Obstructive sleep apnoea and Type 2 diabetes mellitus: are they connected?

Obstructive sleep apnea: Overlooked comorbidity in patients with diabetes

In this review article, we explore the interplay between obstructive sleep apnea (OSA) and type 2 diabetes mellitus (T2DM), highlighting a significant yet often overlooked comorbidity. We delve into the pathophysiological links between OSA and diabetes, specifically how OSA exacerbates insulin resistance and disrupts glucose metabolism. The research examines the prevalence of OSA in diabetic patients and its role in worsening diabetes-related complications. Emphasizing the importance of comprehensive management, including weight control and positive airway pressure therapy, the study advocates integrated approaches to improve outcomes for patients with T2DM and OSA. This review underscores the necessity of recognizing and addressing OSA in diabetes care to ensure more effective treatment and better patient outcomes.

[Diabetes and obstructive sleep apnoea: A case-control study]

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.

Personalized Medicine and Obstructive Sleep Apnea

Obstructive sleep apnea (OSA) is a common disease that is often under-diagnosed and under-treated in all ages. This is due to differences in morphology, diversity in clinical phenotypes, and differences in diagnosis and treatment of OSA in children and adults, even among individuals of the same age. Therefore, a personalized medicine approach to diagnosis and treatment of OSA is necessary for physicians in clinical practice. In children and adults without serious underlying medical conditions, polysomnography at sleep labs may be an inappropriate and inconvenient testing modality compared to home sleep apnea testing. In addition, the apnea-hypopnea index should not be considered as a single parameter for making treatment decisions. Thus, the treatment of OSA should be personalized and based on individual tolerance to sleep-quality-related parameters measured by the microarousal index, harmful effects of OSA on the cardiovascular system related to severe hypoxia, and patients' comorbidities. The current treatment options for OSA include lifestyle modification, continuous positive airway pressure (CPAP) therapy, oral appliance, surgery, and other alternative treatments. CPAP therapy has been recommended as a cornerstone treatment for moderate-to-severe OSA in adults. However, not all patients can afford or tolerate CPAP therapy. This narrative review seeks to describe the current concepts and relevant approaches towards personalized management of patients with OSA, according to pathophysiology, cluster analysis of clinical characteristics, adequate combined therapy, and the consideration of patients' expectations.

BDNF and proBDNF Serum Protein Levels in Obstructive Sleep Apnea Patients and Their Involvement in Insomnia and Depression Symptoms

Introduction: Obstructive sleep apnea (OSA) is a disorder that, apart from somatic sequelae, increases the risk of developing psychiatric conditions. Brain-derived neurotrophic factor (BDNF) signaling pathway is involved in the pathophysiology of depression and insomnia. Therefore, the study aimed to investigate differences in concentrations of BDNF and proBDNF in patients with OSA and healthy individuals, to evaluate diurnal changes of these proteins, and to assess the correlations with psychiatric symptoms. Methods: Sixty individuals following polysomnography (PSG) were divided into two groups based on the apnea-hypopnea index (AHI): OSA patients (AHI ≥ 30; n = 30) and control group (AHI < 5; n = 30). Participants filled out questionnaires: Beck Depression Inventory (BDI), Athens Insomnia Scale (AIS), and Pittsburgh Sleep Quality Index (PSQI). Peripheral blood was collected before and after PSG. Protein concentrations were measured using ELISA. OSA group was divided into subgroups: AIS (−)/AIS (+) (AIS > 5), PSQI (−)/PSQI (+) (PSQI > 5), and BDI (−)/BDI (+) (BDI > 19). Results: No differences in BDNF and proBDNF protein levels were observed between OSA and the control groups. However, BDNF and proBDNF evening protein concentrations were higher in the AIS (+) and PSQI (+) groups (p < 0.001 for all). The BDI (+) group was characterized by lower morning levels of both proteins (p = 0.047 and p = 0.003, respectively). Conclusions: BDNF signaling pathway might be involved in the pathophysiology of depression and insomnia in patients with OSA. BDNF and proBDNF protein levels might be useful in defining OSA phenotypes.

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.

Intermittent Hypoxia and Atherosclerosis: From Molecular Mechanisms to the Therapeutic Treatment

Intermittent hypoxia (IH) has a dual nature. On the one hand, chronic IH (CIH) is an important pathologic feature of obstructive sleep apnea (OSA) syndrome (OSAS), and many studies have confirmed that OSA-related CIH (OSA-CIH) has atherogenic effects involving complex and interacting mechanisms. Limited preventive and treatment methods are currently available for this condition. On the other hand, non-OSA-related IH has beneficial or detrimental effects on the body, depending on the degree, duration, and cyclic cycle of hypoxia. It includes two main states: intermittent hypoxia in a simulated plateau environment and intermittent hypoxia in a normobaric environment. In this paper, we compare the two types of IH and summarizes the pathologic mechanisms and research advances in the treatment of OSA-CIH-induced atherosclerosis (AS), to provide evidence for the systematic prevention and treatment of OSAS-related AS.

The prevalence of obstructive sleep apnea in patients with type 2 diabetes: a systematic review and meta-analysis

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.

Compared to Individuals with Mild to Moderate Obstructive Sleep Apnea (OSA), Individuals with Severe OSA Had Higher BMI and Respiratory-Disturbance Scores

Objective: Individuals with obstructive sleep apnea (OSA) are at increased risk to suffer from further somatic and sleep-related complaints. To assess OSA, demographic, anthropometric, and subjective/objective sleep parameters are taken into consideration, but often separately. Here, we entered demographic, anthropometric, subjective, and objective sleep- and breathing-related dimensions in one model. Methods: We reviewed the demographic, anthropometric, subjective and objective sleep- and breathing-related data, and polysomnographic records of 251 individuals with diagnosed OSA. OSA was considered as a continuous and as categorical variable (mild, moderate, and severe OSA). A series of correlational computations, X²-tests, F-tests, and a multiple regression model were performed to investigate which demographic, anthropometric, and subjective and objective sleep dimensions were associated with and predicted dimensions of OSA. Results: Higher apnea/hypopnea index (AHI) scores were associated with higher BMI, higher daytime sleepiness, a higher respiratory disturbance index, and higher snoring. Compared to individuals with mild to moderate OSA, individuals with severe OSA had a higher BMI, a higher respiratory disturbance index (RDI) and a higher snoring index, while subjective sleep quality and daytime sleepiness did not differ. Results from the multiple regression analysis showed that an objectively shorter sleep duration, more N2 sleep, and a higher RDI predicted AHI scores. Conclusion: The pattern of results suggests that blending demographic, anthropometric, and subjective/objective sleep- and breathing-related data enabled more effective discrimination of individuals at higher risk for OSA. The results are of practical and clinical importance: demographic, anthropometric, and breathing-related issues derived from self-rating scales provide a quick and reliable identification of individuals at risk of OSA; objective assessments provide further certainty and reliability.

Impact of Obstructive Sleep Apnea on In-Hospital Outcomes of Patients with Non-ST Elevation Myocardial Infarction

Background: Obstructive sleep apnea (OSA) is one of the most common breathing disorders. There are uncertainties about its impact on the in-hospital outcomes of patients who suffer acute coronary syndromes. We studied the largest publicly available all-payer inpatient healthcare database in the United States (National Inpatient Sample) to determine the effects of obstructive sleep apnea on the in-hospital outcomes of patients admitted with non-ST elevation myocardial infarction (NSTEMI). Methods: All adult patients (age ≥ 18) admitted primarily for NSTEMI between September 2010 and September 2015 were identified in the National Inpatient Sample. They were then categorized into those with OSA and those without OSA. The main outcome was in-hospital mortality. Propensity scoring and logistic regression models were created to determine the outcomes. Results: There were 1,984,432 patients with NSTEMI (weighted estimates), 123,551 (6.23%) of who had diagnosed OSA while 1,860,881 (93.77%) did not. In-hospital mortality was significantly lower in the OSA group [2.61% vs. 3.53%, adjusted odd ratio (aOR) 0.73 and confidence interval (CI) (0.66–0.81)]. Patients with OSA were also less likely to require coronary artery bypass surgery: 13.85% and 12.77% (p-value 0.0003). The patients with OSA had higher mean hospital costs compared to the patients who did not have OSA: $17,326 vs. $16,984, adjusted mean ratio (aMR) 1.02; CI (1.01–1.02). Conclusion: In-hospital mortality was lower in NSTEMI patients with diagnosed OSA compared to patients without diagnosed OSA. This appears to contrast with the widely recognized adverse effects of OSA on the cardiovascular system.

Major risk factors for obstructive sleep apnea monitored in the home. A cross-sectional study

BACKGROUND

Obstructive sleep apnea (OSA) is characterized by recurrent pharyngeal wall collapse during sleep caused by anatomical or functional changes associated with obesity or dislocation of maxillofacial structures.

OBJECTIVE

To determine the major risk factors for obstructive sleep apnea monitored in the home.

DESIGN AND SETTING

Cross-sectional study conducted in a private clinic in Fortaleza (CE), Brazil.

METHODS

Between 2015 and 2018, 427 patients were screened for OSA with home-based monitoring, yielding 374 positives. Information was collected on age, sex, body mass index (BMI), hypertension, diabetes (DM), dyslipidemia, coronary artery disease (CAD), arrhythmia, peripheral artery occlusive disease (PAOD), heart failure (HF) and lung disease. The home sleep apnea test result was then compared with the clinical diagnosis. Lastly, parameters identified as significant in the univariate analysis were subjected to multivariate logistic regression.

RESULTS

Male sex predominated, although not significantly. OSA was associated with hypertension, DM, dyslipidemia, age and BMI. The risk of OSA being associated with these parameters was 2.195 (hypertension), 11.14 (DM), 2.044 (dyslipidemia) and 5.71 (BMI). The association was also significant for BMI categories (normal, overweight or obese). No significant association was observed for CAD, arrhythmia, PAOD, HF or lung disease. After multivariate logistic analysis, only age and BMI (and its categories) remained significant.

CONCLUSION

OSA was associated with hypertension, DM, dyslipidemia, age and BMI in univariate analyses, but only with age and BMI (and its categories) in multivariate logistic analysis.

Lipid accumulation product (LAP) was independently associatedwith obstructive sleep apnea in patients with type 2 diabetes mellitus

BACKGROUND

Lipid accumulation product (LAP) is a new index based on a combination of waist circumference (WC) and serum triglycerides (TG) reflecting lipid accumulation. In this cross-sectional study, we aimed to explore whether LAP was independently associated with obstructive sleep apnea (OSA) in Type 2 diabetes mellitus (T2DM) patients.

METHODS

A cross-sectional study of 317 T2DM patients who underwent overnight polysomnography (PSG) tests was conducted. The clinical data between non-OSA group and OSA group were compared. Multivariable linear regression and multivariable logistic regression analyses were performed to determine associations of LAP, with apnea-hypopnea index (AHI) and OSA.

RESULTS

Among 317 patients, 219 (69.1%) were men, and the mean ages (±SD) were 51.4 (±13.5) years for men and 54.6 (±15.1) years for women (p = 0.067). The prevalence rates of OSA were 63.0% for men and 68.4% for women (p = 0.357). LAP (log-transformed) was significantly correlated with AHI (log-transformed), with the Pearson's correlation coefficient of 0.170 (p = 0.002). With adjustment for potential confounding factors, multivariate linear regression analyses showed the association of LAP with AHI was not statistically significant, with the adjusted linear regression coefficients (95% CI) of per SD increase of LAP for AHI (log-transformed) was 0.092 (- 0.011-0.194, p = 0.080). Multivariate logistic regression analyses showed LAP was significantly associated with increased risk of OSA, with the adjusted OR (95%CI) of per SD increase of LAP of 1.639 (1.032-2.604, p = 0.036). However, as constituents of LAP, neither TG nor WC was significantly associated with AHI and OSA.

CONCLUSION

LAP was independently associated with OSA and might be used as a potential OSA risk marker in T2DM patients, beyond the general index of obesity.

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.

Inspiratory Muscle Training in Obstructive Sleep Apnea Associating Diabetic Peripheral Neuropathy: A Randomized Control Study

Objective

This work is aimed at assessing the effects of inspiratory muscle training on lung functions, inspiratory muscle strength, and aerobic capacity in diabetic peripheral neuropathy (DPN) patients with obstructive sleep apnea (OSA).

Methods

A randomized control study was performed on 55 patients diagnosed with DPN and OSA. They were assigned to the training group (IMT, n = 28) and placebo training group (P-IMT, n = 27). Inspiratory muscle strength, lung functions, and aerobic capacity were evaluated before and after 12 weeks postintervention. An electronic inspiratory muscle trainer was conducted, 30 min a session, three times a week for 12 consecutive weeks.

Results

From seventy-four patients, 55 have completed the study program. A significant improvement was observed in inspiratory muscle strength (p < 0.05) in the IMT group while no changes were observed in the P-IMT group (p > 0.05). No changes were observed in the lung function in the two groups (p > 0.05). Also, VO₂max and VCO₂max changed significantly after training in the IMT group (p < 0.05) while no changes were observed in the P-IMT group (p > 0.05). Other cardiopulmonary exercise tests did not show any significant change in both groups (p > 0.05).

Conclusions

Based on the outcomes of the study, it was found that inspiratory muscle training improves inspiratory muscle strength and aerobic capacity without a notable effect on lung functions for diabetic patients suffering from DPN and OSA.

Associations between ankle-brachial index, diabetes, and sleep apnea in the Hispanic community health study/study of Latinos (HCHS/SOL) database

BACKGROUND

Sleep apnea and diabetes mellitus (DM) negatively impact cardiovascular health. One important indicator of cardiovascular health is the Ankle-Brachial Index (ABI). Either low ABI or high ABI are signs of peripheral vascular impairment. Impaired vascular health and DM, together, might provoke sleep apnea; however, information regarding these relationships is limited. Therefore, this study aimed to investigate the association between ABI, DM status, and severity of obstructive sleep apnea in people of Hispanic/Latino descent who are diverse in culture, environmental exposures, nativity, socioeconomic status, and disease burden.

METHODS

A cross sectional analysis from a multi-center epidemiologic study, Hispanic Community Health Study/Study of Latinos, was utilized and included 3779 participants (mean age 55.32 ± 7.67, females 57.9%). The sample was divided into 4 groups based on the American Diabetes Association diagnostic guidelines (no DM or DM), and the ABI status (normal and abnormal). Multiple linear regression analysis was used to determine the association of the four groups and other independent variables with severity of sleep apnea measured by apnea-hypopnea index. Kruskal-Wallis H test was used for comparisons between groups for the apnea-hypopnea index. The significant level was set at 0.01.

RESULTS

There were significant differences between groups in the mean of apnea-hypopnea index (P < 0.001; no DM + normal ABI = 5.42 ± 9.66, no DM + abnormal ABI = 7.11 ± 11.63, DM + normal ABI = 10.99 ± 15.16, DM + abnormal ABI = 12.81 ± 17.80). Linear regression showed that DM and abnormal ABI were significantly associated with severe sleep apnea (β = 3.25, P = 0.001) after controlling for age, sex, BMI, income, education, alcohol use, cigarette use, hypertension or related medication, stroke and statin use.

CONCLUSION

These findings suggest that people with DM and abnormal ABI were more likely to have high apnea-hypopnea index compared to the other groups. We observed gradual increasing in the severity of sleep apnea from low abnormality groups to high abnormality groups for Hispanic/Latino. Further work should elucidate the association of DM, abnormal ABI and sleep apnea with longer term outcomes, and replicate this work in different populations.

Prevalence of obstructive sleep apnea in patients with type 2 diabetes: A systematic review and meta-analysis

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.

"Mind" in Betel-quid Use and Related Disorders

Oral squamous cell carcinoma is characterized by a unique predisposing state called oral potentially malignant disorders (OPMDs). Wide variety of carcinogenic insult in the form of detrimental habits can contribute to the causation of variety of OPMDs.1,2.

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.