Obstructive sleep apnoea in people with Type 1 diabetes: prevalence and association with micro- and macrovascular complications

Association between obstructive sleep apnea and multiple adverse clinical outcomes: evidence from an umbrella review

Background and objective

In recent years, there has been a notable rise in awareness regarding obstructive sleep apnea (OSA), and a significant number of potential OSA cases have been identified. Numerous studies have established associations between OSA and various adverse clinical outcomes. This umbrella review aims to summarize and evaluate the available evidence on the relationship between OSA and multiple adverse clinical outcomes.

Methods

PubMed, Embase, and Web of Science databases were systematically searched from inception to September 2023. The AMSTAR and GRADE were used to evaluate the quality of meta-analysis literature and classify the quality of literature evidence. Furthermore, the size of the effect size of the association between OSA and adverse clinical outcomes were assessed by using either a random or fixed-effect model and 95% confidence interval (CI).

Results

A total of 27 meta-analyses were enrolled with 43 adverse clinical outcomes. The umbrella review primarily reported the associations between sleep apnea syndrome and thyroid cancer (HR = 2.32,95%CI:1.35-3.98), kidney cancer (RR = 1.81, 95% CI: 1.20-2.74), liver cancer (RR = 1.19, 95% CI: 1.10-1.29), GERD (Gastroesophageal reflux disease)(OR = 1.53, 95% CI: 1.23-1.91), Atrial fibrillation (AF) (OR = 2.54, 95% CI: 2.20-2.92), osteoporosis (OR = 2.03, 95% CI: 1.26-3.27), and diabetes (OR = 1.40, 95% CI: 1.32-1.48). Overall, the AMSTAR rating scale and GRADE quality assessment included in the meta-analysis were generally low.

Conclusion

Our study shows that OSA is significantly associated with a variety of adverse clinical outcomes, especially an increased risk of certain malignancies, and some adverse clinical outcomes are closely related to OSA severity.

Obstructive Sleep Apnoea and Type 1 Diabetes Mellitus: A Neglected Relationship?

Obstructive sleep apnoea (OSA) is regarded as a major health condition, progressively affecting an increased number of people around the world. The interplay between OSA and type 2 diabetes mellitus (T2DM) has been extensively studied. However, little is known about the relationship between OSA and type 1 diabetes mellitus (T1DM). This review provides insight into the prevalence of OSA in T1DM and its relationship with diabetic complications. Studies have hitherto yielded contradictory results on the occurrence of OSA in T1DM. Indeed, the risk of OSA in T1DM has ranged from 1 in 10 to more than 1 in 2 T1DM subjects. This high occurrence was confirmed by objective polysomnography as well as widely used subjective questionnaires. Multiple studies revealed the important correlation between OSA and diabetes complications. Both microvascular (nephropathy, neuropathy and retinopathy) and macrovascular complications appear to be associated with OSA occurrence, although some associations were not significant due to inadequate data. In conclusion, T1DM subjects carry a higher risk of undiagnosed OSA. Additional studies are needed to clarify the exact correlation between the two conditions.

Sleep Disturbances in Type 1 Diabetes and Mitigating Cardiovascular Risk

Cardiovascular disease (CVD) is a major cause of morbidity and mortality in persons with type 1 diabetes (T1D). Despite control of known cardiovascular (CV) risk factors and better glycemic management, persons with T1D still face heightened CVD risk, suggesting additional contributing factors. Sleep has recently been recognized as a CV risk factor; however; the role of sleep in CVD specifically in T1D population has only started to emerge. Extensive evidence suggests that persons with T1D often encounter sleep disturbances. This review aims to comprehensively explore the relationship between sleep disturbances and CVD in T1D, proposed possible mediators including glycemic control, which has been studied more extensively, and less studied factors such as blood pressure, lipid metabolism, and weight management. Stress and self-care behaviors likely also play a role in the relationship between sleep disturbances and CVD. The evidence regarding sleep interventions in the context of T1D in mitigating these CV risk factors has recently been shown in early, small-scale studies. Sleep assessments should be a part of the standard of care in persons with T1D. Further research should focus on understanding the impact and mechanistic pathways of sleep disturbances on CV risk and developing T1D-specific sleep interventions to reduce CVD burden in this population.

Estimated prevalence of obstructive sleep apnea by occupation and industry in England: a descriptive study

Study Objectives

Obstructive sleep apnea (OSA) can induce excessive sleepiness, causing work-related injuries and low productivity. Most individuals with OSA in the United Kingdom are undiagnosed, and thus, theoretically, workplace screening, might by identifying these individuals improve both their individual health and overall productivity. However, the prevalence of OSA in different workplaces is unclear. This study aimed to estimate the prevalence of OSA by industries and occupations in England.

Methods

The Health Survey for England 2019 dataset was combined with Sleep Heart Health Study dataset. We applied multiple imputation for the combined dataset to estimate OSA in the English population aged 40-64. We estimated the pooled prevalence of OSA by both industry and occupation by separating samples by Standard Industry Classification and Standard Occupation Classification.

Results

The overall OSA prevalence estimated by imputation for ages 40-64 was 17.8% (95% CI = 15.9% to 19.9%). Separating those samples into industrial/occupational groups, the estimated prevalence of OSA varied widely by industry/occupation. Descriptive analysis revealed that the estimated prevalence of OSA was relatively higher in the Accommodation and food, Public administration and defence; compulsory social security, Construction industries, and Protective service occupations, health and social care associate professionals, and skilled construction and building trades occupations.

Conclusions

In England in 2019, Accommodation and food, Public administration and defence; compulsory social security, Construction industries, and Protective service occupations, health and social care associate professionals, and skilled construction and building trades occupations showed a relatively higher prevalence of OSA indicating that they may be target populations for workplace screening.

FOUND Trial: randomised controlled trial study protocol for case finding of obstructive sleep apnoea in primary care using a novel device

INTRODUCTION

Obstructive sleep apnoea (OSA) is a common, but underdiagnosed, sleep disorder. If untreated, it leads to poor health outcomes, including Alzheimer's disease, cancer, cardiovascular disease and all-cause mortality. Our aim is to determine the feasibility and cost-effectiveness of moving the testing for OSA into general practice and how general practitioner (GP)-based screening affects overall detection rates.

METHODS AND ANALYSIS

Randomised controlled trial of case finding of OSA in general practice using a novel Medicines and Healthcare products Regulatory Agency-registered device (AcuPebble SA100) compared with usual care with internal feasibility phase. A diverse sample of general practices (approximately 40) from across the West Midlands Clinical Research Network will identify participants from their records. Eligible participants will be aged 50-70 years with body mass index >30 kg/m2 and diabetes (type 1 or 2) and/or hypertension (office blood pressure >145/90 mm Hg or on treatment). They will exclude individuals with known OSA or chronic obstructive pulmonary disease, or those they deem unable to take part. After eligibility screening, consent and baseline assessment, participants will be randomised to either the intervention or control group. Participants in the intervention arm will receive by post the AcuPebble sleep test kit. Those in the control arm will continue with usual care. Follow-up questionnaires will be completed at 6 months. The study is powered (90%) to detect a 5% difference and will require 606 patients in each arm (713 will be recruited to each arm to allow for attrition). Due to the nature of the intervention, participants and GPs will not be blinded to the allocation.

OUTCOMES

Primary: Detection rate of moderate-to-severe OSA in the intervention group versus control group. Secondary: Time to diagnosis and time to treatment for intervention versus control group for mild, moderate and severe OSA; cost-effectiveness analysis comparing the different testing pathways.

ETHICS AND DISSEMINATION

The trial started on 1 November 2022. Ethical approval was granted from the South Central Oxford A Research Ethics Committee on 9 June 2023 (23/SC/0188) (protocol amendment version 1.3; update with amendment and approval to renumber to V2.0 on 29 August 2023). Patient recruitment began on 7 January 2024; initial planned end date will be on 31 April 2025.Results will be uploaded to the ISRCTN register within 12 months of the end of the trial date, presented at conferences, submitted to peer-reviewed journals and distributed via our patient and public involvement networks.The University of Warwick will act as the trial sponsor. The trial will be conducted in accordance with the Sponsor and Primary Care Clinical Trials Unit standard operating procedures.

TRIAL REGISTRATION NUMBER

ISRCTN 16982033.

Circadian dysfunction and cardio-metabolic disorders in humans

The topic of human circadian rhythms is not only attracting the attention of clinical researchers from various fields but also sparking a growing public interest. The circadian system comprises the central clock, located in the suprachiasmatic nucleus of the hypothalamus, and the peripheral clocks in various tissues that are interconnected; together they coordinate many daily activities, including sleep and wakefulness, physical activity, food intake, glucose sensitivity and cardiovascular functions. Disruption of circadian regulation seems to be associated with metabolic disorders (particularly impaired glucose tolerance) and cardiovascular disease. Previous clinical trials revealed that disturbance of the circadian system, specifically due to shift work, is associated with an increased risk of type 2 diabetes mellitus. This review is intended to provide clinicians who wish to implement knowledge of circadian disruption in diagnosis and strategies to avoid cardio-metabolic disease with a general overview of this topic.

Multidimensional sleep health and diabetic retinopathy: Systematic review and meta-analysis

Diabetic retinopathy (DR) is one of the most prevalent microvascular diabetic complications. Poor sleep health and obstructive sleep apnea (OSA) are risk factors for diabetes and poor glycemic control. Recent studies have suggested associations between poor sleep health/OSA and DR. Furthermore, there have been suggestions of melatonin dysregulation in the context of DR. We conducted a systematic review and meta-analysis exploring the associations between multidimensional sleep health (duration, satisfaction, efficiency, timing/regularity and alertness), OSA and melatonin with DR. Forty-two studies were included. Long, but not short sleep, was significantly associated with DR, OR 1.41 (95%CI 1.21, 1.64). Poor sleep satisfaction was also significantly associated with DR, OR 2.04 (1.41, 2.94). Sleep efficiency and alertness were not associated with DR, while the evidence on timing/regularity was scant. Having OSA was significantly associated with having DR, OR 1.34 (1.07, 1.69). Further, those with DR had significantly lower melatonin/melatonin metabolite levels than those without DR, standardized mean difference -0.94 (-1.44, -0.44). We explored whether treating OSA with continuous positive airway pressure (CPAP) led to improvement in DR (five studies). The results were mixed among studies, but potential benefits were observed in some. This review highlights the association between poor multidimensional sleep health and DR.

The effects of disease severity and comorbidity on oxidative stress biomarkers in obstructive sleep apnea

PURPOSE

Ischemia-modified albumin (IMA), total oxidant status (TOS), and total antioxidant status (TAS) are biomarkers used to evaluate oxidative stress status in various diseases including obstructive sleep apnea (OSA). In this study, we investigated the effects of disease severity and comorbidity on IMA, TOS and TAS levels in OSA.

METHODS

Patients with severe OSA (no-comorbidity, one comorbidity, and multiple comorbidities) and mild-moderate OSA (no-comorbidity, one and multiple comorbidities), and healthy controls were included in the study. Polysomnography was applied to all cases and blood samples were taken from each participant at the same time of day. ELISA was used to measure IMA levels in serum samples and colorimetric commercial kits were used to perform TOS and TAS analyses. In addition, routine biochemical analyses were performed on all serum samples.

RESULTS

A total of 74 patients and 14 healthy controls were enrolled. There was no statistically significant difference between the disease groups according to gender, smoking status, age, body mass index (BMI), HDL, T3, T4, TSH, and B12 (p > 0.05). As the severity of OSA and comorbidities increased, IMA, TOS, apnea-hypopnea index (AHI), desaturation index (T90), cholesterol, LDL, triglyceride, AST, and CRP values increased significantly (p < 0.05). On the other hand, TAS, minimum desaturation, and mean desaturation values decreased significantly (p < 0.05).

CONCLUSIONS

We concluded that IMA, TOS, and TAS levels may indicate OSA-related oxidative stress, but as the severity of OSA increases and with the presence of comorbidity, IMA and TOS levels may increase and TAS levels decrease. These findings suggest that disease severity and presence/absence of comorbidity should be considered in studies on OSA.

Continuous Positive Airway Pressure Effect on Progression of Retinal Disease in Patients with Sleep Apnea and Nonproliferative Diabetic Retinopathy: A Randomized Clinical Trial

Rationale: Obstructive sleep apnea (OSA) is associated with impaired glycemic control and a higher risk of vascular complications, such as diabetic retinopathy. However, the effect of apnea-hypopnea suppression on retinal disease progression is unclear. Objectives: To evaluate the efficacy and safety of continuous positive airway pressure (CPAP) for the reduction of retinal lesions in patients with non-proliferative diabetic retinopathy (NPDR) and OSA. Methods: This open-label, parallel-group, randomized controlled trial was conducted between October 2016 and February 2020 at a university hospital in Spain. The date of final follow-up was March 2, 2021. Eighty-three patients with OSA and mild to moderate NPDR receiving stable treatment were randomized to receive CPAP and usual care (43 patients with 79 available eyes) or usual care alone (40 patients with 67 available eyes) for 52 weeks. The primary outcomes were the change in the percentage of eyes with retinal exudates and the number of retinal microhemorrhages from baseline to week 52. We also assessed the effects of both interventions on retinal thickness by means of optical coherence tomography, serum concentrations of glycated hemoglobin, blood pressure, lipid concentrations, sleepiness, and quality of life. Results: Fifty-two weeks of CPAP treatment was associated with reductions from baseline in the percentage of eyes with hard exudates (overall difference, -21.7%; P = 0.035) and in optical coherence tomography indices of retinal edema, including central subfield thickness and cube volume. However, in patients who met prespecified criteria for CPAP adherence, treatment was also associated with a higher number of retinal microhemorrhages at 52 weeks (intergroup adjusted difference, 6.0 [95% confidence interval, 0.6-11.5]; P = 0.029), which was directly related to prescribed pressure levels. CPAP treatment also improved glycemic control, sleepiness, and general health-related quality of life. Conclusions: In patients with OSA and NPDR, long-term CPAP treatment in addition to usual care may result in slower progression of retinal disease, although it could also induce an increase in retinal microhemorrhages. Clinical trial registered with www.clinicaltrials.gov (NCT02874313).

The Role of Obstructive Sleep Apnea in Vision-Threatening Diabetic Retinopathy-A National Register-Based Study

INTRODUCTION

we investigated the association between OSA and vision-threatening diabetic retinopathy (VTDR).

METHODS

we used three nationwide registers to identify subjects with and without OSA and patients with type 1 (T1DM) or type 2 diabetes mellitus (T2DM). The Danish Civil Registration System was used to link OSA with diabetes diagnosis. The primary outcome was the occurrence of VTDR in diabetic patients with and without OSA. The secondary outcome was the prevalence of diabetes mellitus in patients with and without OSA.

RESULTS

we included 532,828 diabetic subjects comprising 13,279 patients with OSA (2.5%) and 519,549 without OSA (97.5%). Diabetic patients with OSA had a 57% lower risk of VTDR compared to diabetic patients without OSA (OR 0.43, 95% CI 0.38-0.50, p < 0.0001).

CONCLUSIONS

our findings indicate that OSA is associated with a lower risk of VTDR. Since we did not adjust our outcomes for diabetes duration, hypertension control and hemoglobin A1c, future studies are needed to confirm our findings.

Cardiovascular Disease Outcomes Associated with Obstructive Sleep Apnea in Diabetics: A Systematic Review and Meta-Analysis

BACKGROUND

There is significant pathogenic and epidemiological overlap between diabetes and obstructive sleep apnea (OSA). This systematic review aimed to ascertain the association between OSA and cardiovascular disease (CVD) in a diabetic population.

METHODS

The study protocol was registered with PROSPERO (CRD42023404126). On 15 July 2023, a comprehensive search of the literature was performed in PubMed, EBSCO, Scopus, ProQuest, and Web of Science, using keywords and synonyms of OSA, diabetes, and CVD, coupled with specific terms for different CVDs. Only observational studies that reported CVD events in diabetics (with and without OSA) were included. The quality of the studies included in the analysis was assessed using the Newcastle-Ottawa Scale.

RESULTS

In the primary literature search, 8795 studies were identified, of which 9 met the inclusion criteria and included 17,796 participants. Eight studies were eligible for meta-analysis, and a pooled risk ratio (RR) of 1.29 (95% CI = 0.91-1.83) was found for developing CVD in diabetics with OSA at a 95% prediction interval of 0.30-5.60. The included studies showed significant heterogeneity with an I2 value of 91%.

CONCLUSION

These findings show the possible association between OSA and diabetes and their impact on CVDs. Identifying and managing OSA in individuals with diabetes at an early phase could potentially reduce the risk of CVDs and its related complications.

Prevalence of sleep apnoea in patients with type 1 diabetes and its association with comorbidities and diabetic complications: A French nationwide prospective study

AIM

To investigate sleep apnoea prevalence, factors influencing severity, and associations between sleep apnoea severity and micro-/macrovascular complications in a large population of patients with type 1 diabetes.

MATERIALS AND METHODS

This French multicentre prospective cohort study was conducted between July 2016 and June 2020. Adults with type 1 diabetes using an insulin pump were eligible. Home care provider nurses collected demographic and clinical data and set up oximetry to determine the oxygen desaturation index (ODI). No, mild-moderate and severe sleep apnoea were defined as ODI <15 events/h, 15 to <30 events/h and ≥30 events/h, respectively. Univariate and multivariate analyses were performed to identify factors associated with sleep apnoea, and associations between sleep apnoea severity and micro-/macrovascular complications were determined using logistic regression.

RESULTS

Of 769 participants, 12.4% and 3.4% had mild-to-moderate or severe sleep apnoea, respectively. Factors significantly associated with sleep apnoea on multivariate analysis were age, sex, body mass index (BMI) and hypertension. After adjustment for age, sex and BMI, presence of severe sleep apnoea was significantly associated with macrovascular complications (odds ratio vs. no sleep apnoea: 3.96 [95% confidence interval 1.43-11.11]; P < 0.01), while mild-to-moderate sleep apnoea was significantly associated with presence of diabetic retinopathy (odds ratio 2.09 [95% confidence interval 1.10-3.74]; P < 0.01).

CONCLUSION

Sleep apnoea is a significant comorbidity in patients with type 1 diabetes, especially with respect to diabetic complications. This highlights the need for sleep apnoea screening and management in these individuals.

Endocrine disorders in obstructive sleep apnoea syndrome: A bidirectional relationship

Obstructive sleep apnoea (OSA) is a common disorder characterized by recurrent episodes of apnoea or hypopnea due to total or partial pharyngeal collapse and temporary upper airway obstruction during sleep. The prevalence of OSA is increasing and currently affects about 30% of men and 13% of women in Europe. Intermittent hypoxia, oxidative stress, systemic inflammation, and sleep fragmentation resulting from OSA can provoke subsequent cardiometabolic disorders. The relationships between endocrine disorders and OSA are complex and bidirectional. Indeed, several endocrine disorders are risk factors for OSA. Compared with the general population, the prevalence of OSA is increased in patients with obesity, hypothyroidism, acromegaly, Cushing syndrome, and type 1 and 2 diabetes. In some cases, treatment of the underlying endocrine disorder can improve, and occasionally cure, OSA. On the other hand, OSA can also induce endocrine disorders, particularly glucose metabolism abnormalities. Whether continuous positive airway pressure (CPAP) treatment for OSA can improve these endocrine disturbances remains unclear due to the presence of several confounding factors. In this review, we discuss the current state-of-the-art based on the review of the current medical literature for key articles focusing on the bidirectional relationship between endocrine disorders and OSA and the effects of treatment. Screening of OSA in endocrine patients is also discussed, as it remains a subject of debate.

Obstructive sleep apnea risk and its associated factors among type 2 diabetes mellitus patients at wolkite university specialized hospital, Wolkite, Southern Ethiopia, 2021. A comparative cross-sectional study

BACKGROUND

Obstructive sleep apnea is a syndrome characterized by recurrent partial, or complete upper airway collapse during sleep. Although obstructive sleep apnea is common in type 2 diabetes mellitus, the majority of patients remain undiagnosed because of the prohibitive cost of the test and paucity of the sleep clinic, especially in developing nations. The study aimed to assess high-risk obstructive sleep apnea and its associated factors among type 2 diabetes mellitus patients at Wolkite University Specialized Hospital.

METHODS

A Hospital-based comparative cross-sectional study was employed from October 15 to December 5, 2021, among 204 participants. Data collection was done by semi-structured interviewer-administered questionnaires. Data was entered into the Epi data version 4.6 and exported to SPSS version 25.0 for analysis. Independent t-test and chi-square test were used to compare continuous and categorical variables accordingly. Binary and multiple logistic regression analysis was used to assess factors associated with high-risk obstructive sleep apnea. Statistical significance was set at P-value < 0.05.

RESULTS

A total of 204 participants with an equal proportion of the two groups were included with a 100% response rate. About 56.9% of the participants were males. The mean age of type 2 diabetes mellitus patients was 57.1 (± 12.0) years and the non-diabetic group was 55.3 (± 10.9) years. The prevalence of high-risk obstructive sleep apnea among type 2 diabetes mellitus was 42.2%, and that of non-diabetics was 13.7% (p < 0.001). Age (AOR: 1.13; 95%CI: 1.04, 1.22), neck grasp (AOR: 6.48; 95%CI: 1.56, 26.96), waist circumference (AOR: 4.44; 95%CI: 1.12, 17.61) and the presence of diabetes-related complications (AOR: 4.18; 95%CI: 1.13, 15.43) were independently associated with high-risk obstructive sleep apnea among type 2 diabetes mellitus patients.

CONCLUSION

The prevalence of high-risk obstructive sleep apnea among type 2 diabetes mellitus was higher with a significant difference from their comparison group. Age, neck grasp, waist circumference, and diabetes-related complications were significantly associated with high-risk obstructive sleep apnea among type 2 diabetes mellitus patients. Therefore, type 2 diabetes mellitus patients should be screened for obstructive sleep apnea in the early course of their follow-up to take preventive measures and early treatments.

Associations between Sleep Characteristics and Cardiovascular Risk Factors in Adolescents Living with Type 1 Diabetes

Adolescents living with type 1 diabetes (T1D) have an increased risk of developing cardiovascular disease. Sleep patterns have physiological and behavioral impacts on diabetes outcomes. This study aimed to investigate the associations between sleep patterns and CVD risk factors in adolescents living with T1D and their peers living without T1D. This cross-sectional study assessed CVD risk factors and sleep characteristics (and their associations) in adolescents, aged 12-18 years, living with T1D (n = 48) and their peers (n = 19) without T1D. Outcomes included blood pressure, lipid profiles, and sleep characteristics (accelerometry). Statistical differences between groups were determined with chi-square or independent samples t-tests. The associations between sleep characteristics and CVD risk factors were assessed with multivariate linear regression analyses. We found no significant differences between the two groups in terms of sleep duration, efficiency, sleep onset and offset, and frequency of awakenings, and there were associations between sleep efficiency and LDL-C (β = -0.045, p = 0.018, model R2 = 0.230) and triglycerides (β = -0.027, p = 0.012, model R2 = 0.222) after adjusting confounders (diabetes status, sex, age, pubertal stage) in all participants. In conclusion, adolescents with T1D and without T1D sleep less than the recommended eight hours per night. The associations between sleep efficiency and LDL-C and triglycerides are independent of sleep duration, regardless of sex, age, and pubertal stage.

Risk of incident obstructive sleep apnoea in patients with type 1 diabetes: a population-based retrospective cohort study

AIMS/HYPOTHESIS

People with type 2 diabetes are at increased risk of developing obstructive sleep apnoea. However, it is not known whether people with type 1 diabetes are also at an increased risk of obstructive sleep apnoea. This study aimed to examine whether people with type 1 diabetes are at increased risk of incident obstructive sleep apnoea compared with a matched cohort without type 1 diabetes.

METHODS

We used a UK primary care database, The Health Improvement Network (THIN), to perform a retrospective cohort study between January 1995 and January 2018 comparing sleep apnoea incidence between patients with type 1 diabetes (exposed) and without type 1 diabetes (unexposed) (matched for age, sex, BMI and general practice). The outcome was incidence of obstructive sleep apnoea. Baseline covariates and characteristics were assessed at the start of the study based on the most recent value recorded prior to the index date. The Cox proportional hazards regression model was used to estimate unadjusted and adjusted hazard ratios, based on a complete-case analysis.

RESULTS

In total, 34,147 exposed and 129,500 matched unexposed patients were included. The median follow-up time was 5.43 years ((IQR 2.19-10.11), and the mean BMI was 25.82 kg/m2 (SD 4.33). The adjusted HR for incident obstructive sleep apnoea in patients with type 1 diabetes vs those without type 1 diabetes was 1.53 (95% CI 1.25, 1.86; p<0.001). Predictors of incident obstructive sleep apnoea in patients with type 1 diabetes were older age, male sex, obesity, being prescribed antihypertensive or lipid-lowering drugs, atrial fibrillation and depression.

CONCLUSIONS/INTERPRETATION

Individuals with type 1 diabetes are at increased risk of obstructive sleep apnoea compared with people without diabetes. Clinicians should suspect obstructive sleep apnoea in patients with type 1 diabetes if they are old, have obesity, are male, have atrial fibrillation or depression, or if they are taking lipid-lowering or antihypertensive drugs.

Improving the screening of risk factors in diabetic retinopathy

INTRODUCTION

In 2002, Diabetic Retinopathy was reported as the leading cause of blindness in the working age group. The introduction of systematic screening programs in the UK has reduced visual loss and blindness due to diabetic retinopathy, but it does still occur with catastrophic consequences for the individual.

AREAS COVERED

The author conducted an ongoing search for articles relating to diabetic retinopathy since 2000 utilizing Zetoc Alert with keywords and contents page lists from relevant journals. This review covers the risk factors for loss of vision due to diabetic retinopathy and discusses ways in which the awareness of these risk factors can be used to further reduce visual loss. Some risk factors such as glycemic and B/P control are well known from landmark trials. This review has included these factors but concentrated more on the evidence behind those risk factors that are not so clearly defined or so well known.

EXPERT OPINION

The major risk factors are well known, but one continues to find that people with diabetes lose vision in situations in which a better awareness of the risks by both the individual with diabetes and the health workers involved may have prevented the visual loss.

Examining the Relationship Between Diabetic Macular Edema, and Obstructive Sleep Apnea

Purpose

This prospective cohort study examined the relationship between diabetic macular edema (DME), diabetic retinopathy (DR) and obstructive sleep apnea (OSA) in patients after 1 year of treatment with anti-VEGF injection and/or continuous positive airway pressure (CPAP).

Patients and Methods

The study included adults with type 1 or 2 diabetes mellitus with diabetic retinopathy. Polysomnography metrics were measured at baseline. Ophthalmologic metrics were measured at baseline, six-month (6m) and twelve-month (12m) follow-up. All DME+ patients received standard care, and all OSA+ patients were advised continuous positive airway pressure (CPAP). Logistic regression between DR severity and OSA severity was performed. Analysis of variance (ANOVA) was performed between subgroups.

Results

Seventy-four eyes of 49 patients with DR were included. Prevalence of OSA was significantly higher in the DME+ group (70.7%) than DME- group (42.4%, p < 0.05). A significantly lower average minimum SaO₂ was noted in OSA+DME+ (81.74%) than OSA+DME- eyes (88.23%, p < 0.05). Logistic regression analysis of ophthalmological and sleep metrics showed no correlation between DR and OSA severity. CPAP adherence was 20% (6/30) in the OSA+DME+ cohort and 36% (5/14) in the OSA+DME- cohort. At 12m, CPAP-adherent OSA+DME+ showed significantly lower DR severity score (1.00 ± 0.0) than CPAP non-adherent OSA+DME+ (1.36 ± 0.80, p = 0.042). No significant patterns were noted for visual acuity and mean central retinal thickness.

Conclusion

DME is associated with the presence of OSA. Minimum SaO₂ is a significant OSA clinical variable for DME. DR severity is not associated with OSA severity. CPAP coupled with intravitreal anti-VEGF therapy may be helpful for reducing DR severity in DME+ eyes. Presence of OSA may diminish intravitreal anti-VEGF efficacy on anatomical (mean CRT) and functional (VA) outcomes of DME.

Screening for sleep-disordered breathing in people with type 1 diabetes by combining polysomnography with glucose variability assessment

AIMS

There are few published data on sleep-disordered breathing (SDB) in type 1 diabetes (T1DM). Here, we used a combination of polysomnography and glucose variability assessment to screen for SDB.

METHODS

In a prospective, single-centre study, adults with T1DM underwent polysomnography and continuous glucose monitoring during a single night. We measured high glucose variability and the occurrence of a low or very low glucose level. Mild and moderate-to-severe SDB were defined as an apnoea-hypopnoea index above 5/h and 15/h, respectively.

RESULTS

We studied 46 patients (25 men; median age: 42 [35-54]; diabetes duration: 18 years [13-29]; body mass index (BMI): 24.8 kg/m² [23.0-28.9]). SDB was present in 17 patients (37.0%) overall (mild SDB: n = 9; moderate-to-severe SDB; n = 8). When compared with the absence of SDB or mild SDB, moderate-to-severe SDB was associated with a higher BMI (29.8 kg/m² [27.8-31.1]) and a longer diabetes duration (26 years [18-31]) but not with above-target glucose variability or more sleep disorder symptoms. Conversely, sleep disorder symptoms were not more frequent in patients with above-target glucose variability.

CONCLUSION

SDB was highly prevalent and associated with obesity. According to the methods used here, sleep disorders were not associated with above-target glucose variability or low glucose values.

Sleep apnea and eye diseases: evidence of association and potential pathogenic mechanisms

Eye diseases are an important group of increasingly prevalent disorders that contribute very significantly to disability and represent a considerable health burden. Some data suggest that several of these diseases may be associated with sleep-disordered breathing, mainly obstructive sleep apnea (OSA), due to intermediate mechanisms, such as intermittent hypoxia or sleep fragmentation. The aims of this systematic review were to identify and critically evaluate the current evidence supporting the existence of a possible relationship between OSA and the more relevant eye diseases as well as to evaluate the potential pathogenic mechanisms. There is a body of largely low-level evidence for the association of OSA with glaucoma, nonarteritic ischemic optic neuropathy, central serous chorioretinopathy, and diabetic retinopathy. Meta-analysis of available case-control studies shows that OSA increases the risk of glaucoma (pooled odds ratio: 1.50; 95% confidence interval: 1.25 to 1.80; P < .001), nonarteritic ischemic optic neuropathy (3.62; 1.94 to 6.76; P < .001), and diabetic retinopathy (1.57; 1.09 to 2.27; P = .02). Moreover, several pathogenic pathways have been identified, mainly related to hypoxic damage, mechanical stress, systemic inflammation, oxidative stress, sympathetic tone, and endothelial dysfunction. In contrast, information about the effect of apnea-hypopnea suppression on the development and progression of eye damage is either nonexistent or of a very low level of evidence. In conclusion, OSA has emerged as an additional potential risk factor for many eye diseases, although their link is weak and contradictory, so further examination is required.

CITATION

García-Sánchez A, Villalaín I, Asencio M, García J, García-Rio F. Sleep apnea and eye diseases: evidence of association and potential pathogenic mechanisms. J Clin Sleep Med. 2022;18(1):265-278.

Obstructive Sleep Apnoea, Other Sleep Parameters and Diabetic Retinopathy

PURPOSE OF REVIEW

To summarise the association between obstructive sleep apnoea and diabetic retinopathy and diabetic macular oedema. To examine the effects of other sleep parameters on diabetic retinopathy and diabetic macular oedema. To discuss the pathophysiology of diabetic eye changes and how it is related to obstructive sleep apnoea.

RECENT FINDINGS

Conflicting data exists in terms of the association of diabetic eye changes with sleep apnoea and/or other sleep parameters. Various cross-sectional studies show PDR to be associated with the prevalence of OSA. Patients who underwent continuous positive airway pressure (CPAP) treatment were significantly less likely to develop pre/proliferative DR. Secondary sleep parameters generally are not associated with DR except for long duration of sleep. Differences in reporting could be due to the different thresholds set to define OSA/ODI and severity of DR/DME, in addition to factors used in multivariate analysis. There is a need for further studies with long-term follow-up and to assess the impact of CPAP on the development and progression of diabetic eye change(s).

Type 1 Diabetes, Sleep, and Hypoglycemia

PURPOSE OF REVIEW

To review the relationship between sleep and hypoglycemia, sleep characteristics, and their associations with glycemic control in persons with type 1 diabetes (T1D). The effects of sleep interventions and diabetes technology on sleep are summarized.

RECENT FINDINGS

Nocturnal hypoglycemia affects objective and subjective sleep quality and is related to behavioral, psychological, and physiological factors. Sleep disturbances are common, including inadequate sleep, impaired sleep efficiency, poor subjective satisfaction, irregular timing, increased daytime sleepiness, and sleep apnea. Some have a bidirectional relationship with glycemic control. Preliminary evidence supports sleep interventions (e.g., sleep extension and sleep coach) in improving sleep and glycemic control, while diabetes technology use could potentially improve sleep. Hypoglycemia and sleep disturbances are common among persons with T1D. There is a need to develop sleep promotion programs and test their effects on sleep, glucose, and related outcomes (e.g., self-care, psychological health).

Screening for obstructive sleep apnea in a diabetic retinopathy clinic in a tertiary care center

Purpose:

To screen for obstructive sleep apnea (OSA) in patients presenting to diabetic retinopathy (DR) clinic and to correlate its presence with the severity of DR.

Methods:

A prospective, cross-sectional study of diabetes mellitus patients in retina clinic of a tertiary care referral center, North India (January 2019–March 2020). All were subjected to STOP-Bang Questionnaire and Epworth Sleepiness Scale (ESS) score. Patients at high OSA risk (STOP-Bang score ≥5 and ESS score ≥10) were referred to Department of Otorhinolaryngology (sleep clinic) for polysomnography. Based on Apnea Hypopnea Index (AHI), OSA was graded as mild (AHI = 5–14/h), moderate (AHI = 15–30/h), and severe (AHI >30/h). Statistical analysis was done using three models of outcome measures: (1) “No DR” versus “any DR,” (2) “Less severe DR” versus “More severe DR,” and (3) “No diabetic macular edema (DME)” versus “DME.”

Results:

Of 362 patients screened, 18 (4.97%) had OSA (11 mild, 5 moderate, and 2 severe). Though OSA did not show a significant association with various outcome measures, patients with moderate–severe OSA had higher odds in developing “any DR” (OR = 7.408; 95% CI = 0.533–102.898), “more severe DR” (OR = 1.961; 95% CI = 0.153–25.215), and “DME” (OR = 2.263; 95% CI = 0.357–14.355), on multiple logistic regression.

Conclusion:

Ours is the first screening study of OSA in DR patients in India, the diabetes capital of the world. We detected OSA in 4.97% of patients in a DR clinic, with an increased risk of “any DR,” “more severe DR,” and “DME” in the presence of moderate–severe OSA.

Association Between Obstructive Sleep Apnea and Diabetic Macular Edema in Patients with Type 2 Diabetes

PURPOSE

To evaluate the relationship between obstructive sleep apnea (OSA) and diabetic macular edema (DME) and the effect of OSA on refractory DME in patients with type 2 diabetes (T2DM).

DESIGN

Retrospective clinical cohort study.

METHODS

A population-based study was conducted at Chang Gung Memorial Hospital from March 1, 2009, to March 1, 2020. Among 14,152 patients who had undergone polysomnography (PSG) and whose data were registered on the sleep center's PSG database, 121 patients (242 eyes) with T2DM were enrolled according to the International Classification of Diseases, Ninth Revision (ICD-9) code 3620 for diabetic retinopathy (DR). Patients with a secondary cause of macular edema and those lacking medical records were excluded. All patients with T2DM enrolled in our study received both optical coherence tomography (OCT) and PSG. The prevalence of severe (apnea-hypopnea index [AHI] ≥30) and nonsevere (AHI <30) OSA was compared between patients with and without DME and refractory DME.

RESULTS

In total, 102 eyes (54 patients) were divided into groups of 40 eyes with DME or 62 eyes without DME. Severe OSA (odds ratio, 7.36; 95% confidence interval [CI]: 1.32-40.96; P = .023) was significantly associated with DME. Refractory DME was significantly more frequent in patients with severe OSA (27%) than in those with nonsevere OSA (0%; P = .009). Cox proportional hazards regression analysis revealed that OSA (hazard ratio, 2.97; CI, 1.08-8.16; P = .034) independently increased the DME risk after adjustment for age, sex, glycohemoglobin level, hypertension, and hypercholesterolemia.

CONCLUSIONS

Severe OSA is a risk factor for DME and is associated with having refractory DME.

Blood pressure during sleep is associated with arterial stiffness and urine microalbumin to creatinine ratio in youth with type 1 diabetes

AIMS

To determine whether sleep blood pressure (BP) is associated with increased cardiovascular disease (CVD) risk in youth with type 1 diabetes (T1DM).

METHODS

We enrolled youth with T1DM, 12-21 years old. Carotid-femoral Pulse Wave Velocity (PWV_cf) assessed arterial stiffness, a CVD marker. Sleep systolic and diastolic BP variables were obtained from 24-hour BP Monitoring. Linear regression models analyzed the relationship of each BP variable with PWV_cf, adjusted for HbA1c. Correlation of sleep BP with urine microalbumin-to-creatinine ratio (UAC) was examined.

RESULTS

Nocturnal hypertension was found in 36% and abnormal dipping in 48% of the 25 participants, aged 17.7 ± 2.2 years old. Sleep systolic BP [beta = 0.039, 95% Confidence Interval (CI; 0.006-0.073)], diastolic BP [beta = 0.058, 95% CI (0.003-0.114)], Mean Arterial Pressure (MAP) [beta = 0.075, 95% CI (0.018-0.131)] and MAP index [beta = 3.547, 95% CI (0.867-6.227)] were significantly associated with PWV_cf. Sleep diastolic BP, load, MAP correlated with UAC.

CONCLUSIONS

Blood pressure alterations during sleep are common in youth with T1DM and they are associated with arterial stiffness and UAC. Larger studies are needed to confirm our results and examine whether interventions that target sleep and night-time BP could decrease CVD risk.

Impact of sleep apnoea-hypopnoea syndrome on diabetic neuropathy. A systematic review

INTRODUCTION

Diabetes mellitus and sleep apnoea-hypopnoea syndrome appear to be related, but it is not well defined whether there is an increased risk of peripheral neuropathy in patients with both diseases. For this reason, we conducted a systematic review.

METHODS

Bibliographic search in 3 electronic databases using a predefined strategy and the PRISMA methodology. Only original studies (any type of design) published from 2000 onwards in English, French, Portuguese or Spanish were included. A study quality scale was established.

RESULTS

Twelve articles were selected, of which six studied type 2 diabetic patients. The overall prevalence of sleep apnoea-hypopnoea syndrome was 43.7% (1,559/3,564 patients). Diabetic neuropathy was more frequent in patients with sleep apnoea-hypopnoea syndrome in nine studies, although significantly only in four (60% vs 27%, P<.001; 64.5% vs 36%, P=.03; 37% vs 23.4%, P<.02; 66.6% vs 0%, P=.007). In one study, diabetic neuropathy was more frequent in patients without sleep apnoea-hypopnoea syndrome (although not statistically significant) and in 2 no comparison was made between patients with/without sleep apnoea/hypopnoea syndrome.

CONCLUSIONS

The observed results suggest a relationship between diabetes mellitus and sleep apnoea-hypopnoea syndrome in the occurrence of diabetic neuropathy.

Prevalence of Obstructive Sleep Apnea in Patients With Diabetic Foot Ulcers

Objectives: Diabetic foot ulcers (DFUs) are a considerable burden on patients and the healthcare service system. Patients with DFUs have many risk factors that might contribute to obstructive sleep apnea (OSA). The purposes of this study were to assess the prevalence of OSA and associated features in patients with DFUs. Methods: Between July 2017 and June 2019, we recruited 245 consecutive patients who sought for treatment at West China Hospital because of DFUs. Polysomnography data from 127 Patients were included in the final analysis. Results: Of the 127 patients, with a median age of 64 years (interquartile range, 55-73 years; range, 36-86 years) and a mean body mass index (BMI) 24.09 ± 0.37 kg/m2, 91 (72%) were men. The prevalence of OSA [apnea-hypopnea index (AHI) ≧5/h] was 92% in men and 97% in women (P = 0.304). Moderate to severe OSA (AHI ≧15/h) was noted in 44 men (48%) and 26 women (72%) (P = 0.015). The risk factors associated with the severity of OSA were sex, age, smoking, alcohol use, and duration of diabetes. After multivariable adjustment, duration of diabetes and age were independent predictive factors of the severity of OSA. No significant association was observed between BMI, waist circumference, Epworth score, and the severity of OSA. There were no significant associations between OSA and ischemic heart disease, cerebral infarction, hypertension, diabetic retinopathy, diabetic kidney disease, and peripheral artery disease. Conclusions: The prevalence of OSA was high in patients with DFUs, with moderate to severe OSA accounting for more than half of the patients. Age and duration of diabetes were independent predictive factors of the severity of OSA.

Sleep Apnea, Obesity, and Disturbed Glucose Homeostasis: Epidemiologic Evidence, Biologic Insights, and Therapeutic Strategies

PURPOSE OF REVIEW

Obstructive sleep apnea (OSA), obesity, and disturbed glucose homeostasis are usually considered distinct clinical condition, although they are tightly related to each other. The aim of our manuscript is to provide an overview of the current evidence on OSA, obesity, and disturbed glucose homeostasis providing epidemiologic evidence, biological insights, and therapeutic strategies.

RECENT FINDINGS

The mechanisms hypothesized to be involved in this complex interplay are the following: (1) "direct weight-dependent" mechanisms, according to which fat excess compromises respiratory mechanics, and (2) "indirect weight-dependent" mechanisms such as hyperglycemia, insulin resistance and secondary hyperinsulinemia, leptin resistance and other hormonal dysregulations frequently found in subjects with obesity, type 2 diabetes, and/or sleep disorders. Moreover, the treatment of each of these clinical conditions, through weight loss induced by diet or bariatric surgery, the use of anti-obesity or antidiabetic drugs, and continuous positive airway pressure (CPAP), seems to positively influence the others. These recent data suggest not only that there are multiple connections among these diseases but also that treating one of them may result in an improvement of the others.

Differences in sleep architecture according to body mass index in children with type 1 diabetes

Slow wave sleep (SWS), or deep sleep, is thought to be the most restorative stage of sleep and may be of a particular interest in the pathophysiology of obesity. The aim of this study was to investigate differences in sleep architecture based on body mass index (BMI) among a pediatric population with type 1 diabetes mellitus (T1DM). We hypothesized that children with T1DM who are obese would have less SWS than those who are not obese. Of 105 children with T1DM (mean age 13.54 years, 49.5% females) in this study, 19% were obese, 22% were overweight, and 59% had a normal BMI (81% non-obese). The overall SWS% among the participants was 13.2%. In contrast to our hypothesis, there was no significant difference in SWS% between obese and non-obese participants. However, the percent of time spent in rapid eye movement (REM) sleep among obese participants was significantly lower than those who were not obese (P = .022), which remained after adjusting the result for multiple covariates. While we found no significant association between the SWS time and BMI, obese adolescents with T1DM spent less time in REM sleep than those who were not obese. This study adds to the growing body of evidence supporting the importance of addressing sleep in clinical care of youth with T1DM.

Sleep-related disorders in patients with type 1 diabetes mellitus: current insights

Type 1 diabetes mellitus (T1DM) is an autoimmune condition that results from destruction of beta cells in the pancreas. Several reviews have concluded that sleep contributes to poor glycemic control, diabetes management, and diabetes-related complications in individuals with T1DM and represents an untapped opportunity for intervention. However, at the current juncture, the American Diabetes Association's Standards of Medical Care are devoid of recommendations about how to address sleep in the management of T1DM. This article summarizes reviews of sleep in youth and adults with T1DM and empirical studies that have examined various sleep parameters ranging from sleep disturbances (general, perceived sleep quality, sleepiness, awakenings, and sleep efficiency), sleep duration, sleep consistency, sleep-disordered breathing (SDB), and sleep architecture. The data show that many individuals with T1DM sleep less than recommendations; individuals with the poorest sleep have difficulties with diabetes management; and sleep deficiency including SDB often corresponds to several disease morbidities (neuropathy, nephropathy, etc). Mixed findings exist regarding direct associations of various sleep parameters and glycemic control. SDB appears to be just as prevalent, if not more, than other conditions that have been recommended for universal screening in individuals with T1DM. The article concludes with recommendations for collaborative research efforts to further elucidate the role of sleep in diabetes-related outcomes; investigations to test behavioral strategies to increase sleep quantity and consistency; and considerations for clinical care to address sleep.

RELATIONSHIP BETWEEN OBSTRUCTIVE SLEEP APNEA AND THE PRESENCE AND SEVERITY OF DIABETIC RETINOPATHY

PURPOSE

To evaluate the relationship between obstructive sleep apnea (OSA) and the presence and severity of diabetic retinopathy (DR).

METHODS

Three hundred seventeen patients with International Classification of Diseases diagnoses of both DR and OSA were evaluated retrospectively. Diabetic retinopathy severity and diabetic macular edema status were determined by diagnostic coding and medical records. Obstructive sleep apnea severity and additional sleep measures were obtained from overnight polysomnography. Analysis was performed using multivariable logistic regression.

RESULTS

After adjustment, an association was seen between DR and severe OSA (odds ratio [OR]: 2.18, 95% confidence interval [CI]: 1.14-4.18, P = 0.019). Proliferative DR was associated with severe OSA versus no DR (OR: 2.40, 95% CI: 1.12-5.14, P = 0.024) and mild nonproliferative DR (OR: 2.87, 95% CI: 1.26-6.55, P = 0.012). Comparing all nonproliferative DR with proliferative DR, proliferative DR and severe OSA were associated (OR: 2.20, 95% CI: 1.03-4.70, P = 0.043), as well as diabetic macular edema and severe OSA (OR: 2.89, 95% CI: 1.58-5.27, P = 0.001). No association was seen between DR/diabetic macular edema and secondary sleep measures.

CONCLUSION

The findings suggest an increased risk of DR, proliferative DR, and diabetic macular edema in patients with severe OSA. Ophthalmologists following these patients should be aware of this association to better manage ocular sequelae of diabetes.

Metabolic Consequences of Obstructive Sleep Apnea Especially Pertaining to Diabetes Mellitus and Insulin Sensitivity

Obstructive sleep apnea (OSA) and diabetes has been known to be closely related to each other and both diseases impact highly on the public health. There are many evidence of reports that OSA is associated with diabetes with a bidirectional correlation. A possible causal mechanism of OSA to diabetes is intermittent hypoxemia and diabetes to OSA is microvascular complication. However, OSA and diabetes have a high prevalence rate in public and shares the common overlap characteristic and risk factors such as age, obesity, and metabolic syndrome that make it difficult to establish the exact pathophysiologic mechanism between them. In addition, studies demonstrating that treatment of OSA may help prevent diabetes or improve glycemic control have not shown convincing result but have become a great field of interest research. This review outlines the bidirectional correlation between OSA and diabetes and explore the pathophysiologic mechanisms by approaching their basic etiologies.

Sleep and type 1 diabetes in children and adolescents: Proposed theoretical model and clinical implications

Youth with type 1 diabetes mellitus (T1D) experience more sleep disturbances and shorter sleep durations compared to their healthy peers. Researchers have now uncovered the negative mental health and physical health outcomes associated with poor sleep in youth with T1D. The field of T1D sleep research currently operates under the broad notion that sleep behaviors impact treatment adherence, which ultimately lead to worse long-term health outcomes. This model however does not explain how behavior influences T1D management and sleep outcomes on a day-to-day basis, leading to difficulties in providing tailored treatment recommendations. In this review, we present a theoretical framework that describes the recursive cycle between sleep behaviors, T1D outcomes, and symptoms of negative affect/stress over a 24-hour period. This model is guided by the sleep literature, showing a clear relationship between poor sleep and negative affect, and the T1D literature demonstrating a link between poor sleep and disease management for youth with T1D. Further, emerging literature indicates a need for additional parent sleep assessment considering that T1D management and fear of hypoglycemia negatively impact parent sleep behaviors. Recommendations are provided to move the field toward effective intervention studies and new areas of research to evaluate and modify the proposed model.

Elevated obstructive sleep apnoea risk score is associated with poor healing of diabetic foot ulcers: a prospective cohort study

AIMS

To assess the prevalence of risk factors for obstructive sleep apnoea in people with diabetic foot ulcers and to determine whether this risk predicts diabetic foot ulcer healing.

METHODS

We studied 94 consecutive people (69% men) with diabetic foot ulcers (Type 2 diabetes, n=66, Type 1 diabetes, n=28) attending a university hospital foot unit. All participants were screened for obstructive sleep apnoea using the STOP-BANG questionnaire, with a score ≥4 identifying high risk of obstructive sleep apnoea. The primary outcome was poor diabetic foot ulcer healing, defined as diabetic foot ulcer recurrence (diabetic foot ulcers which healed and re-ulcerated in same anatomical position) and/or diabetic foot ulcer persistence (no evidence of healing on clinical examination). All participants were evaluated at 12 months.

RESULTS

Of the 94 participants, 60 (64%) had a STOP-BANG score ≥4. Over 12 months, 27 participants with a score ≥4 had poor diabetic foot ulcer healing as compared to seven with a score <4 (45% vs 20.5%; P=0.025). A STOP-BANG score ≥4 significantly increased the relative risk of poor healing more than twofold, independently of other risk factors in multivariable analyses.

CONCLUSIONS

There is a high prevalence of features and risk of obstructive sleep apnoea in people with diabetic foot ulcers. A STOP-BANG score ≥4 predicts poor diabetic foot ulcer healing. Obstructive sleep apnoea may be a potential, modifiable risk factor/treatment target to improve diabetic foot ulcer outcomes.

The correlation between obstructive sleep apnea and diabetic neuropathy: A meta-analysis

BACKGROUND

The aim of this study was to explore the correlation between obstructive sleep apnea (OSA) and diabetic neuropathy.

MATERIALS AND METHODS

After working out searching strategy, literatures were screened from the electronic databases: PubMed, Embase, and the Cochrane library. R 3.12 was utilized to perform meta-analysis, and odds ratio (OR) and its 95% confidence interval (CI) were used to present effect size. Heterogeneity was assessed by χ²-based Q test and I² statistics. Publication bias was estimated by Egger's test and sensitivity was evaluated by leave one out methods.

RESULTS

According to the criteria, a total of 11 studies with 1842 patients were enrolled in this study. With a significant heterogeneity (Q=31.83, I²=68.60%), the random effects model was utilized to assess the effect size of pooled data. A remarkable correlation was identified OSA and diabetic neuropathy (OR=1.84, 95% CI: 1.18-2.87) without publication bias (t=1.68, P=0.13). Meanwhile, the result of leave one out performed a well sensitivity. Moreover, the subgroup analyses presented that OSA was significantly correlated with type 1 diabetic neuropathy (OR=1.97, 95% CI: 1.19-3.25), but no remarkable correlation was identified between OSA and type 1 (OR=1.84, 95% CI: 0.86-3.93) or 1+2 (OR=1.30, 95% CI: 0.43-3.92) diabetic neuropathy.

CONCLUSION

OSA was significantly correlated with neuropathy in type 1 diabetes, but not in type 2 and type 1+2 diabetes.

Predictors of Sleep Apnea in the Canadian Population

Older age, obesity, hypertension, snoring, and excessive daytime sleepiness have been associated with sleep apnea. The objective of this study was to determine the prevalence (crude and adjusted), as well as the risk factors, of sleep apnea in the adult Canadian population. Data from the 2009 Sleep Apnea Rapid Response (SARR) questionnaire were used to identify the risk factors, and all sleep-related questions in the SARR questionnaire were used. The outcome variable of interest was health professional-diagnosed sleep apnea. Covariates of interest were demographic variables, population characteristics, respiratory and cardiovascular diseases, and enabling resources. The multiple logistic regression model adjusted for the clustering effect was used to analyze the data. Sleep apnea was diagnosed in 858,913 adults (3.4% of the population), and more men (65.4%) than women (34.6%) were diagnosed with sleep apnea. Multivariable logistic regression analysis indicated that age (45 and older), loud snoring, sudden awakening with gasping/choking (rare/sometimes and once or more a week), and nodding off/falling asleep in driving in the past 12 months were significantly associated with diagnosed sleep apnea. Predictive probability demonstrated that in overweight and obese persons, ≥15 minutes of daily exercise significantly decreased the risk of diagnosed sleep apnea. The conclusion of this study is that in the Canadian population, sleep apnea is associated with older age, loud snoring, and sleeping problems. The protective effect of exercise warrants further investigation.

Short-term metabolic control and sleep in children and adolescents with type 1 diabetes mellitus

AIMS

The aim of this study was to examine sleep in T1D children and in healthy controls by polysomnographic (PSG) examination and to determine the influence of short-term metabolic compensation on sleep quality and sleep disordered breathing (SDB).

METHODS

The prospective cross-sectional study included 44 T1D subjects and 60 healthy controls, aged 10-19 years. Subjects underwent anthropometric measurements, laboratory testing and standard overnight in-laboratory video polysomnography with continuous glucose monitoring (CGM).

RESULTS

No significant differences were found in total sleep time, sleep efficiency, percentage of sleep stages and respiratory parameters between T1D and healthy group. T1D children with more optimal short-term metabolic control (AvgSG < 10 mmol/l, n = 18) had a significantly lower apnea-hypopnea index (AHI) (0.3(0-0.5) vs. 0.6 (0.2-0.9) events/h, p < 0.05)and respiratory arousal index (0(0-0,1) vs. 0.2(0-0.3)), p < 0.01) compared to children with suboptimal short-term control(n = 26), no significant differences were found in parameters of sleep architecture. Obstructive sleep apnea (OSA) was diagnosed in only one T1D patient, nine T1D children had mild central apnea.

CONCLUSIONS

There may be an association between short-term metabolic compensation and SDB in T1D children without chronic complications, obesity or overweight and hypoglycemia. Further research is needed to confirm this result.

Adrenaline activation of the carotid body: Key to CO2 and pH homeostasis in hypoglycaemia and potential pathological implications in cardiovascular disease

Ventilatory and neuroendocrine counter-regulatory responses during hypoglycaemia are essential in order to maintain glycolysis and prevent rises in P_aCO₂ leading to systemic acidosis. The mammalian carotid body has emerged as an important driver of hyperpnoea and glucoregulation in hypoglycaemia. However, the adequate stimulus for CB stimulation in hypoglycaemia has remained controversial for over a decade. The recent finding that adrenaline is a physiological activator of CB in hypoglycaemia raises the intriguing possibility that CB stimulation and hyperpnoea may be necessary to maintain pH in other adrenaline-related hypermetabolic states such as exercise. This review will therefore focus on 1) The important functional contribution of the CB in the counter-regulatory and ventilatory response to hypoglycaemia, 2) the proposed mechanisms that cause CB stimulation in hypoglycaemia including hormonal activation by adrenaline and direct low glucose sensing and 3) the possible pathological consequences of repetitive CB activation by adrenaline that could potentially be targeted to reduce CB-mediated cardiovascular disease.

Obstructive sleep apnoea

Obstructive sleep apnoea (OSA) is increasing in prevalence due to rising obesity. While OSA is a disorder primarily of the upper airway during sleep, its pathophysiological impact on other body systems is increasingly recognised. There has been interest in the prevalence of OSA in different ophthalmic conditions and possible causation has been postulated. As OSA is common, it can be expected that people with co-existent OSA will be found in any ophthalmic disease population studied. To determine with confidence the significance of finding patients with OSA in a particular cohort requires a well matched control group, ideally matched for age, obesity, gender and co-morbidities. Only if one can say with certainty that the prevalence of OSA is higher in a group with a particular co-existent ophthalmic disease can we begin to speculate about possible mechanisms for the overlap in these conditions. Possible mechanisms for how OSA might affect the eye are discussed in this review. The current literature is reviewed with respect to diabetic retinopathy, glaucoma, floppy eyelid syndrome, non-arteritic ischaemic optic neuropathy, keratoconus and AMD. Associations with OSA have been found, but robust prospective studies using multi-channel sleep studies to diagnose OSA are lacking. Gaps remain in the evidence and in our knowledge. It is hoped that this review will highlight the need for ophthalmologists to consider OSA in their patients. It also makes recommendations for future research, especially to consider whether therapies for OSA can also be effective for ophthalmic disorders.

Diabetic retinopathy: hyperglycaemia, oxidative stress and beyond

Diabetic retinopathy remains a relevant clinical problem. In parallel with diagnostic and therapeutic improvements, the role of glycaemia and reactive metabolites causing cell stress and biochemical abnormalities as treatment targets needs continuous re-evaluation. Furthermore, the basic mechanisms of physiological angiogenesis, remodelling and pruning give important clues about the origins of vasoregression during the very early stages of diabetic retinopathy and can be modelled in animals. This review summarises evidence supporting a role for the neurovascular unit-composed of neuronal, glial and vascular cells-as a responder to the biochemical changes imposed by reactive metabolites and high glucose. Normoglycaemic animal models developing retinal degeneration, provide valuable information about common pathways downstream of progressive neuronal damage that induce vasoregression, as in diabetic models. These models can serve to assess novel treatments addressing the entire neurovascular unit for the benefit of early diabetic retinopathy.

Interactions between and Shared Molecular Mechanisms of Diabetic Peripheral Neuropathy and Obstructive Sleep Apnea in Type 2 Diabetes Patients

Type 2 diabetes (T2D) accounts for about 90% of all diabetes patients and incurs a heavy global public health burden. Up to 50% of T2D patients will eventually develop neuropathy as T2D progresses. Diabetic peripheral neuropathy (DPN) is a common diabetic complication and one of the main causes of increased morbidity and mortality of T2D patients. Obstructive sleep apnea (OSA) affects over 15% of the general population and is associated with a higher prevalence of T2D. Growing evidence also indicates that OSA is highly prevalent in T2D patients probably due to diabetic peripheral neuropathy. However, the interrelations among diabetic peripheral neuropathy, OSA, and T2D hitherto have not been clearly elucidated. Numerous molecular mechanisms have been documented that underlie diabetic peripheral neuropathy and OSA, including oxidative stress, inflammation, endothelin-1, vascular endothelial growth factor (VEGF), accumulation of advanced glycation end products, protein kinase C (PKC) signaling, poly ADP ribose polymerase (PARP), nitrosative stress, plasminogen activator inhibitor-1, and vitamin D deficiency. In this review, we seek to illuminate the relationships among T2D, diabetic peripheral neuropathy, and OSA and how they interact with one another. In addition, we summarize and explain the shared molecular mechanisms involved in diabetic peripheral neuropathy and OSA for further mechanistic investigations and novel therapeutic strategies for attenuating and preventing the development and progression of diabetic peripheral neuropathy and OSA in T2D.

Recognition of Sleep Apnea Is Increasing. Analysis of Trends in Two Large, Representative Databases of Outpatient Practice

RATIONALE

Little is known about recent trends in physician reporting of sleep apnea during outpatient practice visits.

OBJECTIVES

To assess trends in the frequency of adult outpatient visits for sleep apnea in the United States, the clinicians who provided those visits, and the characteristics of patients reported to have sleep apnea; and to assess whether the reporting of a diagnosis of sleep apnea varies across regions of the country as a function of body weight and insurance status.

METHODS

We reviewed annual stratified samples of patients identified as having sleep apnea during physician office visits in the U.S. National Ambulatory Medical Care Survey database, and during visits to hospital outpatient practices in the U.S. National Hospital Ambulatory Medical Care Survey database, between 1993 and 2010. The aggregate data set included records of 838,000 ambulatory practice visits.

MEASUREMENTS AND MAIN RESULTS

During this 17-year period, survey reports of a diagnosis of sleep apnea increased 14.6- fold, from 420,000 to 6.37 million per year (P = 0.0002). Thirty-three percent were reported by primary care providers, 17% by pulmonologists, and 10% by otolaryngologists. Over the period of observation, reports of a diagnosis of sleep apnea by "other groups" increased considerably (P < 0.001). The per capita rate of sleep apnea diagnoses per 1,000 persons per year differed across regions of the United States (P < 0.0001). Regions that reported a higher rate of sleep apnea appeared to be influenced by obesity (P < 0.001) and health insurance status (P < 0.005).

CONCLUSIONS

Diagnoses of sleep apnea during outpatient visits to hospital-based and non-hospital-based practices in the United States were much more frequent in 2010 than in 1993, as reported by outpatient practice clinicians participating in national surveys. Although the majority of diagnoses of sleep apnea were reported by primary care providers, pulmonologists, and otolaryngologists (60%), there was a substantial increase in reports of sleep apnea by clinicians practicing other specialties during the study period. Reporting of a diagnosis of sleep apnea varied by obesity prevalence and health insurance status across U.S. geographic regions.

Relationship of Obstructive Sleep Apnoea with Diabetic Retinopathy: A Meta-Analysis

Until now, the relationship of obstructive sleep apnoea (OSA) with diabetic retinopathy (DR) was controversial. This meta-analysis was performed to obtain definitive conclusion on this topic. Relevant articles were searched on databases of Pubmed, Google Scholar, and Chinese National Knowledge Infrastructure (CNKI). The articles were selected according to inclusion and exclusion criteria. Odds ratio (OR) with 95% confidence interval (CI) was used to evaluate the relationship of OSA with risk of DR. I2 and P value were used to assess the presence of heterogeneity. I2 ≥ 50% or P < 0.05 indicated significant heterogeneity. Sensitivity analysis was performed to evaluate the robustness of pooled results. Begg's funnel plot and Egger's regression analysis were adopted to assess publication bias. 6 eligible studies were selected in the present meta-analysis. The pooled results indicated that OSA was significantly associated with increased risk of DR (OR = 2.01, 95% CI = 1.49-2.72). Subgroup analysis based on type of diabetes mellitus suggested that OSA was related to DR in both Type 1 and Type 2 diabetes mellitus. Sensitivity analysis demonstrated that pooled results were robust. No significant publication bias was observed (P = 0.128). The results indicate that OSA is related to increased risk of DR.

Over-the-counter mouthwash use and risk of pre-diabetes/diabetes

AIMS

Over-the-counter mouthwash comprises part of routine oral care for many; however, potential adverse effects of the long-term daily use have not been evaluated. Most mouthwash contain antibacterial ingredients, which could impact oral microbes critical for nitric oxide formation, and in turn predispose to metabolic disorders including diabetes. Our aim was to evaluate longitudinally the association between baseline over-the-counter mouthwash use and development of pre-diabetes/diabetes over a 3-year follow-up.

MATERIALS AND METHODS

The San Juan Overweight Adults Longitudinal Study (SOALS) recruited 1206 overweight/obese individuals, aged 40-65, and free of diabetes and major cardiovascular diseases; 945 with complete follow-up data were included in the analyses. We used Poisson regression models adjusting for baseline age, sex, smoking, physical activity, waist circumference, alcohol consumption, pre-hypertension/hypertension status; time between visits was included in the models as an offset.

RESULTS

Many participants (43%) used mouthwash at least once daily and 22% at least twice daily. Participants using mouthwash ≥ twice daily at baseline, had a significantly elevated risk of pre-diabetes/diabetes compared to less frequent users (multivariate IRR = 1.55, 95% CI: 1.21-1.99), or non-users of mouthwash (multivariate IRR = 1.49; 95% CI: 1.13-1.95). The effect estimates were similar after adding income, education, oral hygiene, oral conditions, sleep breathing disorders, diet (processed meat, fruit, and vegetable intake), medications, HOMA-IR, fasting glucose, 2hr post load glucose or CRP to the multivariate models. Both associations were also significant among never-smokers and obese individuals. Mouthwash use lower than twice daily showed no association, suggesting a threshold effect at twice or more daily.

CONCLUSIONS

Frequent regular use of over-the-counter mouthwash was associated with increased risk of developing pre-diabetes/diabetes in this population.

Diseases of the retina and the optic nerve associated with obstructive sleep apnea

Many associations between ocular disorders and obstructive sleep apnea (OSA) have been studied, such as nonarteritic anterior ischemic optic neuropathy, glaucoma, papilledema, retinal vein occlusion, eyelid hyperlaxity, lower-eyelid ectropion and recurrent corneal erosions. The objective of this review is to synthetize the possible vascular disorders of the retina and the optic nerve associated with sleep apnea patients and to discuss the underlying pathophysiological hypotheses. Main mechanisms involved in the ocular complications of OSA are related to intermittent hypoxia, sympathetic system activation, oxidant stress, and deleterious effects of endothelin 1. The main evidence-based medicine data suggest that OSA should be screened in patients with ischemic optic neuropathy and diabetic retinopathy. The effect of OSA treatment and emerging therapies are discussed.

Cardiovascular risk assessment in patients with diabetes

Although patients with diabetes have 2 to 4 times increased risk of cardiovascular morbidity and mortality than individuals without diabetes, recent studies indicate that a significant part of patients are in a lower cardiovascular risk category. Men younger than 35 years, women younger than 45 years, patients with diabetes duration of less than 10 years without other risk factors have a much lower risk than patients who have traditional cardiovascular risk factors, and subclinical or established coronary artery disease (CAD). These patients are not risk equivalent as stated in previous studies. On the contrary, when in the presence of traditional risk factors or evidence of subclinical coronary disease (e.g. high coronary calcium score), the coronary risk is much increased and patients may be classified at a higher-risk category. Recent guidelines do not anymore consider diabetes as a CAD risk equivalent and recommend cardiovascular risk stratification for primary prevention. Stratification of diabetic patients improves accuracy in prediction of subclinical CAD, silent ischemia and future cardiovascular events. Stratification also discriminates higher from lower risk patients who may need intensive statin or aspirin prevention, while avoiding overtreatment in lower risk cases. It may also allow the clinician to decide whether to intensify risk reduction actions through specific newer drugs for glucose control such as SGLT-2 inhibitors or GLP-1 agonists, which recently have shown additional cardiovascular protector effect. This review addresses the assessment of cardiovascular disease risk using traditional and non-traditional cardiovascular risk factors. It also reviews the use of risk calculators and new reclassification tools, focusing on the detection of subclinical atherosclerosis as well as silent ischemia in the asymptomatic patients with diabetes.

Obstructive sleep apnea in adults with type 1 and type 2 diabetes: perspectives from a quality improvement initiative in a university-based diabetes center

OBJECTIVE

Obstructive sleep apnea (OSA) and diabetes are frequent comorbid conditions. Screening for OSA in patients with diabetes is recommended but the frequency with which this is done in clinical practice is unknown. The objectives of this quality improvement initiative were to identify clinician and patient perceptions regarding OSA and to identify the prevalence of patients at high risk for OSA (HROSA).

METHODS

A quality improvement initiative was conducted to query clinicians and patients attending a specialty diabetes clinic regarding attitudes and beliefs related to OSA. The Berlin Questionnaire was embedded in patient questionnaires to identify patients as low risk for OSA (LROSA) or HROSA.

RESULTS

35 clinicians completed questionnaires with >80% agreement that OSA contributed to blood pressure (BP), glycemic control, and diabetes complications and that screening is a shared responsibility with other physicians; but only 17% indicated regular screening due predominantly to insufficient time. Of 107 patients (26 type 1 diabetes mellitus (T1DM) and 81 type 2 diabetes mellitus (T2DM)), 30% were aware that OSA could affect diabetes outcomes. The prevalence of known OSA, LROSA, and HROSA was similar in T1DM (15%, 50%, 35%) and T2DM (36%, 33%, 31%, respectively) (p=0.21). 59% of all HROSA patients indicated that OSA screening had never been discussed with them.

CONCLUSIONS

These results demonstrate that providers, but not patients, are knowledgeable about the importance of OSA screening, but insufficient time is a major barrier to wider screening. Approximately, 30% of patients with T1DM and T2DM were identified as HROSA supporting the need for procedures that improve detection and treatment.