CHEST
Volume 146, Issue 4, October 2014, Pages 982-990
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Original Research: Sleep Disorders
Diabetes Mellitus Prevalence and Control in Sleep-Disordered Breathing: The European Sleep Apnea Cohort (ESADA) Study

https://doi.org/10.1378/chest.13-2403Get rights and content

BACKGROUND

OSA is associated with an increased risk of cardiovascular morbidity. A driver of this is metabolic dysfunction and in particular type 2 diabetes mellitus (T2DM). Prior studies identifying a link between OSA and T2DM have excluded subjects with undiagnosed T2DM, and there is a lack of population-level data on the interaction between OSA and glycemic control among patients with diabetes. We assessed the relationship between OSA severity and T2DM prevalence and control in a large multinational population.

METHODS

We performed a cross-sectional analysis of 6,616 participants in the European Sleep Apnea Cohort (ESADA) study, using multivariate regression analysis to assess T2DM prevalence according to OSA severity, as measured by the oxyhemoglobin desaturation index. Patients with diabetes were identified by previous history and medication prescription, and by screening for undiagnosed diabetes with glycosylated hemoglobin (HbA1c) measurement. The relationship of OSA severity with glycemic control was assessed in diabetic subjects.

RESULTS

T2DM prevalence increased with OSA severity, from 6.6% in subjects without OSA to 28.9% in those with severe OSA. Despite adjustment for obesity and other confounding factors, in comparison with subjects free of OSA, patients with mild, moderate, or severe disease had an OR (95% CI) of 1.33 (1.04-1.72), 1.73 (1.33-2.25), and 1.87 (1.45-2.42) (P < .001), respectively, for prevalent T2DM. Diabetic subjects with more severe OSA had worse glycemic control, with adjusted mean HbA1c levels 0.72% higher in patients with severe OSA than in those without sleep-disordered breathing (analysis of covariance, P < .001).

CONCLUSIONS

Increasing OSA severity is associated with increased likelihood of concomitant T2DM and worse diabetic control in patients with T2DM.

Section snippets

Materials and Methods

The ESADA study is a pan-European, multicenter, prospective study involving 24 sleep clinics across 15 European countries and Israel. The underlying design and investigative techniques used in ESADA have been discussed in detail previously.17 Briefly, ESADA was established to investigate the role of OSA in driving cardiovascular and metabolic morbidity and mortality, with the goal of prospectively evaluating a large cohort of subjects with suspected sleep-disordered breathing. ESADA uses a

Population Characteristics

From March 2007 to July 2012, 12,636 subjects were enrolled in ESADA. A total of 6,616 of these had both a sleep study performed and a valid HbA1c level measured during the study period. Figure 1 summarizes the recruitment and evaluation process of these patients. Descriptive characteristics of the study population, stratified by OSA severity, are presented in Table 1. A total of 2,833 patients (42.8%) underwent PSG, the remainder PG. More severe OSA was associated with greater male

Discussion

In the largest study in this field to date, to our knowledge, we observed a significant relationship between OSA severity and the likelihood of a coexistent diagnosis of T2DM in a multinational population of subjects attending sleep services across Europe, alongside evidence of worse glycemic control in diabetic subjects with more severe sleep-disordered breathing. These relationships persisted despite adjustment for important confounding factors such as age, obesity, smoking history,

Acknowledgments

Author contributions: B. D. K. assumes responsibility for the content of the manuscript. B. D. K., L. G., S. R., J.-L. P., M. R. B., R. T., T. S., J. V., P. L., J. H., and W. T. M. contributed to study design, data collection, and manuscript preparation, and provided final approval for submission.

Financial/nonfinancial disclosures: The authors have reported to CHEST the following conflicts of interest: Dr Saaresranta received grants from Turku University Hospital (Governmental EVO Grant), the

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    Part of this article has been published in abstract form (Kent BD, Grote L, Bonsignore MR, et al. Am J Respir Crit Care Med. 2012;185:A5379).

    FUNDING/SUPPORT: The maintenance of the European Sleep Apnea (ESADA) study database is supported by unrestricted grants from ResMed and Philips Respironics (Koninklijke Philips N.V.). Drs Kent and Ryan are supported by grants from the Health Research Board, Ireland [HPF/2009/033], and Dr Grote is supported by grants from the Swedish Heart and Lung Foundation.

    Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.

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