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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 9  |  Issue : 1  |  Page : 61-65

To assess the risk of obstructive sleep apnea in type 2 diabetes mellitus patients in a tertiary care center in Eastern India


1 Department of Physiology, Veer Surendra Sai Institute of Medical Sciences and Research, Burla, Odisha, India
2 Department of Medicine, Veer Surendra Sai Institute of Medical Sciences and Research, Burla, Odisha, India

Date of Submission21-Jul-2021
Date of Acceptance11-Jan-2022
Date of Web Publication23-Mar-2022

Correspondence Address:
Dr. Satarupa Dash
Department of Physiology, Veer Surendra Sai Institute of Medical Sciences and Research, Burla 768017, Odisha.
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mgmj.mgmj_54_21

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  Abstract 

Background: Obstructive sleep apnea (OSA) and type 2 diabetes mellitus have a major health impact because of their high prevalence worldwide. Obesity is a common risk factor for both OSA and type 2 diabetes mellitus in middle-aged persons. Aim: This study was conducted to assess the risk of OSA in type 2 diabetes mellitus patients. Materials and Methods: A cross-sectional study was performed at the tertiary care center of Veer Surendra Sai Institute of Medical Sciences and Research, Burla, Odisha, India. Type 2 diabetic patients were evaluated to assess the risk of OSA using the STOP-BANG sleep apnea questionnaire (consisting of eight questions). Results: Of the 150 type 2 diabetic patients, 53.8% had low risk, 28.6% had intermediate risk, and 17.6% had a severe risk for OSA based on questionnaires. Patients with comorbid conditions like hypertension (odds ratio 1.5) and obesity (odds ratio 1.06) have a high risk of OSA. There was a significant relationship between the type of medication and the risk of developing OSA (P < 0.05) in diabetic patients. The patients taking both insulin and oral drugs have a high-risk OSA as compared to those taking only insulin or only oral drugs. Conclusion: The prevalence of OSA is much higher in diabetics than in the general population, the risk is increasing with comorbid conditions like obesity and hypertension, patients who are receiving both oral hypoglycemic drugs and insulin. The screening of OSA among diabetic patients is necessary to identify those at high risk and manage this problem, which may remain undiagnosed in many patients.

Keywords: Obstructive sleep apnea, oral hypoglycemic agent, STOP-BANG sleep apnea questionnaire, type 2 diabetes


How to cite this article:
Dash S, Thakur A. To assess the risk of obstructive sleep apnea in type 2 diabetes mellitus patients in a tertiary care center in Eastern India. MGM J Med Sci 2022;9:61-5

How to cite this URL:
Dash S, Thakur A. To assess the risk of obstructive sleep apnea in type 2 diabetes mellitus patients in a tertiary care center in Eastern India. MGM J Med Sci [serial online] 2022 [cited 2022 May 17];9:61-5. Available from: http://www.mgmjms.com/text.asp?2022/9/1/61/340587




  Introduction Top


Obstructive sleep apnea (OSA) is defined as the complete or near-complete cessation of airflow for a minimum of 10 s during sleep. OSA is the third most common serious respiratory disorder (after asthma, COPD). OSA affects 3%–7% of adult males and 2%–5% of adult females worldwide.[1] OSA is common in both developing and developed countries and its prevalence has increased in the last two decades.[2]

The OSA has several risk factors. The most important is obesity reflected by body mass index (BMI), neck circumference, and waist to hip ratio.[3] The prevalence of OSA increases with aging. The prevalence in males and females (30–60 years) is 24% and 9%, respectively. Prevalence in India is 7.5% in males.[2] Other risk factors are smoking, alcoholism, and craniofacial anomalies.[4],[5]

Cross-sectional studies indicate an association between OSA and certain medical conditions like hypertension, heart failure, coronary heart disease, polycystic ovarian disease (PCOD), and hypothyroidism.[6],[7] OSA could be a novel risk factor of type 2 diabetes or vice versa.[8] The glucose control in diabetics with OSA is poor and the severity of OSA is directly related to hemoglobin A1c values.[9] Studies reported a significant association between insulin resistance and sleep apnea in the general population independently of any confounder especially obesity.[10],[11] The study aimed to assess the risk of OSA in type 2 diabetes mellitus patients in Eastern India.


  Materials and methods Top


Study design

This was a cross-sectional observational study. The study was conducted in the outpatient department (OPD) of the Department of Medicine, in Veer Surendra Sai Institute of Medical Sciences and Research, Burla, India from March to May 2016. The patient’s consent was taken before asking them for filling the questionnaires and providing history.

Inclusion criteria

Patients attending OPD and diagnosed with type 2 diabetes mellitus according to World Health Organization (WHO) criteria were included in the study.

Exclusion criteria

The patients with type 1 diabetes were excluded from the study.

Sample size estimation



Data were collected using the STOP-BANG sleep apnea screening questionnaire.[12] H/O comorbidities conditions such as hypertension, coronary heart disease, heart failures, stroke, or others were collected. H/O of medication – optimal oral hypoglycemic agents (OHA)/ insulin/both were also collected.

Data of HbA1c and last fasting blood sugar (FBS) were collected.

Statistical analysis

Collected data were analyzed using IBM Statistical Package for the Social Sciences (SPSS) Statistics version 20.0. Continuous variables were reported as mean with standard deviation. Categorical variables are reported as frequencies and percentages with CIs. The risk of association between categorical variables and OSA was evaluated using Pearson’s chi-square test. The risk of association between continuous variables and OSA was evaluated using Student’s t test. The risk factors with significant association with OSA were evaluated for independent involvement by multivariate analysis using logistic regression. A value of P < 0.05 was considered statistically significant.


  Results Top


[Table 1] contains all the eight questions of STOP-BANG Questionnaires and scores.
Table 1: Questionnaire that includes eight dichotomous questions

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[Table 2] shows that of a total of 150 types 2 diabetic 108 are male and 42 female. All are with an average age of 54.3 ± 6.5 years. The average height of a male is 151 ± 4.6 cm and female is 146 ± 3.7 cm. The weight of the male is 80.5 ± 1.2 kg and the female is 76.8 ± 3.7 kg. BMI of the male is on average 35.7 ± 3.8 kg/m2 and female is 35.6 ± 2.3 kg/m2.
Table 2: Physical characteristics of participants

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[Table 3] depicts the STOP-BANG Questionnaire Score in type 2 diabetic patients from March to May 2016 at Veer Surendra Sai Institute of Medical Sciences and Research, Burla, India (n = 150). The total score ranges from 0 to 7 with a mean of 2.48 ± 1.68. [Figure 1] depicts the risk of developing OSA in diabetic patients based on the STOP-BANG questionnaire score. Approximately 53.8% of diabetics have mild OSA, 28.6% have moderate OSA, and 17.6% have severe OSA. The risk of developing OSA in a diabetic patient with comorbid conditions 68% have mild, 12% have moderate, and 20% have severe OSA as described in [Figure 2].
Table 3: STOP-BANG questionnaire score in type 2 diabetic patients from March to May 2021 at VIMSAR BURLA (n = 150)

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Figure 1: Risk of developing OSA in diabetic patients in percentage

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Figure 2: Risk of developing OSA in diabetic patients with comorbid condition in percentage

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[Figure 3] shows the number of diabetic patients with associated disorders. Approximately 70% suffer from hypertension, 30% from coronary heart disease, 2% have heart failure, and 10% have a stroke. [Table 4] informs about the medication used in diabetic patients. Approximately 48.7% are taking OHA and 29.1% are on insulin and the rest 22.2% diabetes was controlled by both OHA and insulin.
Figure 3: Number of diabetic patient with associated disorder in percentage

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Table 4: Type of treatment and its association with severity of OSA in Type 2 diabetes patients

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It also informs about the type of treatment and its association with the severity of OSA in type 2 diabetes patients. There was a significant relationship between the type of medication and the risk of developing OSA (P < 0.05). Among the patients taking only OHA, 75% have mild, 15% have moderate, and 10% have a severe risk of OSA. Among the patients taking only insulin, 68% have mild, 22% have moderate, and 10% have a severe risk of OSA. Of those taking both OHA and insulin 60% have mild, 20% have moderate, and 20% have a severe risk of OSA.

[Table 5] shows binary logistic regression was performed to assess the impact of the various variables on developing OSA in diabetic patients. The model contains six variables (age, male, BMI, hypertension, CHD, OHA + insulin therapy). All the variables were statistically significant P < 0.05BMI, hypertension, and OHA + insulin therapy have unique significant contributions. The strongest predictor for OSA was hypertension with an odds ratio of 1.5 (95% CI: 1.6–4.2).
Table 5: Predictors of obstructive sleep apnea risk

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  Discussion Top


A total of 150 type 2 diabetic patients participated in our study. The study aimed to assess the risk of OSA in type 2 diabetic patients using the STOP-BANG questionnaire. The association between OSA and type II DM is recognized.[13],[14] Cross-sectional studies suggest that up to 30% of patients with OSA have type II DM and up to 86% of obese patients with type II DM have OSA.[15],[16],[17]

BMI of the male is on average 35.77 kg/m2 and female is 35.68 kg/m2. Therefore, all the patients were obese. The prevalence of OSA was very high in the obese population. BMI was the significant predictor of severe OSA (OR: 1.06, 95% CI 1.02–1.33, P < 0.05). Independent of other variables and that one unit increase in BMI was associated with a 10% increase in the predicted odds of severe OSA.[15]The prevalence of OSA is strongly associated with overweight and obesity in cross-sectional and clinical studies.[18],[19],[20] Obesity is known to be a cause of OSA and is likely to be a consequence thereof. The score of the STOP-BANG questionnaire was calculated for all the patients, the mean was 2.48 and the standard deviation was 1.6. According to the scores of the patients, 53.8% of patients had mild risk, 28.6% had moderate risk, and 17.6% had a severe risk for OSA. As the STOP-BANG score increases the probability of OSA increases. Using the STOP-BANG questionnaire, sleep clinicians can quickly and reliably identify those at risk of severe OSA and prioritize patients for polysomnography or out-of-center sleep testing.[12]

In obese individuals, adipose tissue releases increased amounts of glycerol, fatty acids, hormones, a pro-inflammatory cytokine that are involved in the development of insulin resistance and type 2 diabetes. Excess weight creates fat deposits in a person’s neck called pharyngeal fat that can block a person’s upper airway during sleep when the airway is already relaxed. This is why snoring is one of the most common sleep apnea symptoms––air is being squeezed through a restricted airway, causing a loud noise. Additionally, increased abdominal girth from excess fat can compress a person’s chest wall, decreasing lung volume. This reduced lung capacity diminishes airflow, making the upper airway more likely to collapse during sleep.[21]

Of 150 diabetic patients, 70% suffer from hypertension, 30% from coronary heart disease, 2% have heart failure, and 10% have a stroke. The study showed a strong association between hypertension and OSA in diabetic patients. Several cross-section studies describe a strong association between hypertension and OSA.[19],[22] Studies have also reported an increased prevalence of hypertension with increased severity of OSA.[23] OSA has also been shown to increase the risk of hypertension. A previous study in Spain by Marin et al.[24] involving 1889 participants over 12 years reported an increased rate of new hypertension among OSA patients compared with controls, this relationship remained significant after controlling for age and obesity. Another study has shown that there is a high risk of OSA among type 2 diabetic patients and that OSA risk is significantly associated with poor blood pressure (BP) control and obesity.[25]

The presence of a relationship between the type of treatment of diabetes and the risk severity of developing OSA was tested and it was found to be significant with P < 0.05. The percentage of patients with severe risk was higher in those taking both insulin and oral drugs than those taking insulin alone or oral drugs alone. The results of this study can be compared to the study by Kalakattawia et al.,[26] which also uses the STOP-BANG questionnaires.


  Conclusion Top


This study has shown that there is a high risk of OSA among type 2 diabetic patients and the risk is significantly more in patients with obesity, hypertension, and treatment. STOP-BANG questionnaire is a reliable and effective tool for screening OSA. It can facilitate the early diagnosis and treatment of previously unrecognized OSA.

The result suggests that diabetic patients should be evaluated for OSA risk as a part of their routine evaluation using STOP-BANG score or another similar validated instrument at least once a year. Therefore, the screening of OSA among diabetic patients is necessary to identify those at severe risk and manage this problem, which may remain undiagnosed in many patients.

Limitation of the study

STOP-BANG questionnaire is a screening tool. To confirm the diagnosis of OSA, polysomnography should be done in risky diabetic patients.

Ethical policy and institutional review board statement

The Institutional Ethics Committee has reviewed and approved the research study entitled: “To assess the risk of obstructive sleep apnea in type 2 diabetes mellitus patients in a tertiary care center in Eastern India” in its meeting held on September 1, 2015 communicated vide letter no. IEC/IRB: 22/15 dated September 26, 2015.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Udwadia ZF, Doshi AV, Lonkar SG, Singh CI Prevalence of sleep-disordered breathing and sleep apnea in middle-aged urban Indian men. Am J Respir Crit Care Med 2004;169:168-73.  Back to cited text no. 1
    
2.
Garvey JF, Pengo MF, Drakatos P, Kent BD Epidemiological aspects of obstructive sleep apnea. J Thorac Dis 2015;7:920-9.  Back to cited text no. 2
    
3.
Punjabi NM The epidemiology of adult obstructive sleep apnea. Proc Am Thorac Soc 2008;5:136-43.  Back to cited text no. 3
    
4.
Tishler PV, Larkin EK, Schluchter MD, Redline S Incidence of sleep-disordered breathing in an urban adult population: The relative importance of risk factors in the development of sleep-disordered breathing. JAMA 2003;289:2230-7.  Back to cited text no. 4
    
5.
Al Lawati NM, Patel SR, Ayas NT Epidemiology, risk factors, and consequences of obstructive sleep apnea and short sleep duration. Prog Cardiovasc Dis 2009;51:285-93.  Back to cited text no. 5
    
6.
Young T, Skatrud J, Peppard PE Risk factors for obstructive sleep apnea in adults. JAMA 2004;291:2013-6.  Back to cited text no. 6
    
7.
Franklin KA, Lindberg E Obstructive sleep apnea is a common disorder in the population-a review on the epidemiology of sleep apnea. J Thorac Dis 2015;7:1311-22.  Back to cited text no. 7
    
8.
Pamidi S, Tasali E Obstructive sleep apnea and type 2 diabetes: Is there a link? Front Neurol 2012;3:126.  Back to cited text no. 8
    
9.
Aronsohn RS, Whitmore H, Van Cauter E, Tasali E Impact of untreated obstructive sleep apnea on glucose control in type 2 diabetes. Am J Respir Crit Care Med 2010;181:507-13.  Back to cited text no. 9
    
10.
Punjabi NM, Shahar E, Redline S, Gottlieb DJ, Givelber R, Resnick HE; Sleep Heart Health Study Investigators. Sleep-disordered breathing, glucose intolerance, and insulin resistance: The sleep heart health study. Am J Epidemiol 2004;160:521-30.  Back to cited text no. 10
    
11.
Punjabi NM, Beamer BA Alterations in glucose disposal in sleep-disordered breathing. Am J Respir Crit Care Med 2009;179:235-40.  Back to cited text no. 11
    
12.
Chung F, Abdullah HR, Liao P STOP-BANG questionnaire: A practical approach to screen for obstructive sleep apnea. Chest 2016;149:631-8.  Back to cited text no. 12
    
13.
Tasali E, Leproult R, Spiegel K Reduced sleep duration or quality: Relationships with insulin resistance and type 2 diabetes. Prog Cardiovasc Dis 2009;51:381-91.  Back to cited text no. 13
    
14.
Shaw JE, Punjabi NM, Wilding JP, Alberti KG, Zimmet PZ; International Diabetes Federation Taskforce on Epidemiology and Prevention. Sleep-disordered breathing and type 2 diabetes: A report from the international diabetes federation taskforce on epidemiology and prevention. Diabetes Res Clin Pract 2008;81:2-12.  Back to cited text no. 14
    
15.
Foster GD, Sanders MH, Millman R, Zammit G, Borradaile KE, Newman AB, et al; Sleep AHEAD Research Group. Obstructive sleep apnea among obese patients with type 2 diabetes. Diabetes Care 2009;32:1017-9.  Back to cited text no. 15
    
16.
Einhorn D, Stewart DA, Erman MK, Gordon N, Philis-Tsimikas A, Casal E Prevalence of sleep apnea in a population of adults with type 2 diabetes mellitus. Endocr Pract 2007;13:355-62.  Back to cited text no. 16
    
17.
Laaban JP, Daenen S, Léger D, Pascal S, Bayon V, Slama G, et al. Prevalence and predictive factors of sleep apnoea syndrome in type 2 diabetic patients. Diabetes Metab 2009;35:372-7.  Back to cited text no. 17
    
18.
Young T, Palta M, Dempsey J, Skatrud J, Weber S, Badr S The occurrence of sleep-disordered breathing among middle-aged adults. N Engl J Med 1993;328:1230-5.  Back to cited text no. 18
    
19.
Nieto FJ, Young TB, Lind BK, Shahar E, Samet JM, Redline S, et al. Association of sleep-disordered breathing, sleep apnea, and hypertension in a large community-based study: Sleep heart health study. JAMA 2000;283:1829-36.  Back to cited text no. 19
    
20.
Shah N, Roux F The relationship of obesity and obstructive sleep apnea. Clin Chest Med 2009;30:455-65, vii.  Back to cited text no. 20
    
21.
Schwartz AR, Patil SP, Laffan AM, Polotsky V, Schneider H, Smith PL Obesity and obstructive sleep apnea: Pathogenic mechanisms and therapeutic approaches. Proc Am Thorac Soc 2008;5:185-92.  Back to cited text no. 21
    
22.
Hla KM, Young TB, Bidwell T, Palta M, Skatrud JB, Dempsey J Sleep apnea and hypertension: A population-based study. Ann Intern Med 1994;120:382-8.  Back to cited text no. 22
    
23.
Lavie P, Herer P, Hoffstein V Obstructive sleep apnoea syndrome as a risk factor for hypertension: Population study. BMJ 2000;320:479-82.  Back to cited text no. 23
    
24.
Marin JM, Agusti A, Villar I, Forner M, Nieto D, Carrizo SJ, et al. Association between treated and untreated obstructive sleep apnea and risk of hypertension. JAMA 2012;307:2169-76.  Back to cited text no. 24
    
25.
Umoh VA, Akpan EE, Ekrikpo UE, Idung AU, Ekpe EE The risk of obstructive sleep apnea among patients with type 2 diabetes mellitus. Niger Med J 2020;61:32-6.  Back to cited text no. 25
    
26.
Kalakattawi RMN, Kalakattawi AMN, Alsuqati FA, Alzhrani SA, Alhamyani AH, Alhamyani AH, et al. Risk of obstructive sleep apnea assessment among patients with type 2 diabetes in Taif, Saudi Arabia. J Clin Med Res 2017;9:1002-6.  Back to cited text no. 26
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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