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Diabetes and Sleep Apnoea Impact of Obstructive Sleep Apnoea on Type 2 Diabetes and Vice Versa Kurt Rasche, 1 Tanja Keller, 2 Claus Hader, 2 Markus Leidag 3 and Christian Prinz 4 1. Head Pulmonologist and Professor of Internal Medicine, HELIOS Clinic Wuppertal, University of Witten/Herdecke, Wuppertal, Germany; 2. Pulmonologist, Pulmonary Practice Aeroprax Wuppertal, Germany; 3. Deputy Head Pulmonologist, HELIOS Clinic Wuppertal, University of Witten/Herdecke, Wuppertal, Germany; 4. Head Internal Specialist and Professor of Internal Medicine, Chair of Internal Medicine, HELIOS Clinic Wuppertal, University of Witten/Herdecke, Wuppertal, Germany Abstract Type 2 diabetes and obstructive sleep apnoea (OSA) are diseases with high prevalence and major public health impact. There is evidence that OSA is independently associated with alterations in glucose metabolism. Furthermore, OSA is a significant risk factor for the development of type 2 diabetes. Possible causes might be intermittent hypoxaemia and sleep fragmentation with increased oxidative stress and sympathetic activity, which are typical features of OSA. OSA might also be a reason for ineffective treatment of type 2 diabetes. There is further evidence that the treatment of OSA by continuous positive airway pressure (CPAP) therapy might improve glucose metabolism. On the other hand, there are also hints in the literature that type 2 diabetes might induce sleep apnoea, especially in patients with autonomic neuropathy, but that OSA also facilitates the development of neuropathy in terms of mutual interactions between OSA, type 2 diabetes and diabetic neuropathy. Based on the current scientific data, clinicians have to be aware of the relations between OSA and type 2 diabetes, both from the sleep medical and the diabetological point of view. Keywords Type 2 diabetes, obstructive sleep apnoea, diabetic neuropathy, continuous positive airway pressure Disclosure: The authors have no conflicts of interest to declare. Acknowledgements: Bogdan Tautz provided us with unpublished data concerning the prevalence of obstructive sleep apnoea in diabetic patients in his GP’s surgery. Received: 21 May 2013 Accepted: 30 July 2013 Citation: European Endocrinology, 2013;9(2):107–9 Correspondence: Kurt Rasche, Direktor der Klinik für Pneumologie, Allergologie, Schlaf- und Beatmungsmedizin, HELIOS Klinikum Wuppertal, Heusnerstr. 40, D-42283 Wuppertal, Germany. E: Type 2 diabetes and obstructive sleep apnoea (OSA) are both highly prevalent conditions with a major impact on public health. 1,2 Obesity is a common feature of both groups of patients. Thus, the metabolic syndrome, which is characterised by obesity, insulin resistance (IR), dyslipidaemia and hypertension, can often be found in both type 2 diabetes and OSA. In many cases the metabolic syndrome seems to be the most important underlying disease both of type 2 diabetes and OSA. 3–5 But what is the impact of type 2 diabetes on OSA and vice versa? Is there only a coincidental or even a causal relationship between the two diseases? Has OSA treatment in terms of continuous positive airway pressure (CPAP) application had an impact on glucose metabolism? Impact of Obstructive Sleep Apnoea on Type 2 Diabetes Several studies support the hypothesis that habitual snoring and OSA have an impact on glucose metabolism in both patients with and without diabetes. 3 Furthermore, OSA has been shown to be an independent risk factor for the occurrence of IR and type 2 diabetes. 6–9 OSA is characterised by intermittent apnoeas and hypoxia during sleep with consecutive arousals and sleep fragmentation. Intermittent hypoxia and sleep fragmentation might lead to an increase in sympathetic activity and in chronic inflammation due to serological mediators such as interleukin 6 and 8, leptin and tumour necrosis factor (TNF)-alpha. Intermittent hypoxia per se is a risk factor for the development of type 2 diabetes 10 One reason for this might be an increase of oxidative stress due to intermittent hypoxia. Increased sympathetic activity © To u ch MEdical ME d ia 2013 additionally leads to incretion of catecholamines and cortisol, which are both prodiabetogenic hormones. Thus, sleep apnoea might lead to a disturbance of glucose metabolism and to the development of type 2 diabetes and neuropathy. 11 To look at some studies in detail: In a 10-year follow-up study in 69,852 nurses with an age between 40 and 65 years, regular snoring was independently associated with a twofold increased risk of developing diabetes. 12 Also in hypertensive men OSA was – besides obesity – a risk factor for diabetes. 13 In the study of Elmasry and co-workers the prevalence of OSA defined by an apnoea-hypopnoea-index (AHI) of at least 20 per hour was 36.0  % in the diabetic group versus 14.5  % in hypertensive men without diabetes. Individuals suffering from OSA in combination with a waist-to-hip-ratio of at least 1 had an odds ratio (OR) of 11.8 for development of type 2 diabetes. Our own population- based study in Turkey, which included 1,946 individuals, investigated the possible association between OSA syndrome, the metabolic syndrome and IR. In this study, however, OSA syndrome was associated with the metabolic syndrome rather than with IR, which was estimated by homeostatic model assessment (HOMA). 14 The reason for this opposite finding could be the very high percentage of the metabolic syndrome within the female population. In any case the prevalence of OSA is increased in type 2 diabetes and vice versa – depending on the definition of OSA and OSA syndrome the prevalence of diabetes in OSA patients seems to be in the range of 15 to 30 %. 15,16 Preliminary data of our own working group also show a high prevalence of sleep disordered breathing 107