Clinical research study
Obstructive Sleep Apnea as a Risk Factor for Type 2 Diabetes

https://doi.org/10.1016/j.amjmed.2009.04.026Get rights and content

Abstract

Purpose

Cross-sectional studies have documented the co-occurrence of obstructive sleep apnea (hereafter, sleep apnea) with glucose intolerance, insulin resistance, and type 2 diabetes mellitus (hereafter, diabetes). It has not been determined, however, whether sleep apnea is independently associated with the subsequent development of diabetes, accounting for established risk factors.

Methods

This observational cohort study examined 1233 consecutive patients in the Veteran Affairs Connecticut Healthcare System referred for evaluation of sleep-disordered breathing; 544 study participants were free of preexisting diabetes and completed a full, attended, diagnostic polysomnogram. The study population was divided into quartiles based on severity of sleep apnea as measured by the apnea-hypopnea index. The main outcome was incident diabetes defined as fasting glucose level >126 mg/dL and a corresponding physician diagnosis. Compliance with positive airway pressure therapy, and its impact on the main outcome, also was examined.

Results

In unadjusted analysis, increasing severity of sleep apnea was associated with an increased risk of diabetes (P for linear trend <.001). After adjusting for age, sex, race, baseline fasting blood glucose, body mass index, and weight change, an independent association was found between sleep apnea and incident diabetes (hazard ratio per quartile 1.43; confidence interval 1.10-1.86). Among patients with more severe sleep apnea (upper 2 quartiles of severity), 60% had evidence of regular positive airway pressure use, and this treatment was associated with an attenuation of the risk of diabetes (log-rank test P = .04).

Conclusion

Sleep apnea increases the risk of developing diabetes, independent of other risk factors. Among patients with more severe sleep apnea, regular positive airway pressure use may attenuate this risk.

Section snippets

Study Design and Patient Population

This observational cohort study examined nondiabetic patients referred to the Veterans Affairs (VA) Connecticut Sleep Center from January 2000 to December 2005. Eligible participants include patients referred for initial evaluation of sleep-disordered breathing who had at least 2 hours of sleep monitoring and a fasting glucose level <126 mg/dL. Participants were excluded if the entire polysomnographic study was performed with airway pressurization for therapeutic purposes. The study was

Results

Between January 2000 and July 2005, 1233 consecutive patients were referred to the VA Connecticut Sleep Center; 407 (33%) patients were ineligible because they were referred for conditions other than sleep-disordered breathing, or they had no initial diagnostic study. An additional 233 (19%) patients were ineligible because they had previously diagnosed diabetes, and 49 (4%) patients were excluded because they had incomplete polysomnographic data. Data for the remaining 544 patients were

Discussion

We conducted an observational cohort study examining the impact of sleep apnea on the development of type 2 diabetes mellitus. Our results show that sleep apnea is a risk factor for the development of diabetes; increasing severity of sleep apnea is associated with an increasing risk for the development of diabetes; and among patients with moderate to severe sleep apnea (upper 2 quartiles of severity), regular use of positive airway pressure is associated with an attenuated risk for the

References (45)

  • H.K. Yaggi et al.

    Sleep duration as a risk factor for the development of type 2 diabetes

    Diabetes Care

    (2006)
  • S.R. Coughlin et al.

    Obstructive sleep apnoea is independently associated with an increased prevalence of metabolic syndrome

    Eur Heart J

    (2004)
  • M.S. Ip et al.

    Obstructive sleep apnea is independently associated with insulin resistance

    Am J Respir Crit Care Med

    (2002)
  • N. Meslier et al.

    Impaired glucose-insulin metabolism in males with obstructive sleep apnoea syndrome

    Eur Respir J

    (2003)
  • N.M. Punjabi et al.

    Sleep-disordered breathing and insulin resistance in middle-aged and overweight men

    Am J Respir Crit Care Med

    (2002)
  • H.E. Resnick et al.

    Diabetes and sleep disturbances: findings from the Sleep Heart Health Study

    Diabetes Care

    (2003)
  • M. Tiihonen et al.

    The severity of obstructive sleep apnoea is associated with insulin resistance

    J Sleep Res

    (1993)
  • M.W. Johns

    A new method for measuring daytime sleepiness: the Epworth Sleepiness Scale

    Sleep

    (1991)
  • Sleep-related breathing disorders in adults: recommendations for syndrome definition and measurement techniques in clinical researchThe Report of an American Academy of Sleep Medicine Task Force

    Sleep

    (1999)
  • A.L. Meoli et al.

    Hypopnea in sleep-disordered breathing in adults

    Sleep

    (2001)
  • A. Rechtschaffen et al.

    A Manual of Standardized Terminology, Techniques and scoring System for Sleep Stages of Human Subjects

    (1968)
  • Diagnosis and classification of diabetes mellitus

    Diabetes Care

    (2008)
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    Funding: VA Health Services Research and Development/Clinical Science, Career Development Awards to Dr. Yaggi. National Research Service Award Institutional Research Training Grant (5T32HL07778) to Dr. Botros.

    Conflict of Interest: The authors have no relevant conflicts of interest to disclose.

    Authorship: All authors had access to the data and a role in writing the manuscript.

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