis. SLEEP SCIENCE AND PRACTICE 2022. [DOI: 10.1186/s41606-022-00074-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Obstructive Sleep Apnea (OSA) is one of the diseases related to diabetes. Considering the varying prevalence of OSA in patients with type 2 diabetes in different parts of the world, in order to aggregate the results and come to a general review about the topic mentioned, the current study performed a systematic review and meta-analysis of OSA in patients with type 2 diabetes.
Methods
In this study, the international databases (PubMed, Scopus, Web of science, and Cochran library) were searched without time limit using keywords diabetes, obstructive sleep apnea, and prevalence or epidemiology. Homogeneity was investigated among studies using Cochran Q test and I2 index. Given the heterogeneity of studies, random effect model was used to estimate the prevalence of OSA. Meta-regression was used to investigate the effect of quantitative variables on the prevalence of OSA. Comprehensive Meta-analysis (CMA) software was used for data analysis.
Results
Twenty studies were included in the meta-analysis. In these 19 studies, the total number of patients with type 2 diabetes was 10,754, with a mean age of 58.6 ± 4.1 years. Final estimation of OSA prevalence was calculated to be 56.0%. The results of meta-regression showed the prevalence of OSA increased with a rise in the mean age, the percentage of male sex, body mass index, and sample size.
Conclusion
Given the high prevalence of OSA in patients with type 2 diabetes, weight control can partly mitigate their problems and possibly reduce OSA prevalence.
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Ding S, Zhang P, Wang L, Wang D, Sun K, Ma Y, Wang H, Xu C, Zhang R, Zhang X, Wang H, Zhao F, Li X, Ji L, Guo L. Prevalence of obstructive sleep apnoea syndrome in hospitalized patients with type 2 diabetes in Beijing, China. J Diabetes Investig 2022; 13:1889-1896. [PMID: 35778970 PMCID: PMC9623507 DOI: 10.1111/jdi.13868] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 06/06/2022] [Accepted: 06/10/2022] [Indexed: 11/29/2022] Open
Abstract
Aims/Introduction To estimate the prevalence, and patient clinical and demographic profile, as well as risk factors associated with obstructive sleep apnea syndrome (OSAS) in hospitalized patients with type 2 diabetes mellitus in Beijing, China. Materials and Methods Hospitalized adult patients with type 2 diabetes mellitus were consecutively screened and invited for an overnight polysomnography from four hospitals in Beijing, China, from May 2016 to February 2017. We used the American Academy of Sleep Medicine 2012 polysomnography recording techniques and scoring criteria to identify the type of apnea and the severity of OSAS. The χ2‐test was used to evaluate differences between groups regarding the prevalence, and demographic and other clinical parameters. Results A total of 735 patients were found eligible for the study, of whom 309 patients completed the overnight polysomnography. The mean age of the patients was 58.2 ± 10.9 years, and most (67.3%) were men. The prevalence of overall (apnea hypopnea index ≥5/h), moderate‐to‐severe (apnea hypopnea index ≥15/h) and severe (apnea hypopnea index ≥30/h) OSAS was 66.3% (95% confidence interval 60.8–71.6%), 35.6% (95% confidence interval 30.3–41.2%) and 16.5% (95% confidence interval 12.5–21.1%), respectively. Central and mixed apnea contributed 12% to all sleep‐disordered breathing. With the aggravation of OSAS, the combined prevalence for central, mixed and obstructive apnea increased from 57% to 70%. We found OSAS to be associated with older age, obesity, self‐reported snoring and apnea, and diabetes complications. Conclusions Guidelines on screening and treatment of OSAS among hospitalized patients with diabetes are needed to direct the routine practice for diabetes endocrinologists for optimal clinical care of such patients.
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Affiliation(s)
- Shan Ding
- Department of Endocrinology, Beijing Hospital, National Center of Gerontology; Institute of Geriatric Medicine Chinese Academy of Sciences Beijing P.R. China
| | - Puhong Zhang
- The George Institute for Global Health at Peking University Health Science Center Beijing P.R. China
- Faculty of Medicine University of New South Wales Sydney Australia
| | - Li Wang
- Department of Endocrinology, Xuanwu Hospital Capital Medical University Beijing P.R. China
| | - Du Wang
- The George Institute for Global Health at Peking University Health Science Center Beijing P.R. China
| | - Kaige Sun
- The George Institute for Global Health at Peking University Health Science Center Beijing P.R. China
| | - Yahui Ma
- Department of Endocrinology, Xuanwu Hospital Capital Medical University Beijing P.R. China
| | - Hongbing Wang
- Sleep Center Lab, Beijing Hospital, National Center of Gerontology Beijing P.R. China
| | - Chun Xu
- Department of Endocrinology, The Third Medical Center of Chinese Hospital of People’s Liberation Army Beijing P.R. China
| | - Rui Zhang
- Department of Endocrinology and Metabolism Peking University People’s Hospital No. 11, Xizhimen Nan Da Jie, Xicheng District Beijing China
| | - Xianbo Zhang
- Department of Endocrinology, Beijing Hospital, National Center of Gerontology; Institute of Geriatric Medicine Chinese Academy of Sciences Beijing P.R. China
| | - Hongyu Wang
- Department of Endocrinology, The Third Medical Center of Chinese Hospital of People’s Liberation Army Beijing P.R. China
| | - Fang Zhao
- The George Institute for Global Health at Peking University Health Science Center Beijing P.R. China
| | - Xian Li
- The George Institute for Global Health at Peking University Health Science Center Beijing P.R. China
| | - Linong Ji
- Department of Endocrinology and Metabolism Peking University People’s Hospital No. 11, Xizhimen Nan Da Jie, Xicheng District Beijing China
| | - Lixin Guo
- Department of Endocrinology, Beijing Hospital, National Center of Gerontology; Institute of Geriatric Medicine Chinese Academy of Sciences Beijing P.R. China
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Shnaimer JA, Dahlan HM, Hanbashi FM, Bahammam AS, Gosadi IM. Assessment of the risk of obstructive sleep apnoea among patients with type 2 diabetes and its associated factors using the STOP-BANG questionnaire: A cross-sectional study. J Taibah Univ Med Sci 2022; 17:606-613. [PMID: 35983435 PMCID: PMC9356349 DOI: 10.1016/j.jtumed.2021.11.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 11/11/2021] [Accepted: 11/29/2021] [Indexed: 11/30/2022] Open
Abstract
Objective To assess the risk of obstructive sleep apnoea (OSA) and its associated risk factors among patients with type 2 diabetes in southern KSA. Methods This was a cross-sectional study conducted at the Armed Forces Hospital in Jazan. The prevalence of OSA was assessed using a validated Arabic translation of the STOP-BANG screening questionnaire. The odds of a higher OSA risk were calculated via regression analysis, according to the measured clinical and demographic variables. Results The total number of participants was 306, of which 213 (69.6%) were over the age of 50, 247 (80.7%) were married, and 161 (52.6%) were female. The overall median score of the OSA risk level assessed by the STOP-BANG items was three on a scale of 0–8, of which 193 (63.1%) of the participants in the sample were classified as being at high risk of developing OSA. Several statistically significant associations were identified, where odds ratios (ORs) with a higher OSA risk level were detected according to age, sex, marital status, waist and neck circumference, haemoglobin A1c (HbA1c) and body mass index levels, duration of diabetes, and comorbidity with hypertension (p < 0.05). Conclusion The higher risk of OSA identified in our sample of diabetic patients can be related to a high prevalence of obesity, larger neck circumferences, hypertension, and other factors linked to the duration and treatment of diabetes. Additionally, the association between waist circumference, HbA1c, and duration since the diagnosis of diabetes suggests an interaction effect that requires further investigation.
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Affiliation(s)
| | - Hesham M. Dahlan
- Department of Family Medicine, Jazan Armed Forces Hospital, Abu Arish, KSA
| | - Fatima M. Hanbashi
- Department of Family Medicine, Jazan Armed Forces Hospital, Abu Arish, KSA
| | - Ahmed S. Bahammam
- Department of Medicine, University Sleep Disorders Center, College of Medicine, King Saud University, Riyadh, KSA
| | - Ibrahim M. Gosadi
- Department of Family and Community Medicine, Faculty of Medicine, Jazan University, Jazan, KSA
- Corresponding address: Department of Family and Community Medicine, Faculty of Medicine, Jazan University, P.O. Box: 2349, Jazan, 82621, KSA.
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Insomnia symptoms are associated with an increased risk of type 2 diabetes mellitus among adults aged 50 and older. Sleep Breath 2021; 26:1409-1416. [PMID: 34564818 DOI: 10.1007/s11325-021-02497-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Revised: 09/09/2021] [Accepted: 09/21/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE To evaluate the association of the different degrees of insomnia symptoms with subsequent incidence of type 2 diabetes mellitus (T2DM). METHODS The data were extracted from Health and Retirement Study 2006-2014 waves. The association of insomnia symptoms with T2DM incidence was evaluated by the competing risk model with cumulative incidence function (death was considered a competing event) and Cox proportional hazard model with the Kaplan-Meier method. Population attributable fraction (PAF) was calculated. All analyses related to our study were conducted between November 2020 and January 2021. RESULTS A total of 14,112 patients were included in this study, with an average follow-up of 6.4 years, and the incidence density was 17.9 per 1000 person-years. Insomnia symptoms were positively associated with T2DM incidence compared with those with no insomnia symptoms, regardless of competing risk model (≥ 1 symptoms: sub-distribution hazard ratio (SHR) 1.13; 95% confidence interval (CI) 1.02-1.26; P-trend = 0.012) and Cox proportional hazard model (≥ 1 symptoms: hazard ratio (HR) 1.13; 95% CI 1.02-1.26; P-trend = 0.013). The cumulative incidence function (Gray's test, p < 0.001) and Kaplan-Meier estimate (log-rank test, p < 0.001) also presented this positive relationship. This positive association was more apparent in women and participants with ages from 50 to 65 years. The PAF was 4.1% with 95% CI (0.7-7.9%). CONCLUSIONS Insomnia symptoms may be an important risk factor for the development of T2DM, which is unbiased by the death competing risk. These findings suggest that management of sleep problems may be an important part of strategies to prevent T2DM.
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Thakur A, Sharma D, Gupta B, Kramadhari N, Rajagopal R, Simmons D, Piya MK. Severe obesity in a specialist type 2 diabetes outpatient clinic: an Australian retrospective cohort study. BMC Endocr Disord 2021; 21:55. [PMID: 33757476 PMCID: PMC7988916 DOI: 10.1186/s12902-021-00722-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 03/11/2021] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Obesity is a major risk factor for the development of type 2 diabetes (T2DM) and its complications. Significant weight loss has been shown to improve glycaemia in people with T2DM and obesity. National and international guidelines recommend considering bariatric surgery for body mass index (BMI) ≥ 35 kg/m2. We assessed the proportion of people with T2DM meeting criteria for surgery, how many had been offered a bariatric/obesity service referral, and compared the characteristics of people with BMI ≥ 35 kg/m2 and BMI < 35 kg/m2. METHODS Retrospective data were collected for all people with T2DM aged ≥18 years, attending a hospital specialist diabetes outpatient service over three calendar years, 2017-2019. RESULTS Of 700 people seen in the service, 291 (42%) had BMI ≥ 35 kg/m2 (the "BMI ≥ 35 group") and met criteria for bariatric surgery, but only 54 (19%) of them were offered referral to an obesity service. The BMI ≥ 35 group was younger than those with a BMI < 35 kg/m2 (56.1 ± 14.8 vs 61.4 ± 14.6 years, p < 0.001) (mean ± SD), with similar diabetes duration (11.0 ± 9.0 vs 12.3 ± 8.9 years, p = 0.078), and there was no significant difference in initial HbA1c (75 ± 27 vs 72 ± 26 mmol/mol, p = 0.118) (9.0 ± 2.5 vs 8.7 ± 2.4%) or proportion treated with insulin (62% vs 58%). There was more GLP1 agonist use in the BMI ≥ 35 group (13% vs 7%, p = 0.003) but similar rates of SGLT2 inhibitor use (25% vs 21%, p = 0.202). The BMI ≥ 35 group received more new medication and/or dose adjustments (74% vs 66%, p = 0.016). Only 29% in the BMI ≥ 35 kg group achieved HbA1c < 53 mmol/mol (7.0%). CONCLUSIONS In spite of frequently meeting the criteria for bariatric surgery and not achieving glycaemic targets, people with T2DM in this specialist clinic received limited medical or surgical management of their obesity. This study suggests opportunities for improvement in care of people with T2DM at several levels including increased referrals from T2DM services to weight management/bariatric services, as well as an increased use of GLP1 agonists and SGLT2 inhibitors where appropriate. Our data support the need to prioritise obesity management in the treatment of type 2 diabetes.
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Affiliation(s)
- Arunav Thakur
- School of Medicine, Western Sydney University, Campbelltown, New South Wales, 2560, Australia
| | - Dharmesh Sharma
- School of Medicine, Western Sydney University, Campbelltown, New South Wales, 2560, Australia
| | - Bhavya Gupta
- School of Medicine, Western Sydney University, Campbelltown, New South Wales, 2560, Australia
| | - Nikitha Kramadhari
- School of Medicine, Western Sydney University, Campbelltown, New South Wales, 2560, Australia
| | - Rohit Rajagopal
- Macarthur Diabetes Service, Camden and Campbelltown Hospitals, Campbelltown, New South Wales, 2560, Australia
| | - David Simmons
- School of Medicine, Western Sydney University, Campbelltown, New South Wales, 2560, Australia
- Macarthur Diabetes Service, Camden and Campbelltown Hospitals, Campbelltown, New South Wales, 2560, Australia
| | - Milan Kumar Piya
- School of Medicine, Western Sydney University, Campbelltown, New South Wales, 2560, Australia.
- Macarthur Diabetes Service, Camden and Campbelltown Hospitals, Campbelltown, New South Wales, 2560, Australia.
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11
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The impact of sleep disorders on microvascular complications in patients with type 2 diabetes (SLEEP T2D): the protocol of a cohort study and feasibility randomised control trial. Pilot Feasibility Stud 2021; 7:80. [PMID: 33752759 PMCID: PMC7982768 DOI: 10.1186/s40814-021-00817-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 03/09/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Obstructive sleep apnoea (OSA) is very common in patients with type 2 diabetes (T2D). We and others have shown that OSA was associated with diabetes-related microvascular complications in patients with T2D in cross-sectional and longitudinal studies and that compliance with continuous positive airway pressure (CPAP) reduced the progression of microvascular complications. Hence, we hypothesised that adequate CPAP reduces the development of microvascular complication in patients with T2D. METHODS SLEEP T2D is a cohort study with embedded feasibility, open-label, parallel-arm, randomised control trial (RCT) over 2 years. The primary aim is the feasibility of conducting a definitive RCT assessing the impact of CPAP on chronic kidney disease and other microvascular complications in patients with T2D. The main parameters are to assess willingness of participants to be randomised, follow-up rates, CPAP adherence/compliance, to optimise the choice of outcome measures for a substantive trial, and to identify the parameters for sample size calculations. The secondary aims of the study are related to the impact of CPAP, sleep-related disorders, and sleep chronotype on a variety of diabetes-related end points. The study participants were recruited from the T2D services in multiple NHS trusts across England. The main exclusion criteria for the cohort study are as follows: T1D, eGFR < 15 mL/min/1.73 m2, known OSA, active malignancy or chronic kidney disease from reasons other than diabetes, pregnancy, professional drivers, and a history of falling asleep whilst driving within last 2 years. The main exclusion criteria from the RCT were as follows: Apnoea-Hypopnoea Index < 10 and Epworth Sleepiness Score ≥ 11. Study participants were extensively phenotyped clinically and biochemically. The OSA diagnosis was based on multichannel portable device (ApneaLink AirTM, Resmed). DISCUSSION The feasibility RCT will help us design the future RCT to assess the impact of CPAP on diabetes-related microvascular complications. The cohort study will generate preliminary data regarding the impact of sleep quality, duration, and chronotype on diabetes-related outcomes which could lead to further mechanistic and interventional studies. TRIAL REGISTRATION ISRCTN, ISRCTN12361838 . Registered 04 April 2018, Protocol version: v5.0 02.12.19.
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12
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Qin H, Chen C, Steenbergen N, Cheng Y, Penzel T. Time-dependence and comparison of regional and overall anthropometric features between Asian and Caucasian populations with obstructive sleep apnea: a cumulative meta-analysis. J Thorac Dis 2021; 13:1746-1759. [PMID: 33841965 PMCID: PMC8024799 DOI: 10.21037/jtd-20-1799] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Background Anthropometric measurements are simple and reachable tools for self-evaluating and screening patients with a high risk of obstructive sleep apnea (OSA). However, the accumulated relationship of obesity on the anthropometric characteristics of OSA is not well understood. The aim of the study was to show the time-dependent trend of OSA patients and compare overall and regional anthropometric between two ethnicities. Methods A cumulative meta-analysis was performed to assess obesity metrics in patients with and without OSA between Asians and Caucasians. We searched PubMed, Web of Science, Embase, and Scopus up to Jun 2020. Included studies used body mass index (BMI), neck circumference (NC), waist circumference (WC) and waist-to-hip ratio (WHR) as measures of anthropometric features in the adult OSA population and controls, utilized in-lab polysomnography or home sleep testing with apnea-hypopnea index (AHI) or respiratory disturbance index (RDI) classification, reported ethnicity/race, and were published in English. Any studies lacking one of these criteria or sufficient data were excluded. Results Forty studies with a total of 19,142 subjects were investigated. Comparison of changes between patients with and without OSA showed that OSA patients had a higher BMI [mean difference (MD) 3.12, 95% confidence interval (CI): 2.51–3.73], NC (MD 3.10, 95% CI: 2.70–3.51), WC (MD 9.84, 95% CI: 8.42–11.26) and waist-hip ratio (MD 0.04, 95% CI: 0.03–0.05) than the control subjects. The accumulated time-dependent increase in population with OSA was significantly apparent with all anthropometric features. BMI increased from 2000 (MD 0.50) to 2012 (MD 3.08–3.48) and remained stable afterwards (MD 2.70–3.17), NC increased from 2000 (MD 0.40) to 2013 (MD 3.09) and remained stable afterwards too (MD 3.06–3.21). WC increased from 2000 (MD 2.00) to 2012 (MD 9.37–10.03) and also remained stable afterwards (MD 8.99–9.84). WHR was stable from 2000 to 2004 with an MD of 0.01 and then stable from 2007 onwards with an increased MD of 0.03–0.04. Compared with Caucasian patients, Asian patients had lower obesity relevant variates. Conclusions BMI, NC, WC and WHR are associated with OSA in both ethnic groups. Anthropometry for overall and regional obesity could facilitate differentiation of patients with OSA from individuals without OSA by ethnicity.
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Affiliation(s)
- Hua Qin
- Interdisciplinary Center of Sleep Medicine, Charité University Hospital, Berlin, Germany
| | - Chongxiang Chen
- Guangzhou Institute of Respiratory Diseases, the First Affiliated Hospital of Guangzhou Medical University, State Key Laboratory of Respiratory Disease, Guangzhou, China
| | | | - Yang Cheng
- Department of Respiratory and Critical Care Medicine, Beijing Jishuitan Hospital, the Fourth Medical College of Peking University, Beijing, China
| | - Thomas Penzel
- Interdisciplinary Center of Sleep Medicine, Charité University Hospital, Berlin, Germany.,Saratov State University, Saratov, Saratov Oblast, Russia
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13
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Prevalence of obstructive sleep apnea risk and associated factors among patients with type 2 diabetes mellitus on follow up at Jimma Medical Center, Southwest Ethiopia. JOURNAL OF CLINICAL AND TRANSLATIONAL ENDOCRINOLOGY 2020; 21:100234. [PMID: 32923370 PMCID: PMC7475117 DOI: 10.1016/j.jcte.2020.100234] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Revised: 08/13/2020] [Accepted: 08/15/2020] [Indexed: 12/14/2022]
Abstract
Obstructive sleep apnea is a periodic, partial or complete obstruction in the upper airway during sleep. It is highly prevalent among obese patients with type two diabetes mellitus. There were high numbers of participants with high risk of OSA among the study participants.
Background Obstructive sleep apnea (OSA) is a periodic, partial or complete obstruction in the upper airway during sleep that disrupts normal sleep pattern. Despite its significant morbidities and mortality, the majority of patients with OSA remain undiagnosed. The purpose of this study was to assess the prevalence and associated factors of OSA risk among type 2 diabetes patients on follow up at Jimma Medical Center from January 13 to March 2, 2020. Method A hospital based cross-sectional study was conducted and consecutive sampling technique was employed. The stop bang questionnaire was used to assess OSA risk. Data were collected using structured questionnaire and entered into EPI data 3.1 and exported to SPSS version 20 for analysis. Logistic regression was employed to identify factors associated with high risk OSA. A variable having a p-value of <0.2 in the bivariate model was subjected to multivariate analysis. Adjusted odds ratios were calculated at 95% confidence interval and considered significant with a p-value of ≤0.05. Result 253 patients seen in the outpatient clinic were involved with mean age and mean duration of diabetes was 50.27 ± 14.08 and 6.48 ± 5.20 years respectively. The study finding showed that the prevalence of high risk OSA was 45.5%. According to multivariate analysis comorbid hypertension (AOR = 2; 95% CI: 1.04, 3.89), physical inactivity (AOR = 2.11; 95% CI: 1.11,4), BMI ≥ 30 kg/m2: (AOR = 5.41; 95% CI: 1.68,17.3 and neck circumference > 40 cm: (AOR = 6.3; 95% CI: 2.8,14.2 were independently associated with an increased risk of OSA. Conclusion There is high number of participants with high risk of OSA. BMI of ≥ 30 kg/m2, physical inactivity, neck circumference of > 40 cm and comorbid hypertension were associated with high risk OSA among participants. Early detection and appropriate interventions are important among high risk groups.
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Abstract
Obstructive sleep apnea (OSA), characterized by recurrent episodes of apnea during sleep and daytime sleepiness, seriously affects human health and may lead to systemic organ dysfunction. The pathogenesis of OSA is complex and still uncertain, but multiple surveys have shown that obesity is an important factor, and the incidence of OSA in people with obesity is as high as 30%. Adipokines are a group of proteins secreted from adipocytes, which are dysregulated in obesity and may contribute to OSA. Here, we review the most important and representative research results regarding the correlation between obesity-related adipokines including leptin, adiponectin, omentin-1, chemerin, and resistin and OSA in the past 5 years, provide an overview of these key adipokines, and analyze possible intrinsic mechanisms and influencing factors. The existing research shows that OSA is associated with an increase in the serum levels of leptin, chemerin, and resistin and a decrease in the levels of adiponectin and omentin-1; the findings presented here can be used to monitor the development of OSA and obesity, prevent future comorbidities, and identify risk factors for cardiovascular and other diseases, while different adipokines can be linked to OSA through different pathways such as insulin resistance, intermittent hypoxia, and inflammation, among others. We hope our review leads to a deeper and more comprehensive understanding of OSA based on the relevant literature, which will also provide directions for future clinical research.
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Affiliation(s)
- Xiongye Xu
- The First Clinical Medical College of Nanchang University, Nanchang, People's Republic of China
| | - Jixiong Xu
- The First Clinical Medical College of Nanchang University, Nanchang, People's Republic of China
- Department of Endocrinology and Metabolism, First Affiliated Hospital of Nanchang University, Nanchang, People's Republic of China
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15
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Moderate to severe obstructive sleep apnea during REM sleep as a predictor of metabolic syndrome in a Korean population. Sleep Breath 2020; 24:1751-1758. [DOI: 10.1007/s11325-019-02005-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Revised: 12/12/2019] [Accepted: 12/20/2019] [Indexed: 12/14/2022]
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16
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Feher M, Hinton W, Munro N, de Lusignan S. Obstructive sleep apnoea in Type 2 diabetes mellitus: increased risk for overweight as well as obese people included in a national primary care database analysis. Diabet Med 2019; 36:1304-1311. [PMID: 31001841 PMCID: PMC6767542 DOI: 10.1111/dme.13968] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/15/2019] [Indexed: 12/13/2022]
Abstract
AIMS To determine obstructive sleep apnoea prevalence in people with Type 2 or Type 1 diabetes in a national primary care setting, stratified by BMI category, and to explore the relationship between patient characteristics and obstructive sleep apnoea. METHODS Using the Royal College of General Practitioners Research and Surveillance Centre database, a cross-sectional analysis was conducted. Diabetes type was identified using a seven-step algorithm and was grouped by Type 2 diabetes, Type 1 diabetes and no diabetes. The clinical characteristics of these groups were analysed, BMI-stratified obstructive sleep apnoea prevalence rates were calculated, and a multilevel logistic regression analysis was completed on the Type 2 diabetes group. RESULTS Analysis of 1 275 461 adult records in the Royal College of General Practitioners Research and Surveillance Centre network showed that obstructive sleep apnoea was prevalent in 0.7%. In people with Type 2 diabetes, obstructive sleep apnoea prevalence increased with each increasing BMI category, from 0.5% in those of normal weight to 9.6% in those in the highest obesity class. By comparison, obstructive sleep apnoea prevalence rates for these BMI categories in Type 1 diabetes were 0.3% and 4.3%, and in those without diabetes 1.2% and 3.9%, respectively. Obstructive sleep apnoea was more prevalent in men than women in both diabetes types. When known risk factors were adjusted for, there were increased odds ratios for obstructive sleep apnoea in people with Type 2 diabetes in the overweight and higher BMI categories. CONCLUSIONS Obstructive sleep apnoea was reported in people with both types of diabetes across the range of overweight categories and not simply in the highest obesity class.
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Affiliation(s)
- M. Feher
- Department of Clinical and Experimental MedicineUniversity of SurreyGuildfordUK
| | - W. Hinton
- Department of Clinical and Experimental MedicineUniversity of SurreyGuildfordUK
| | - N. Munro
- Department of Clinical and Experimental MedicineUniversity of SurreyGuildfordUK
| | - S. de Lusignan
- Department of Clinical and Experimental MedicineUniversity of SurreyGuildfordUK
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17
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Fallahi A, Jamil DI, Karimi EB, Baghi V, Gheshlagh RG. Prevalence of obstructive sleep apnea in patients with type 2 diabetes: A systematic review and meta-analysis. Diabetes Metab Syndr 2019; 13:2463-2468. [PMID: 31405661 DOI: 10.1016/j.dsx.2019.06.030] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Accepted: 06/27/2019] [Indexed: 10/26/2022]
Abstract
Obstructive sleep apnea (OSA) is highly prevalent among patients with diabetes, intensifying the complications of the disease. Various studies in Iran have reported different prevalence rates. This systematic review and meta-analysis was performed to determine OSA prevalence in patients with type 2 diabetes in Iran. In this study, we evaluated five articles published in Persian and English. The articles were searched using the keywords of obstructive sleep apnea, sleep disordered breathing, sleep apnea, OSA, diabetes mellitus and Iran and all possible combinations of these terms in national databases of Scientific Information Database (SID) and Magiran and international databases of Google Scholar, Web of Science, PubMed and Scopus with no time limit. Data were analyzed using the meta-analysis and random effects model. In addition, the heterogeneity between studies was assessed using I2 statistic, and data analysis was performed in Stata version 11. In this study, five articles with a total sample size of 2360 were evaluated. According to the results, the prevalence of OSA in diabetic patients was reported to be 54.50% (95% Confidence Interval [CI]: 39.90-69.09). In addition, the results were indicative of a lower prevalence of OSA in men (63.26%; 95% CI: 43.26-83.26), compared to women (66.22%; 95% CI: 57.60-74.84). According to the results of the study, there was a high OSA prevalence in patients with type 2 diabetes. Therefore, it is crucial to recognize diabetic patients at risk of OSA to decrease the adverse effects of this condition.
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Affiliation(s)
- Arezoo Fallahi
- Social Determinants of Health Research Center, Research Institute for Health Development, Kurdistan University of Medical Sciences, Sanandaj, Iran.
| | - Dashty Ismil Jamil
- Department of Health and Hospital Administration, Lebanese French University, Erbil, Kurdistan, Iraq.
| | | | - Vajiheh Baghi
- Be'sat Hospital, Kurdistan University of Medical Sciences, Sanandaj, Iran.
| | - Reza Ghanei Gheshlagh
- Clinical Care Research Center, Research Institute for Health Development, Kurdistan University of Medical Sciences, Sanandaj, Iran.
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Shinoda M, Yamakawa T, Takahashi K, Nagakura J, Suzuki J, Sakamoto R, Kadonosono K, Terauchi Y. PREVALENCE OF OBSTRUCTIVE SLEEP APNEA DETERMINED BY THE WATCHPAT IN NONOBESE JAPANESE PATIENTS WITH POOR GLUCOSE CONTROL AND TYPE 2 DIABETES. Endocr Pract 2019; 25:170-177. [PMID: 30817196 DOI: 10.4158/ep-2018-0200] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Diagnosing obstructive sleep apnea (OSA) usually involves high cost, patient inconvenience, and the need for examination at a specialized center. This study employed a portable, wearable, diagnostic device (WatchPAT) to investigate the prevalence of OSA in nonobese Japanese patients with type 2 diabetes. METHODS Patients with type 2 diabetes were tested for OSA over one night using the WatchPAT. Logistic regression analysis was used to estimate the odds ratios (ORs) of risk factors for OSA in nonobese subjects. RESULTS A total of 200 eligible patients with type 2 diabetes were studied (64.5% men; aged 60.1 ± 13.6 years; body mass index [BMI], 26.3 ± 5.2 kg/m2). When OSA was defined as apnea-hypopnea index ≥5/hour, its prevalence was 80.5%. The prevalence of OSA in subjects with a BMI <20 kg/m2, ≥20 and <25 kg/m2, ≥25 and <30 kg/m2, and ≥30 kg/m2 was 38.9%, 73.5%, 86.5%, and 97.5%, respectively. The severity of OSA increased in proportion to BMI, especially when the BMI was >25 kg/m2. The prevalence of OSA was also high (66.3%) in normal-weight subjects (BMI <25 kg/m2). Furthermore, the serum triglyceride level (OR, 1.01; 95% confidence interval, 1.00 to 1.02; P = .042) was significantly related to OSA. CONCLUSION A high prevalence of OSA was observed in this nonobese population of Japanese patients with type 2 diabetes. The triglyceride level was associated with OSA among nonobese patients. ABBREVIATIONS AHI = apnea-hypopnea Index; BMI = body mass index; CI = confidence interval; ESS = Epworth Sleepiness Scale; HbA1c = glycated hemoglobin; OR = odds ratio; OSA = obstructive sleep apnea; PAT = peripheral arterial tone; T2D = type 2 diabetes; TG = triglyceride.
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19
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Kahal H, Kyrou I, Uthman O, Brown A, Johnson S, Wall P, Metcalfe A, Tahrani AA, Randeva HS. The association between obstructive sleep apnea and metabolic abnormalities in women with polycystic ovary syndrome: a systematic review and meta-analysis. Sleep 2019; 41:4990841. [PMID: 29722890 DOI: 10.1093/sleep/zsy085] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Indexed: 12/18/2022] Open
Abstract
Study Objectives In this systematic review and meta-analysis, we aimed to examine the relationship between obstructive sleep apnea (OSA) and metabolic abnormalities in women with polycystic ovary syndrome (PCOS). Methods Electronic databases (Medline, Embase, Cinahl, PsycInfo, Scopus, Web of Science, Opengrey, and CENTRAL), conference abstracts, and reference lists of relevant articles were searched. No restriction was applied for language or publication status. Results Six studies involving 252 participants were included. Women with PCOS and OSA had significantly higher body mass index (mean difference [MD]: 6.01 kg/m2, 95% confidence intervals [CI]: 4.69-7.33), waist circumference (MD: 10.93 cm, 95% CI: 8.03-13.83), insulin resistance, systolic and diastolic blood pressure, and worse lipids' profile and impaired glucose regulation compared with women with PCOS without OSA. Most studies did not adjust for weight in their between-groups analysis. Total and free testosterone levels were not significantly different between the two groups. The majority of studies were found to be at high risk of selection bias, did not account for important confounders, were conducted in one country (United States), and used different methodologies to assess testosterone levels (preventing a meta-analysis for this specific outcome). Conclusions OSA is associated with obesity and worse metabolic profiles in women with PCOS. However, whether the effects of OSA are independent of obesity remain unclear. As OSA is a treatable condition, research focused on the independent effects of OSA on key clinical outcomes in women with PCOS, including fertility, psychological health, type 2 diabetes, and cardiovascular risk, is lacking and needed. PROSPERO registration number: CRD42016048587.
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Affiliation(s)
- Hassan Kahal
- Division of Translational and Experimental Medicine, Warwick Medical School, University of Warwick, Coventry CV4 7AL, United Kingdom.,Warwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism (WISDEM), University Hospitals Coventry and Warwickshire NHS Trust, Coventry CV2 2DX, United Kingdom
| | - Ioannis Kyrou
- Division of Translational and Experimental Medicine, Warwick Medical School, University of Warwick, Coventry CV4 7AL, United Kingdom.,Warwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism (WISDEM), University Hospitals Coventry and Warwickshire NHS Trust, Coventry CV2 2DX, United Kingdom.,Aston Medical Research Institute, Aston Medical School, Aston University, Birmingham B4 7ET, United Kingdom.,Centre of Applied Biological and Exercise Sciences, Faculty of Health and Life Sciences, Coventry University, Coventry CV1 5FB, United Kingdom
| | - Olalekan Uthman
- Division of Health Sciences, Warwick - Centre for Applied Health Research and Delivery (WCAHRD), Warwick Medical School, University of Warwick, Coventry CV4 7AL, United Kingdom
| | - Anna Brown
- Library and Knowledge Services, University Hospitals Coventry and Warwickshire NHS Trust, Coventry CV2 2DX, United Kingdom
| | - Samantha Johnson
- University of Warwick Library, University of Warwick, Coventry CV4 7AL, United Kingdom
| | - Peter Wall
- Department of Warwick Orthopaedics, Warwick Medical School, University of Warwick, Coventry CV2 2DX, United Kingdom
| | - Andrew Metcalfe
- Department of Warwick Orthopaedics, Warwick Medical School, University of Warwick, Coventry CV2 2DX, United Kingdom
| | - Abd A Tahrani
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT, United Kingdom.,Centre of Endocrinology, Diabetes and Metabolism (CEDAM), Birmingham Health Partners, Birmingham United Kingdom.,Department of Diabetes and Endocrinology, Birmingham Heartlands Hospital, Birmingham, United Kingdom
| | - Harpal S Randeva
- Division of Translational and Experimental Medicine, Warwick Medical School, University of Warwick, Coventry CV4 7AL, United Kingdom.,Warwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism (WISDEM), University Hospitals Coventry and Warwickshire NHS Trust, Coventry CV2 2DX, United Kingdom.,Aston Medical Research Institute, Aston Medical School, Aston University, Birmingham B4 7ET, United Kingdom.,Centre of Applied Biological and Exercise Sciences, Faculty of Health and Life Sciences, Coventry University, Coventry CV1 5FB, United Kingdom
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Khurana S, Sharda S, Saha B, Kumar S, Guleria R, Bose S. Canvassing the aetiology, prognosis and molecular signatures of obstructive sleep apnoea. Biomarkers 2018; 24:1-16. [DOI: 10.1080/1354750x.2018.1514655] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Sartaj Khurana
- Amity Institute of Biotechnology, Amity University, Noida, India
| | - Shivani Sharda
- Amity Institute of Biotechnology, Amity University, Noida, India
| | - Biswajit Saha
- Amity Institute of Biotechnology, Amity University, Noida, India
| | - Sachin Kumar
- Department of Medical Oncology, IRCH, AIIMS, New Delhi, India
| | - Randeep Guleria
- Department of Pulmonary Medicine and Sleep Disorders, AIIMS, New Delhi, India
| | - Sudeep Bose
- Amity Institute of Biotechnology, Amity University, Noida, India
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Raveendran AV, Chacko EC, Pappachan JM. Non-pharmacological Treatment Options in the Management of Diabetes Mellitus. EUROPEAN ENDOCRINOLOGY 2018; 14:31-39. [PMID: 30349592 PMCID: PMC6182920 DOI: 10.17925/ee.2018.14.2.31] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Accepted: 06/13/2018] [Indexed: 02/05/2023]
Abstract
The global prevalence of diabetes, especially type 2 diabetes mellitus, has reached epidemic proportions in the last few decades of the 20th century because of the obesity pandemic resulting from adverse lifestyles. Diabetes as a consequence of obesity (diabesity), continues to increase exponentially in the 21st century. Although there are a multitude of drugs for the effective management of diabesity with modest benefits, most patients will require insulin for control of diabetes at some stage that would worsen obesity, and thereby diabesity. Therefore, effective non-pharmacological therapy needs to be expedited in all patients with diabesity. These measures include medical nutrition interventions, change of lifestyles and bariatric surgery. Non-pharmacological interventions are also useful for the effective management of even type 1 diabetes mellitus when used along with insulin therapy especially in those with obesity. This review summarises the current evidence base for the non-pharmacological interventions in the management of diabetes.
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Affiliation(s)
| | - Elias C Chacko
- Department of Endocrinology, Jersey General Hospital, Jersey
| | - Joseph M Pappachan
- Department of Endocrinology, Diabetes & Metabolism, University Hospitals of Morecambe Bay NHS Foundation Trust, UK
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Association between insomnia and type 2 diabetes mellitus in Han Chinese individuals in Shandong Province, China. Sleep Breath 2018; 23:349-354. [PMID: 29961182 DOI: 10.1007/s11325-018-1687-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Revised: 06/06/2018] [Accepted: 06/18/2018] [Indexed: 12/18/2022]
Abstract
PURPOSE Diabetes and sleep disorders are public health threats worldwide, but the potential association between them is still unclear. METHODS We conducted a community-based cross-sectional study including 5078 participants (2665, 52.5% male) to determine the association between insomnia and diabetes mellitus prevalence. RESULTS In patients with type 2 diabetes mellitus (T2DM) and nondiabetic controls, the prevalence of insomnia was 20.2% (68/377) and 12.2% (578/4741), respectively. The results showed that insomnia was associated with T2DM after adjusting for age, sex, BMI, smoking, alcohol consumption, presence of disease history (hypertension, dyslipidemia, stroke, cardiovascular diseases, cancers), and depression (odds ratio [OR] = 1.31, 95% confidence interval [CI] 1.03-1.66). After stratifying by age and sex, insomnia was significantly associated with diabetes mellitus only in the subgroup of middle-aged participants (40-59 years) (OR = 1.61, 95% CI 1.16-2.23) and males (OR = 1.48, 95% CI 1.08-2.03) after controlling for the above covariates. CONCLUSIONS This study suggests that insomnia is independently and significantly associated with diabetes mellitus in the northern Chinese population, especially in the 40-59-year-old age group and in males.
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Matthews EE, Li C, Long CR, Narcisse MR, Martin BC, McElfish PA. Sleep deficiency among Native Hawaiian/Pacific Islander, Black, and White Americans and the association with cardiometabolic diseases: analysis of the National Health Interview Survey Data. Sleep Health 2018; 4:273-283. [DOI: 10.1016/j.sleh.2018.01.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Revised: 12/17/2017] [Accepted: 01/22/2018] [Indexed: 01/02/2023]
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Obesity, obstructive sleep apnea and type 2 diabetes mellitus: Epidemiology and pathophysiologic insights. SLEEP MEDICINE AND DISORDERS : INTERNATIONAL JOURNAL 2018; 2:52-58. [PMID: 30167574 PMCID: PMC6112821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Obesity is a major global health issue, and its prevalence is increasing. Obesity is associated with much comorbidity such as obstructive sleep apnea (OSA), type 2 diabetes mellitus (T2DM), and cardiovascular diseases (CVD). Obesity is also one of the major causative factors of OSA, and OSA itself can promote the onset of after T2DM because hypoxic episodes decrease insulin sensitivity, and activation of the sympathetic pathway leads to the release of inflammatory markers associated with insulin resistance. Continuous Positive Airway Pressure (CPAP) can be used to ameliorate both conditions, as CPAP decreased hypoxia episodes and increases insulin sensitivity and improves glucose metabolism. Weight-loss strategies play an important role in improving OSA, T2DM, and other associated comorbidities. Lifestyle modification of diet and exercise, medications or bariatric surgery should be considered weight loss. The purpose of this review is to describe the relationship between obesity, OSA, and T2DM.
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Altaf QA, Dodson P, Ali A, Raymond NT, Wharton H, Fellows H, Hampshire-Bancroft R, Shah M, Shepherd E, Miah J, Barnett AH, Tahrani AA. Obstructive Sleep Apnea and Retinopathy in Patients with Type 2 Diabetes. A Longitudinal Study. Am J Respir Crit Care Med 2017; 196:892-900. [PMID: 28594570 DOI: 10.1164/rccm.201701-0175oc] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Obstructive sleep apnea (OSA) is associated with several pathophysiological deficits found in diabetic retinopathy (DR). Hence, it's plausible that OSA could play a role in the pathogenesis of sight-threatening DR (STDR). OBJECTIVES To assess the relationship between OSA and DR in patients with type 2 diabetes and to assess whether OSA is associated with its progression. METHODS A longitudinal study was conducted in diabetes clinics within two U.K. hospitals. Patients known to have any respiratory disorder (including OSA) were excluded. DR was assessed using two-field 45-degree retinal images for each eye. OSA was assessed using a home-based multichannel cardiorespiratory device. MEASUREMENTS AND MAIN RESULTS A total of 230 patients were included. STDR and OSA prevalence rates were 36.1% and 63.9%, respectively. STDR prevalence was higher in patients with OSA than in those without OSA (42.9% vs. 24.1%; P = 0.004). After adjustment for confounders, OSA remained independently associated with STDR (odds ratio, 2.3; 95% confidence interval, 1.1-4.9; P = 0.04). After a median (interquartile range) follow-up of 43.0 (37.0-51.0) months, patients with OSA were more likely than patients without OSA to develop preproliferative/proliferative DR (18.4% vs. 6.1%; P = 0.02). After adjustment for confounders, OSA remained an independent predictor of progression to preproliferative/proliferative DR (odds ratio, 5.2; 95% CI confidence interval, 1.2-23.0; P = 0.03). Patients who received continuous positive airway pressure treatment were significantly less likely to develop preproliferative/proliferative DR. CONCLUSIONS OSA is associated with STDR in patients with type 2 diabetes. OSA is an independent predictor for the progression to preproliferative/proliferative DR. Continuous positive airway pressure treatment was associated with reduction in preproliferative/proliferative DR. Interventional studies are needed to assess the impact of OSA treatment on STDR.
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Affiliation(s)
- Quratul A Altaf
- 1 Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, United Kingdom.,2 Centre of Endocrinology, Diabetes, and Metabolism, Birmingham Heath Partners, Birmingham, United Kingdom.,3 Department of Diabetes and Endocrinology and
| | - Paul Dodson
- 3 Department of Diabetes and Endocrinology and.,4 Heart of England Diabetic Retinopathy Screening Centre, Heart of England NHS Foundation Trust, Birmingham, United Kingdom.,5 School of Life and Health Sciences, Aston University, Birmingham, United Kingdom
| | - Asad Ali
- 6 Department of Respiratory Medicine, University Hospital of Coventry and Warwickshire, Coventry NHS Trust, United Kingdom; and
| | - Neil T Raymond
- 7 Epidemiology, Research Design and Statistical Consulting (ERDASC), Leicestershire, United Kingdom
| | - Helen Wharton
- 3 Department of Diabetes and Endocrinology and.,4 Heart of England Diabetic Retinopathy Screening Centre, Heart of England NHS Foundation Trust, Birmingham, United Kingdom
| | - Hannah Fellows
- 3 Department of Diabetes and Endocrinology and.,4 Heart of England Diabetic Retinopathy Screening Centre, Heart of England NHS Foundation Trust, Birmingham, United Kingdom
| | - Rachel Hampshire-Bancroft
- 3 Department of Diabetes and Endocrinology and.,4 Heart of England Diabetic Retinopathy Screening Centre, Heart of England NHS Foundation Trust, Birmingham, United Kingdom
| | - Mirriam Shah
- 3 Department of Diabetes and Endocrinology and.,4 Heart of England Diabetic Retinopathy Screening Centre, Heart of England NHS Foundation Trust, Birmingham, United Kingdom
| | - Emma Shepherd
- 3 Department of Diabetes and Endocrinology and.,4 Heart of England Diabetic Retinopathy Screening Centre, Heart of England NHS Foundation Trust, Birmingham, United Kingdom
| | - Jamili Miah
- 3 Department of Diabetes and Endocrinology and.,4 Heart of England Diabetic Retinopathy Screening Centre, Heart of England NHS Foundation Trust, Birmingham, United Kingdom
| | - Anthony H Barnett
- 1 Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, United Kingdom.,2 Centre of Endocrinology, Diabetes, and Metabolism, Birmingham Heath Partners, Birmingham, United Kingdom.,3 Department of Diabetes and Endocrinology and
| | - Abd A Tahrani
- 1 Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, United Kingdom.,2 Centre of Endocrinology, Diabetes, and Metabolism, Birmingham Heath Partners, Birmingham, United Kingdom.,3 Department of Diabetes and Endocrinology and
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Abstract
Obstructive sleep apnoea (OSA) is very common in patients with Type 2 diabetes (T2D), which is not surprising considering that obesity is a common risk factor for both conditions. In general population studies, OSA has been shown to be associated with several comorbidities including increased risk of road traffic accidents, T2D, hypertension and lack of nocturnal dipping of blood pressure, hyperlipidaemia, increased inflammation, increased risk of cardiovascular disease and mortality, increased risk of atrial fibrillation, worse quality of life, and erectile dysfunction. However, the impact of OSA on diabetes-related vascular and metabolic outcomes remains unclear. Furthermore, the impact of continuous positive airway pressure (CPAP) treatment in patients with T2D is also unclear. This unclarity regarding the impact of OSA and CPAP in patients with T2D has possibly contributed to the lack of screening for OSA in patients with T2D in the UK despite the high prevalence of OSA in patients with T2D. In this commentary, I provide an overview about OSA with a particular focus on its role and impact in patients with T2D.
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Affiliation(s)
- Abd A Tahrani
- 1 Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
- 2 Department of Diabetes & Endocrinology, Birmingham Heartlands Hospital, Birmingham, UK
- 3 Centre of Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
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Tahrani AA. Ethnic differences in the pathogenesis of obstructive sleep apnoea: Exploring non-anatomical factors. Respirology 2017; 22:847-848. [DOI: 10.1111/resp.13057] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2017] [Accepted: 03/28/2017] [Indexed: 12/15/2022]
Affiliation(s)
- Abd A. Tahrani
- Institute of Metabolism and Systems Research; University of Birmingham; Birmingham UK
- Centre of Endocrinology, Diabetes and Metabolism; Birmingham Health Partners; Birmingham UK
- Department of Diabetes and Endocrinology; Birmingham Heartlands Hospital; Birmingham UK
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