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  1. 1. The IDF Consensus Statement on SLEEP APNOEA ANd TYPE 2 dIABETES
  2. 2. No part of this publication may be reproduced or transmitted in any form or by any means without the prior written permission of the International Diabetes Federation (IDF). Requests to reproduce or translate IDF publications should be addressed to: IDF Communications Avenue Emile De Mot 19 B-1000 Brussels, Belgium By fax at +322 – 5385114 or By e-mail at communications@idf.org © International Diabetes Federation, 2008 ISBN 2-930229-61-6 2
  3. 3. The IDF Consensus Statement on Sleep Apnoea and Type 2 Diabetes was developed during a working group meeting on the initiative of Professors Paul Zimmet and Sir George Alberti. The meeting was held on behalf of the IDF Task Force on Epidemiology and Prevention. The working group members included: Paul Zimmet, co-chair, Melbourne, Australia Sir George Alberti, co-chair, London, UK Stephanie Amiel, London, UK Matthew Cohen, Melbourne, Australia Joachim Ficker, Nürnberg, Germany Greg Fulcher, Sydney, Australia Lee R Goldberg, Philadelphia, USA Leif Groop, Lund, Sweden David Hillman, Perth, Australia Mary Ip, Hong Kong, China Markku Laakso, Kuopio, Finland Pierre Lefèbvre, Liège, Belgium Yuji Matsuzawa, Osaka, Japan Jean-Claude Mbanya, Yaounde, Cameroon Naresh Punjabi, Baltimore, USA Stephan Rossner, Stockholm, Sweden Shaukat Sadikot, Mumbai, India Jonathan Shaw, Melbourne, Australia Martin Silink, Sydney, Australia Eberhard Standl, Munich-Schwabing, Germany. Colin Sullivan, Sydney, Australia John Wilding, Liverpool, UK The workshop on sleep apnoea and type 2 diabetes was supported by an educational grant from the ResMed Foundation. The grant also funded Dr Tanya Pelly to work with the writing group to prepare the manuscript for publication. The Foundation had no involvement in the writing, review or approval of the manuscript, which has been published in Diabetes Research and Clinical Practice in June 20081. This booklet has been developed by IDF based on the manuscript. IDF Executive Office: Anne Pierson 3
  4. 4. 4
  5. 5. Introduction Recent research demonstrates the and Prevention convened a working likelihood of a relationship between group on SDB and type 2 diabetes, sleep-disordered breathing (SDB) with the intention of reviewing and and type 2 diabetes. Whilst the evaluating the current information exact nature of the relationship on these two topics and to make between the two conditions remains recommendations for both therapy uncertain, the association between and further research. The group them has important implications for recognized that there was a need public health and for individuals. for a global, multidisciplinary Additionally, both type 2 diabetes approach to raise awareness, and SDB are strongly associated improve clinical practice and with cardiovascular disease (CVD). coordinate research efforts to better SDB is increasingly considered as understand the links between SDB a condition to be treated for the and type 2 diabetes. prevention of CVD. When type 2 Discussions resulted in the diabetes is already present, the production of a statement focusing treatment of SDB is even more on obstructive sleep apnoea (OSA), relevant, because people with the most common form of SDB, and diabetes are already at high risk of its possible links with type 2 diabetes CVD. and CVD. In addition to highlighting Today, while the enormity of the the need for further research into type 2 diabetes epidemic is well these links, the statement is meant recognized, disorders of breathing to assist healthcare professionals during sleep are not. However, in their approaches to prevention, they make a significant contribution diagnosis and treatment of OSA and to the burden of disease in diabetes and should be the basis for individuals and the financial burden an educational programme for all on communities. In 2007, the healthcare workers involved in the International Diabetes Federation care of people presenting either of (IDF) Task Force on Epidemiology the conditions. 5
  6. 6. Extent of the problem Today type 2 diabetes is certainly Untreated, sleep apnoea can cause well recognized as a rampant global high blood pressure5 and other epidemic. The number of people cardiovascular diseases, memory with type 2 diabetes worldwide is problems, weight gain, impotence set to increase from its present level and headaches. Moreover, untreated of over 250 million to 380 million sleep apnoea may be responsible by 2025.2 Approximately seven for workplace problems and car million people develop it every year accidents. The medical costs of and almost four million die of its untreated OSA in the United States consequences every year2. are estimated at USD 3.4 billion/ year6, but the total economic impact CVD is the major cause of death in of OSA is far greater due to indirect diabetes, accounting for some 50% costs such as loss of productivity, of all diabetes fatalities, and much accidents and disability.7 disability. People with type 2 diabetes are over twice as likely There is increasing evidence that to have a heart attack or stroke as OSA is associated with type 2 people who do not have diabetes2. diabetes and with CVD. It is likely that more than half of the people OSA is the most common form of with type 2 diabetes suffer from SDB. It is often present among people some form of sleep disturbances8 with type 2 diabetes, CVD or obesity. and that up to a third have OSA at OSA has been noted in up to 9% of a level where treatment would be women and 24% of men3. Risk factors recommended. Conversely, estimates include being male, overweight, suggest that up to 40% of people and over the age of forty4, but sleep with OSA will have diabetes.9,10 OSA apnoea can strike anyone at any age, is known to be a risk factor for the even children. Yet because of the development of hypertension5: it has lack of awareness by the public and been shown that people with mild to healthcare professionals, the vast moderate OSA are twice as likely to majority remain undiagnosed and develop hypertension as are people therefore untreated, despite the fact without OSA. Additionally, OSA has that this serious disorder can have been shown to increase the risks of significant consequences. heart attacks.11 6
  7. 7. Obstructive sleep apnoea What is obstructive sleep apnoea? Sleep apnoea is a sleep disorder characterized by pauses in breathing during sleep. There are several forms of sleep apnoea, but the obstructive is the most common form. In OSA, pauses in breathing are caused by a physical block to airflow. OSA is usually defined by interruptions in airflow of at least 10 seconds (apnoeas), or by a decrease in airflow of at least 10 seconds (hypopnoeas) associated with either an arousal (the brain briefly arouses people in order for them to resume breathing) or a blood oxygen desaturation12. OSA occurs two to three times more often in older adults and is twice as common in men as in women. 7
  8. 8. Table 1: Symptoms of sleep apnoea • A history of habitual snoring Cardinal features of sleep apnoea • A record of witnessed apnoeas • Excessive daytime sleepiness • Fatigue, sleepiness during the day, loss of energy • Irritability • Poor memory Associated symptoms of sleep apnoea • Depression • Mood changes • Morning headaches • Sexual dysfunction • Nocturia 1. Symptoms simpler methods are available. Two The person with sleep apnoea is rarely measurements of sleep disturbance aware of having difficulty breathing, can be used: even upon awakening, therefore sleep • the apnoea-hypopnoea index (AHI) apnoea often goes undiagnosed. Sleep (defined as the mean number of apnoea is often first noticed by others apnoea and hypopnoea episodes who witness the person during episodes per hour of sleep) or is suspected because of a history • the blood oxygen desaturation of habitual snoring and/or its daytime index (ODI) (the mean number of effects, such as sleepiness and fatigue. blood oxygen desaturations per The latter are the consequences of sleep that is extremely fragmented hour of sleep). and/or of poor quality. There are other For each of these scores, the common symptoms associated with following categories apply13,14: sleep apnoea (see table 1). < 5 / hour Normal 2. Diagnosis 5-15 Mild Sleep apnoea is often diagnosed 15-30 Moderate with an overnight sleep test called polysomnography, although other ≥30 Severe 8
  9. 9. 3. OSA, excess weight and type 2 sleep apnoea. Avoiding alcohol and diabetes sleeping pills is likely to be beneficial. It is now well recognized that excess weight is associated with a higher Continuous Positive Airway risk of developing hypertension, Pressure (CPAP) is a treatment in hyperlipidemia, impaired glucose which a mask is worn over the nose tolerance and insulin resistance. and/or mouth whilst sleeping. The Excess weight, in particular central mask is linked up to a machine that obesity, is also the strongest risk delivers a continuous stream of factor for the development of compressed air. The positive pressure OSA. OSA affects about 4% of men helps keep the airways open so that and 2% of women in the general breathing is not impaired. population, but the prevalence rate is significantly higher in the obese Oral Devices such as dental population.³ appliances can be made that help keep the airway open during sleep. An increasing number of studies Such devices can be specifically also show that OSA is independently designed by dentists with special associated with insulin resistance expertise in treating sleep apnoea. and type 2 diabetes. It has been reported that the prevalence of Surgery may be considered in some some form of sleep disturbance cases, particularly when people have among people with diabetes is very enlarged tonsils and adenoids or high and can reach 58%.8 Similarly, nasal polyps or if people have facial both impaired glucose tolerance deformities such as a small jaw or a and diabetes have a high prevalence deviated nasal septum. among people with sleep apnoea. Additionally, increasing insulin resistance has been correlated with increasing severity of OSA. 4. Treatment of sleep apnoea There are several options for the treatment of sleep apnoea. Lifestyle changes. Weight loss should be recommended for all overweight or obese people with 9
  10. 10. Type 2 diabetes Type 2 diabetes is primarily diabetes is also linked to genetic characterized by insulin resistance factors, obesity, physical inactivity and relative insulin deficiency. Type 2 and unhealthy diet increase the diabetes can remain undetected risks. Ethnicity, family history and for many years, as it is often intrauterine environment are further asymptomatic. Its diagnosis is often risk factors for the development of made from associated complications type 2 diabetes. or incidentally through an abnormal blood or urine glucose test. Type 2 diabetes is the most common form of diabetes accounting for Type 2 diabetes is often, but not 85 to 95% of all diabetes in always, associated with excess weight developed countries, and for an even and is most common in people older higher percentage in developing than 45 who are overweight. However, countries. If people with type 2 as a consequence of increased obesity diabetes are not diagnosed and among the young, it is becoming treated, they can develop serious more common in children and young complications, which can result in adults. Although the onset of type 2 severe disability and early death. 10
  11. 11. The IdF consensus statement on sleep apnoea & type 2 diabetes The working group analyzed the links between OSA and disorders of glucose metabolism and the links between OSA and CVD. The latter are particularly relevant in the case of people who have both diabetes and OSA, because people with diabetes are already at higher risk of CVD. The group developed recommendations for treatment and care aimed at healthcare professionals working in both type 2 diabetes and SDB. 1. LINKS between OSA the association of these two conditions. and disorders of glucose There is now emerging evidence that the metabolism association between type 2 diabetes, insulin resistance, metabolic syndrome Although there is a recognized and OSA does not totally depend on association between type 2 diabetes obesity15,16,17 however there is not yet and OSA, the question of its exact enough evidence to fully exclude obesity nature has not yet been fully answered. from being the main driver. The additional question is if central obesity, which is a known risk factor Estimates suggest that up to 40% for both sleep apnoea and type 2 of people with OSA will have diabetes, could be the main cause in diabetes,9,10 but the incidence of new 11
  12. 12. diabetes in people with OSA is not that those with mild OSA were known. In people who have diabetes, significantly more likely to have the prevalence of OSA may be up to impaired glucose tolerance and 23%16, and the prevalence of some diabetes than those without form of SDB may be as high as 58%.8 OSA.9 However longitudinal data from the same Wisconsin Does OSA play a role in the study showed that after development of type 2 diabetes? adjusting for obesity, OSA was not a significant predictor of the Some early studies suggested that development of diabetes over the presence of OSA could possibly four years. lead to the development of type 2 diabetes, but these studies showed Further studies are required before significant limitations. To date, two definitive conclusions can be reached types of studies have looked into about the fact that OSA does or does the issue: not play a role in the development of 1. Studies using self-report sleep type 2 diabetes. parameters and type 2 diabetes: two large studies17,18 found Does OSA have effects on snoring to be a risk factor for the glycaemic control in people with development of type 2 diabetes existing type 2 diabetes? over 10 years, independent of other factors. However these Studies have reported that studies used data reported by among people with diabetes, the patient, which assumed the sleep duration and quality were presence of sleep-breathing significantly linked with glycaemic disturbance without objective control (HbA1c).21 Some studies measurement. analyzed whether OSA had effects on glycaemic control by evaluating 2. Studies using the the impact of CPAP treatment of polysomnograph to define OSA on insulin resistance, glycaemic OSA: Several studies such as control and HbA1c. However, these the Sleep Heart Health Study19 studies have had confusing and and the Wisconsin Sleep Study20 conflicting results. More research is reported a correlation between needed before it can be concluded OSA and changes in glucose that OSA has effects on glycaemic metabolism. Additionally, a control in people with type 2 study of French men showed diabetes. 12
  13. 13. Does OSA have effects on OSA has been definitively shown to components of the metabolic be an independent risk factor for syndrome? the development of hypertension5. The study showed that people with A relationship has been suggested mild to moderate OSA were twice between the presence of the as likely to develop hypertension, metabolic syndrome and OSA. and people with severe OSA were People with OSA are more likely to almost three times as likely to have the metabolic syndrome22 and develop hypertension as were those conversely, people with metabolic without OSA. syndrome have been shown to have an increased risk of OSA.23 Other studies showed that OSA was associated with a range of CVD such How can OSA affect glucose as stroke, heart failure and ischaemic metabolism? heart disease31. The prevalence of CVD increased progressively with There is evidence that the the increasing severity of OSA. OSA intermittent shortage of oxygen was also associated with myocardial in the body (hypoxia)24,25,26 and/or infarction32. Studies reported that the sleep fragmentation27,28 that people with known coronary disease result from OSA cause a physiologic and OSA had an increased risk of stress which can have an impact on cardiovascular events and death33 and glucose metabolism and can play an that people with OSA were more likely important role in the development to face sudden cardiac death.34,35,36,37 of insulin resistance. This impact can be explained by one or How can OSA lead to CVD? several biological mechanisms (see appendix 1). Similar to the mechanisms that link OSA with impaired glucose 2. LINKS between OSA and metabolism and type 2 diabetes, CVD there is evidence that a variety of mechanisms and pathways may OSA is associated with a variety of promote the development of CVD in cardiovascular conditions ranging people with OSA. from hypertension to heart failure29,30 and doctors increasingly consider treating OSA in order to prevent CVD. 13
  14. 14. Recommendations for treatment Even if the positive impact of treatment on glucose metabolism and on of OSA on glucose control, obesity achieving and maintaining a healthy and other risk factors has yet to body weight. be consistently demonstrated, the treatment has beneficial effects on Continuous Positive Airway quality of life and blood pressure Pressure (CPAP) treatment control. It has been established that While CPAP treatment of OSA has treatment of OSA improves sleep been shown to have mixed results and consequently reduces fatigue on glucose metabolism, it has been and daytime sleepiness. As it reduces shown to have an impact on CVD. daytime sleepiness, it also reduces risks of car accidents and job impairment. In people without diabetes, the impact of CPAP treatment on the Available therapies include weight improvement in insulin sensitivity was reduction in the overweight and not clearly demonstrated. In people obese, reduction in alcohol intake, with diabetes, the impact of CPAP use of CPAP treatment and/or dental treatment on the improvement in appliances. insulin sensitivity also had confusing results but some studies have shown Weight loss a significant reduction of HbA1c in Although very few data exist from people who had less than optimal controlled trials, weight loss should control.38,39 be the primary treatment strategy for OSA in people who are overweight In people who have CVD, CPAP or obese. Losing weight may treatment of OSA has been shown improve energy, social interaction, to have an impact on their condition. cognition and work performance, In resistant hypertension, guidelines reduce accidents and erectile recommend the investigation for dysfunction. Additionally, reduction and treatment of any existing OSA40. of daytime fatigue may lead to Finally, CPAP treatment of OSA may increased physical activity, which improve cardiovascular outcomes in in turn will have positive effects people with heart failure.41 14
  15. 15. Recommendations for screening Screening people with OSA for pressure measurement and fasting metabolic disorders lipids and glucose (followed with IDF recommends that healthcare a glucose tolerance test (OGTT), professionals monitor people with where appropriate). Treatment is OSA for any metabolic disease, available that is likely to reduce the including type 2 diabetes: screening risk of micro- and macrovascular tests for diabetes and the metabolic diabetic complications. The syndrome are inexpensive and easy monitoring of metabolic parameters to conduct. The screening tests is an essential part of the care of include waist measurement, blood people with OSA. 15
  16. 16. Screening people with type 2 However diagnostic testing is diabetes for OSA expensive and may not be accessible To date, there is not enough in all clinical settings. One screening evidence to support screening of strategy uses a two-stage approach in OSA in all people with diabetes which a structured questionnaire (eg since there is no conclusive evidence the Berlin questionnaire43) is used in that treatment of OSA will improve the first stage to assess the probability metabolic parameters. Additionally, of sleep apnoea. Those at high risk screening questionnaires for OSA undergo a second stage, with an are not well adapted for people overnight evaluation at home with with diabetes, who may experience pulse oximetry or portable monitoring fatigue and daytime sleepiness even (PM). People with a high pretest in the absence of OSA42. However, probability of OSA but a negative since people with symptomatic test on PM may require further daytime sleepiness are likely to investigation by polysomnogram, benefit most from treatment of OSA as a negative test with PM does not (as well as the most likely to comply necessarily rule out OSA.3 with treatment in the long-term), it may be considered worthwhile to People with evidence of some form target these people specifically. of sleep apnoea on PM should be referred, if possible, to a sleep Until more research information specialist. In the absence of such is available, IDF recommends a clinical expertise, an empirical trial practical approach which is to of CPAP therapy with an auto- investigate those people with titrating device can be considered classical symptoms such as witnessed with involvement of a primary care apnoeas, heavy snoring or daytime physician and a trained respiratory sleepiness, despite the fact that therapist. some people with OSA will not be identified this way. People with There is no doubt that further diabetes with refractory hypertension research is needed given the should also be considered for countless barriers in identifying screening since treating OSA may undiagnosed people with OSA. Until improve blood pressure.40 diagnostic strategies are adjusted, a detailed history or a structured The identification of OSA has long assessment followed by a simple relied on the use of an in-laboratory night-time evaluation will identify sleep test called a polysomnogram. those in urgent need for treatment. 16
  17. 17. Recommendations for care There is an evident need for healthcare professionals to be aware, educated and trained in the area of OSA and type 2 diabetes. IDF recommends that healthcare professionals working in both type 2 diabetes and OSA should adopt clinical practices to ensure that a person presenting with one condition is considered for the other. Healthcare professionals should aim to develop routine interventions that are locally appropriate for both type 2 diabetes and sleep services. Sleep services: People with OSA • People should be assessed for should be routinely screened for symptoms of OSA: snoring, markers of metabolic disturbance and observed apnoea during sleep and cardiovascular risk. Minimum testing daytime sleepiness. should include measurement of: • People should be referred to a • waist circumference specialist in an early stage in order • blood pressure to establish a diagnosis, because of • fasting lipids the confirmed benefits of therapy • fasting glucose on hypertension and quality of life. • Management of OSA should focus Diabetes services: The possibility initially on weight reduction for the of OSA should be considered in overweight and obese. CPAP is the the assessment of all people with current best treatment for moderate type 2 diabetes and the metabolic to severe OSA and should be syndrome. considered where appropriate. 17
  18. 18. Recommendations for research Because of the direct impact of • Intervention studies OSA on the individual’s life and its - Appropriately powered randomised financial consequences on society, IDF controlled trials of CPAP and other recommends further research in the therapies in people with type 2 diabetes following areas: with emphasis on cardiovascular risk • Epidemiological studies of factors and outcomes, and glycaemic prevalence of OSA in control. Additional outcomes - people with type 2 diabetes and should also include oxidative stress, metabolic syndrome inflammatory markers and adipokines/ - children with obesity, especially lipid metabolism. those with type 2 diabetes - Trials of weight loss in people with - different ethnic groups OSA and diabetes (including use of - gestational diabetes and pre- anti-obesity medication) eclampsia • Resource development • Studies of the effects of OSA on - A reliable but inexpensive diagnostic - insulin secretion, insulin resistance, strategy for OSA to be used in a mitochondrial function and primary care setting inflammatory markers - Treatments for OSA that are easier - complications of type 2 diabetes to use and cheaper than CPAP 18
  19. 19. Conclusion Type 2 diabetes and OSA are common However, the benefits of treatment disorders that often coexist. There is a of OSA have been established, high prevalence of OSA in people with particularly as they improve quality of type 2 diabetes and abnormal glucose life and blood pressure control. metabolism and, conversely, there is a high prevalence of type 2 diabetes and When people have type 2 diabetes related metabolic disorders in people or OSA, IDF recommends screening with OSA. Additionally, there is a link for the other condition. People with between OSA and hypertension and OSA should be routinely screened for CVD. One explanation for this overlap metabolic disease and type 2 diabetes is the presence of shared risk factors as screening tests are inexpensive and such as obesity but an increasing easy to conduct. People with diabetes number of studies show that these should be screened for OSA particularly two conditions can be associated when they present classical symptoms independently of obesity. such as witnessed apnoeas, heavy snoring or daytime sleepiness. Diagnosis Because both diabetes and OSA are can be confirmed by appropriate associated with increased cardiovascular testing, but where facilities are limited, morbidity and mortality and other simpler home monitoring devices can important adverse consequences, help in the diagnosis of OSA. IDF calls to action to raise awareness, improve clinical practice and support IDF recommends that all healthcare scientific research in the links between professionals involved with diabetes type 2 diabetes and OSA. or OSA should be educated about the links between the two conditions and IDF recommendations for treatment trained in their care. Further research of OSA include weight reduction in is needed to better understand the the overweight and obese, reduction links between the two conditions and in alcohol intake, use of CPAP improve treatment and care. Finally, treatment and/or dental appliances. health policy makers and the general Beneficial effects on glucose control, public must also be made more aware obesity and other cardiovascular risk of OSA and the significant financial factors have been suggested but have and disability burden that it places on yet to be consistently demonstrated. both individuals and societies. 19
  20. 20. Appendix 1: Sleep apnoea is characterized by sleep fragmentation and/or intermittent hypoxemia. Both impose a physiologic stress which may be involved in the pathogenesis of insulin resistance via one or several biological mechanisms (see fig 1). Fig 1: Potential mechanisms linking sleep apnoea to glucose intolerance45 Sleep Apnoea Sleep Fragmentation Intermittent Hypoxemia Sympathetic HPA axis Oxidative Activation of Changes in Activation Alterations stress Inflammatory Adipokine (Catecholamines) (Cortisol) (ROS) Pathways Profiles (IL-6, TNF-α) (Leptin, Adiponectin) Insulin Resistance / Pancreatic β-cell Dysfunction Glucose Intolerance / Type 2 Diabetes 20
  21. 21. References 1 Shaw JE, Punjabi NM, Wilding JP, Alberti 9 Meslier N, Gagnadoux F, Giraud P, Person C, KGMM, Zimmet PZ. Sleep-Disordered Ouksel H, Urban T, Racineux JL: Impaired Breathing and Type 2 Diabetes. Diabetes glucose-insulin metabolism in males with Res Clinical Pract 81(1), 2008 obstructive sleep apnoea syndrome. Eur Respir J 22(1): 156-160, 2003 2 Diabetes Atlas, third edition, International Diabetes Federation,2006 10 Elmasry A, Lindberg E, Berne C, Janson C, Gislason T, Awad Tageldin M, Boman G: Sleep- 3 Young T, Palta M, Dempsey J, Skatrud J, disordered breathing and glucose metabolism Weber S, Badr S: The occurrence of sleep in hypertensive men: a population-based disordered breathing among middle aged study. J Intern Med 249(2): 153-161, 2001 adults. NEJM 328:1230-1235, 1993 11 http://www.sciencedaily.com/ 4 Young, T, Shahar E, Nieto FJ, Redline S, releases/2007/05/070520183533.htm Newman AB, Gottlieb DJ, Walsleben JA, retrieved 06/05/2008 Finn L, Enright P, and Samet JM: Predictors of sleep-disordered breathing in community- 12 Iber C, Ancoli-Israel S, Chesson A, Quan SF. dwelling adults: the Sleep Heart Health The AASM Manual for Scoring of Sleep and Study. Arch Intern Med 162: 893-900, 2002 Associated Events: Rules, Terminology and Technical Specifications. 1st ed. Westchester, 5 Peppard PE, Young T, Palta M, Skatrud J: Illinois: American Academy of Sleep Prospective study of the association between Medicine, 2007 sleep-disordered breathing and hypertension. NEJM 342(19): 1378-1384, 2000 13 Sleep-related breathing disorders in adults: recommendations for syndrome definition 6 Kapur V, Blough DK, Sandblom RE, Hert R, and measurement techniques in clinical de Maine JB, Sullivan SD, Psaty BM: The research. The Report of an American medical cost of undiagnosed sleep apnea. Academy of Sleep Medicine Task Force. Sleep 22(6): 749-755, 1999 Sleep 22(5): 667-689, 1999 7 Hillman DR, Murphy AS, Pezzullo L: The 14 Management of Obstructive Sleep Apnoea/ economic cost of sleep disorders. Sleep. Hypopnoea Syndrome in Adults. A national 29(3): 299-305, 2006 clinical guideline. Scottish Intercollegiate Guidelines Network. Available from http:// 8 Resnick HE, Redline S, Shahar E, Gilpin A, www.sign.ac.uk/guidelines/fulltext/73/index. Newman A, Walter R, Ewy GA, Howard html BV, Punjabi NM: Diabetes and sleep disturbances: findings from the Sleep Heart 15 Coughlin SR, Mawdsley L, Mugarza JA, Health Study. Diabetes Care 26(3): 702-709, Calverley PM, Wilding JP: Obstructive 2003 sleep apnoea is independently associated 21
  22. 22. with an increased prevalence of metabolic community-based Chinese adults in Hong syndrome. Eur Heart J 25(9): 735-741, 2004 Kong. Respir Med 100(6): 980-987, 2006 16 West SD, Nicoll DJ, Stradling JR: Prevalence 24 Larsen JJ, Hansen JM, Olsen NV, Galbo H, of obstructive sleep apnoea in men with type Dela F: The effect of altitude hypoxia on 2 diabetes. Thorax 61(11): 945-950, 2006 glucose homeostasis in men. J Physiol 504 ( Pt 1): 241-249,1997 17 Elmasry A, Janson C, Lindberg E, Gislason T, Tageldin MA, Boman G:The role of habitual 25 Braun B, Rock PB, Zamudio S, Wolfel GE, snoring and obesity in the development of Mazzeo RS, Muza SR, Fulco CS, Moore diabetes: a 10-year follow-up study in a male LG, Butterfield GE: Women at altitude: population. J Intern Med 248(1): 13-20, 2000 short-term exposure to hypoxia and/or alpha(1)-adrenergic blockade reduces insulin 18 Al-Delaimy WK, Manson JE, Willett WC, sensitivity. J Appl Physiol 91(2): 623-631, 2001 Stampfer MJ, Hu FB: Snoring as a risk factor for type II diabetes mellitus: a prospective 26 Oltmanns KM, Gehring H, Rudolf S, Schultes study. Am J Epidemiol 155(5): 387-393, 2002 B, Rook S, Schweiger U, Born J, Fehm HL, Peters A: Hypoxia causes glucose 19 Punjabi NM, Shahar E, Redline S, Gottlieb intolerance in humans. Am J Respir Crit Care DJ, Givelber R, Resnick HE: Sleep- Med 169(11): 1231-1237, 2004 disordered breathing, glucose intolerance, and insulin resistance - The Sleep Heart 27 Spiegel K, Leproult R, Van Cauter E: Impact Health Study. Am J Epidemiol 160(6): 521- of sleep debt on metabolic and endocrine 530, 2004 function. Lancet 354(9188): 1435-1439, 1999 20 Reichmuth KJ, Austin D, Skatrud JB, Young 28 Gottlieb DJ, Punjabi NM, Newman AB, T: Association of sleep apnea and type II Resnick HE, Redline S, Baldwin CM, Nieto diabetes: a population-based study Am J FJ: Association of sleep time with diabetes Respir Crit Care Med 172(12):1590-1595, 2005 mellitus and impaired glucose tolerance. Arch Intern Med165(8): 863-867, 2005 21 Knutson KL, Ryden AM, Mander BA, Van Cauter E: Role of sleep duration and quality 29 Bottini P, Dottorini ML, Cristina Cordoni M, in the risk and severity of type 2 diabetes Casucci G, Tantucci C: Sleep-disordered mellitus. Arch Intern Med 166(16):1768- breathing in nonobese diabetic subjects with 1774, 2006 autonomic neuropathy. Eur Respir J 22: 654- 660, 2003 22 Gruber A, Horwood F, Sithole J, Ali NJ, Idris I. Obstructive sleep apnoea is independently 30 Dincer HE, O’Neill W: Deleterious effects of associated with the metabolic syndrome sleep-disordered breathing on the heart and but not insulin resistance state. Cardiovasc vascular system. Respiration 73(1): 124-130, 2006 Diabetol 5: 22, 2006 31 Shahar E, Whitney CW, Redline S, Lee ET, 23 Lam JC, Lam B, Lam CL, Fong D, Wang JK, Newman AB, Javier Nieto F, O’Connor GT, Tse HF, Lam KS, Ip MS: Obstructive sleep Boland LL, Schwartz JE, Samet JM: Sleep- apnea and the metabolic syndrome in disordered breathing and cardiovascular 22
  23. 23. disease: cross-sectional results of the Sleep JJ,Mokhlesi B.The effect of continuous Heart Health Study. Am J Respir Crit Care positive airway pressure on glucose control in Med 163(1): 19-25, 2001 diabetic patients with severe obstructive sleep apnea. Sleep Breath 9(4): 176-180, 2005 32 Mooe T, Franklin KA, Wiklund U, Rabben T, Holmstrom K: Sleep-disordered breathing 40 Chobanian AV, Bakris GL, Black HR, Cushman and myocardial ischemia in patients with WC, Green LA, Izzo JL Jr, Jones DW, Materson coronary artery disease. Chest 117(6):1597- BJ, Oparil S, Wright JT Jr, Roccella EJ; 1602, 2000 Joint National Committee on Prevention, Detection, Evaluation, and Treatment of 33 Peker Y, Carlson J, Hedner J: Increased High Blood Pressure. National Heart, Lung, incidence of coronary artery disease in sleep and Blood Institute; National High Blood apnoea: a long-term follow-up. Eur Respir J Pressure Education Program Coordinating 28(3): 596-602, 2006 Committee: Seventh report of the Joint National Committee on Prevention, Detection, 34 Mehra R, Benjamin EJ, Shahar E, Gottlieb Evaluation, and Treatment of High Blood DJ, Nawabit R, Kirchner HL, Sahadevan Pressure. Hypertension 42(6): 1206-1252, 2003 J, Redline S:Association of nocturnal arrhythmias with sleep-disordered breathing: 41 Mansfield DR, Naughton MT: Sleep apnea The Sleep Heart Health Study. Am J Respir and congestive heart failure. Minerva Crit Care Med173(8): 910-916, 2006 Medica 95(4): 257-280, 2004 35 Gami AS, Pressman G, Caples SM, Kanagala 42 Bixler EO, Vgontzas AN, Lin HM, Calhoun R, Gard JJ, Davison DE, Malouf JF, Ammash SL, Vela-Bueno AV, Kales A: Excessive NM, Friedman PA, Somers VK: Association daytime sleepiness in a general population of atrial fibrillation and obstructive sleep sample: The role of sleep apnea, age, apnea. Circulation110(4): 364-367, 2004 obesity, diabetes, and depression. J Clin Endocrinol Metab 90(8): 4510-4515, 2000 36 Ryan CM, Usui K, Floras JS, Bradley TD: Effect of continuous positive airway pressure 43 Netzer NC,Stoohs RA,Netzer CM, Clark K, on ventricular ectopy in heart failure patients Strohl KP: Using the Berlin Questionnaire to with obstructive sleep apnoea. Thorax 60(9): identify patients at risk for the sleep apnea 781-785, 2005. syndrome. Ann Intern Med 131(7): 485-491,1999 37 Gami AS, Howard DE, Olson EJ, Somers 44 Collop NA, McDowell Anderson W, VK: Day-night pattern of sudden death in Boehlecke B, Claman D, Goldberg R, obstructive sleep apnea. NEJM 52(12): 1206- Gottlieb DJ, Hudgel D, Sateia M, Schwab R: 1214, 2005 Clinical Guidelines for the Use of Unattended Portable Monitors in the Diagnosis of 38 Babu AR, Herdegen J, Fogelfeld L, Shott Obstructive Sleep Apnea in Adult Patients. J S, Mazzone T: Type 2 diabetes, glycemic Clin Sleep Med 3(7): 737-747, 2007 control, and continuous positive airway pressure in obstructive sleep apnea Arch 45 Zimmet PZ, Punjabi NM: Slide presented Intern Med 165(4): 447-452, 2005 at IDF/ADA symposium at 68th Scientific 39 Hassaballa HA,Tulaimat A,Herdegen Sessions of ADA, June 2008. 23
  24. 24. International Diabetes Federation (IDF) Avenue Emile de Mot 19 • B-1000 Brussels • Belgium Phone: +32-2-5385511 • Fax: +32-2-5385114 w w w. i d f . o r g • c o m m u n i c a t i o n s @ i d f . o r g