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Obstructive Sleep Apnea and Type 1 Diabetes

By Leesha Lentz

Obstructive sleep apnea (OSA) mostly has been associated with type 2 diabetes and obesity, but a new study from France suggests that OSA also may be linked with type 1 diabetes, independent of BMI. The study’s findings were presented by Laurent Meyer, MD, an endocrinologist at Hopitaux Universitaires de Strasbourg, France, at the American Diabetes Association 2015 Scientific Sessions in June.

What is OSA?
According to the National Sleep Foundation, OSA is “a sleep disorder in which breathing is briefly and repeatedly interrupted during sleep,” affecting nearly 18 million people in the United States.1 OSA occurs when throat muscles fail to keep the airway open, leading to pauses in breathing that can last at least 10 seconds.1 The most common cause of OSA is obesity, which is associated with excessive soft tissue in the mouth and throat.2 This condition is known to cause daytime sleepiness from disrupted sleep and low blood oxygen levels, which may lead to “hypertension, heart disease, and mood and memory problems.”1

Traditionally, most research has examined the association between OSA and type 2 diabetes, and how OSA may affect this patient population. For example, in a February 2014 study published in Diabetes Care, Grimalidi and colleagues discovered that severity of OSA in people with type 2 diabetes may cause poorer glycemic control.3 The study emphasized the problems that may persist with OSA in this patient population, stressing the importance of treatment. This same emphasis on diagnosis and treatment of OSA in people with type 1 diabetes hasn’t been closely examined—until now. 

Study Findings
In the French study on OSA and type 1 diabetes, considered the largest study to date, researchers used both continuous glucose monitoring and sleep studies to assess 90 patients. Of those patients, 39 were identified as having OSA, with greater than 10 reported apneas or sleep disruptions per hour, and 18 of the 39 had severe OSA, with more than 30 apneas per hour. OSA was most common in the patients who had the disease longer and had higher rates of diabetes-related complications in the eyes and kidneys.4

What’s most surprising is that of these 39 patients with OSA, most were considered normal weight, which suggests that OSA may be due to factors other than obesity. Meyer said BMI was near normal, and he suspected that OSA might be linked to cardiac autonomic neuropathy, a condition associated with nerve damage.4

In an August 2014 study published in Frontiers in Endocrinology, Janovsky and colleagues from the Universidade Federal de São Paulo in Brazil examined cardiovascular autonomic neuropathy (CAN) and its possible association with OSA in type 1 diabetes patients.5 The study stated that OSA has been frequently explained by obesity associated with type 2 diabetes, but there’s little known about why this occurs in nonobese individuals, which is what the researchers wanted to determine. The researchers analyzed the sleep quality of 20 nonobese adults with type 1 diabetes, some with and without CAN, and found that those with CAN had poorer sleep efficiency than those without the condition.

The study explained how CAN may affect this patient population: “During sleep, respiratory function is partially controlled by the autonomic nervous system. When this system is impaired, as in diabetic autonomic neuropathy, the airway may be less functional and breathing control more variable, resulting in OSA.”5 Therefore, CAN may explain the “occurrence of OSA in diabetic patients regardless of age and weight.”5

Screening Patients
While it’s important to conduct a long-term longitudinal study in the future to expand on and further assess these findings, Meyer believes his study delivers a current message to health care practitioners, including nutrition professionals, to screen their type 1 diabetes patients for OSA.4 As mentioned, OSA presents with serious symptoms beyond daytime sleepiness, so it’s important to be aware of this condition.

In an August 2015 presentation at the American Association of Diabetes Educators annual meeting, Cindi Goldman-Patin, MSN, RN, CDE, BA, a certified diabetes nurse educator, discussed the importance of screening for and recognizing sleep disorders and promoting awareness on how vital sleep is for both mental and physical health in diabetes patients.

Goldman-Patin reviewed screening tools dietitians can use, such as the STOP-Bang questionnaire and the Epworth Sleepiness Scale to assess patients for untreated sleep disorders. The STOP-Bang questionnaire, available at https://www.sleepmedicine.com/files/files/StopBang_Questionnaire.pdf, asks patients to answer questions about their sleep, such as whether they snore loudly or have observed interrupted breathing during the night. The Epworth Sleepiness Scale, available at https://www.slhn.org/docs/pdf/neuro-epworthsleepscale.pdf, asks patients to assess their sleepiness in daytime situations, such as watching TV and when sitting and talking to someone, to determine whether their level of sleepiness may require medical attention.

Once patients are screened and confirmed to have OSA, there are several treatment options available, such as a continuous positive airway pressure device that fits over the mouth or nose to provide a constant airstream during the night.6 In addition, patients can undergo lifestyle modifications, such as smoking cessation and avoidance of alcohol to help lower their risk of OSA.6

— Leesha Lentz is a freelance writer based in Pottstown, Pennsylvania.

References
1. Sleep apnea. National Sleep Foundation website. https://sleepfoundation.org/sleep-disorders-problems/sleep-apnea. Accessed October 22, 2015.

2. Causes of obstructive sleep apnea. WebMD website. http://www.webmd.com/sleep-disorders/sleep-apnea/obstructive-sleep-apnea-causes. Accessed October 22, 2015.

3. Grimaldi D, Beccuti G, Touma C, Van Cauter E, Mokhlesi B. Association of obstructive sleep apnea in rapid eye movement sleep with reduced glycemic control in type 2 diabetes: therapeutic implications. Diabetes Care. 2014;37(2):355-363.

4. Tucker ME. Obstructive sleep apnea common in type 1 diabetes. Medscape website.
http://www.medscape.com/viewarticle/846052. Published June 8, 2015. Accessed October 22, 2015.

5. Janovsky CC, Rolim LC, de Sá JR, et al. Cardiovascular autonomic neuropathy contributes to sleep apnea in young and lean type 1 diabetes mellitus patients. Front Endocrinol (Lausanne). 2014;5:119.

6. How is sleep apnea treated? National Sleep Foundation website. https://sleepfoundation.org/sleep-disorders-problems/sleep-apnea-treatment. Accessed October 23, 2015.