Scientific letter
Type 2 diabetes, risk of sleep apnea-hypopnea syndrome, and quality of life associated to sleep breathing disorders
Diabetes tipo 2, riesgo de síndrome de apnea-hipopnea del sueño y calidad de vida asociada con los trastornos respiratorios del sueño
Albert Lecubea,b,
, Enric Sáncheza, Carolina López-Canoa, Cristina Hernándezb,c, Rafael Simób,c
Corresponding author
a Endocrinology and Nutrition Department, Hospital Universitari Arnau de Vilanova, IRB-Lleida, Universitat de Lleida, Av Rovira Roure 80, 25198 Lleida, Spain
b CIBER de Diabetes y Enfermedades Metabólicas Asociadas (CIBERDEM), Instituto de Salud Carlos III (ISCIII), Spain
c Diabetes and Metabolism Research Unit, Institut de Recerca i Hospital Universitari Vall d’Hebron (VHIR), Universitat Autònoma de Barcelona, Pg Vall d’Hebron 119-129, 08035 Barcelona, Spain
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array:15 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Scientific letter</span>" "titulo" => "Type 2 diabetes, risk of sleep apnea-hypopnea syndrome, and quality of life associated to sleep breathing disorders" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "174" "paginaFinal" => "176" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Albert Lecube, Enric Sánchez, Carolina López-Cano, Cristina Hernández, Rafael Simó" "autores" => array:5 [ 0 => array:4 [ "nombre" => "Albert" "apellidos" => "Lecube" "email" => array:1 [ 0 => "alecube@gmail.com" ] "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => 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"entidad" => "Endocrinology and Nutrition Department, Hospital Universitari Arnau de Vilanova, IRB-Lleida, Universitat de Lleida, Av Rovira Roure 80, 25198 Lleida, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "CIBER de Diabetes y Enfermedades Metabólicas Asociadas (CIBERDEM), Instituto de Salud Carlos III (ISCIII), Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Diabetes and Metabolism Research Unit, Institut de Recerca i Hospital Universitari Vall d’Hebron (VHIR), Universitat Autònoma de Barcelona, Pg Vall d’Hebron 119-129, 08035 Barcelona, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Diabetes tipo 2, riesgo de síndrome de apnea-hipopnea del sueño y calidad de vida asociada con los trastornos respiratorios del sueño" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1067 "Ancho" => 2356 "Tamanyo" => 114005 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Quebec Sleep Questionnaire (QSQ) global score and five health related quality of life domains according to the presence of type 2 diabetes.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Our group has recently communicated how type 2 diabetes (T2D) and high levels of fasting plasma glucose (FPG) are independent risk factors for daytime sleepiness and sleep quality, suggesting the role of sleep questionnaires to evaluate the relationship between T2D and sleep breathing disorders.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> We now provide additional results obtained through the administration of other two specific questionnaires in order to investigate the deleterious effect of T2D and the degree of glycemic control on the risk of having sleep apnea-hypopnea syndrome (SAHS) and quality of life. For this purpose, both questionnaires were administered to a total of 331 patients at the time of a regular visit to the outpatient diabetes unit from Arnau de Vilanova and Vall d’Hebron University Hospitals among February 2012 and December 2014: (i) the Berlin Questionnaire, to measure the risk of having sleep apnea, and (ii) the Quebec Sleep Questionnaire (QSQ) to assess health related quality of life in patients with sleep apnea.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Recruited patients were able to read and recognize the correct meaning of the questions, and also were older than 18 years, of Caucasian origin, and with known T2D for longer than 5 years. In addition, they do not report any nighttime hypoglycemia events or previous episodes of severe hypoglycemia, and a determination of FPG and glycated hemoglobin during the preceding months was available. Subjects with chronic lung illnesses, heart or stroke failure, use of sedatives or alcohol abuse, as well as shift workers, were excluded. Therefore, only data from 135 subjects with T2D were assessed. We designed a case-control study, and one control was selected for every three cases. Then 45 subjects without diabetes and matched to cases by age (59.0<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>12.0 vs. 60.9<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>12.6; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.383), gender (55% of women in each group), BMI (29.6<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>7.0 vs. 30.9<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>5.3; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.192), and smoking status were carefully chosen. In all cases, informed consent was obtained.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Treatment for T2D was assorted, and comprised metformine alone (20.7%), different oral treatment combinations (13.8%), metformin plus basal insulin (42.9%), and basal plus or basal bolus therapy (19.2%). Only four patients were under diet alone (2.9%), and none subject included in this study was treated with glucagon like peptide-1 analogs.</p><p id="par0020" class="elsevierStylePara elsevierViewall">In the Berlin Questionnaire eleven items cover three domains related to risk of obstructive sleep apnea: (i) snoring and sleep-related symptoms, (ii) awake-time sleepiness and drowsiness, and (iii) hypertension and/or a BMI greater than 30<span class="elsevierStyleHsp" style=""></span>kg/m<span class="elsevierStyleSup">2</span>.<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">2,3</span></a>. Responses are coded present or absent for each category, and the final score ranges from 0 to 3. Subjects who score ≥2 are classified as high risk, whereas subjects who score <2 are classified as low risk. Finally, the QSQ is a valid tool to assess, through 32 questions, how SAHS can be implicated in influencing five health related quality of life domains: hypersomnolence, diurnal symptoms, nocturnal symptoms, emotions and social interactions.<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">4,5</span></a> Lower scores reflect worse subjective sleep quality (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">The risk of SAHS, as defined by the Berlin questionnaire, was present in the 58.8% of the whole population, and this group of “high risk” subjects was associated with lower health related quality of life (QSQ: 26.9<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>4.3 vs. 30.2<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>3.1, <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.001). In addition, a higher percentage of patients with T2D in comparison with control subjects were classified as high risk for SAHS (60.0% vs. 40%, <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.015). Furthermore, a lower health related quality of life was present in patients with T2D (QSQ global score: 27.9<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>4.3 vs. 30.0<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>3.2, <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.004), mainly in domains related with daily somnolence (5.6<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>1.1 vs. 6.1<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.7, <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.002) and emotions (5.8<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>1.1 vs. 6.3<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.7, <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.011). However, no differences in diurnal symptoms (6.3<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.8 vs. 6.4<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.8, <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.557), nocturnal symptoms (5.1<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>1.2 vs. 5.3<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>1.2, <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.353) nor social interaction (6.0<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.8 vs. 6.2<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.6, <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.069) were detected.</p><p id="par0030" class="elsevierStylePara elsevierViewall">In the univariate analysis, a significant correlation between FPG and glycated hemoglobin was found only with the domain related with emotions (<span class="elsevierStyleItalic">r</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>−0.267, <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.001 and <span class="elsevierStyleItalic">r</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>−0.182, <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.039, respectively). A stepwise regression analysis showed that the presence of T2D (beta<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>−0.185, <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.001) and BMI (beta<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>−0.198, <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.012), but age or gender independently predicted the QSQ global score (<span class="elsevierStyleItalic">R</span><span class="elsevierStyleSup">2</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.081).</p><p id="par0035" class="elsevierStylePara elsevierViewall">Overall, our results confirm that patients with T2D are a population at risk of SAHS by using the Berlin Questionnaire and also provide evidence for implementing a more accurate screening for SAHS in patients with T2D. Some boundaries should be managed when evaluating the results of our work. The former, as a cross-sectional study we cannot draw a causal relationship between T2D and daytime consequences associated to sleep disturbances. However, the problem is clinically relevant since the prevalence of SAHS in subjects with T2D reaches the 40% to 86%, in comparison to the 2–4% in general population.<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">6,7</span></a> Second, we administered to patients with T2D a specific questionnaire to evaluate health-related quality of life in patients with SAHS. We assumed that a great percentage of patients with T2D will experience intermittent hypoxia and sleep disruption.<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">8–10</span></a> For these reason we found remarkable to investigate the association between perceived sleep and life quality in T2D patients. Third, more than half of subjects with T2D were under insulin therapy. Therefore, although no nighttime hypoglycemia episodes were reported, we cannot rule out the occurrence of unawareness events during the sleeping time that could influence our results.</p><p id="par0040" class="elsevierStylePara elsevierViewall">In conclusion, T2D is associated with worse scores in administered questionnaires evaluating the risk of having SAHS, and quality of life associated to sleep breathing disorders. As questionnaires are simple and economic screening instruments that easily can be used and quickly scored in a demanding clinical practice, our findings highlight the importance of screening subjects with T2D for sleep problems, making an appointment to a sleep medicine specialist if appropriate, and suggesting sleep hygiene approaches as part of diabetes care.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Funding</span><p id="par0045" class="elsevierStylePara elsevierViewall">No other sources of funding exist.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Conflict of interest</span><p id="par0050" class="elsevierStylePara elsevierViewall">No potential conflicts of interest relevant to this article were reported.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Funding" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Conflict of interest" ] 2 => array:2 [ "identificador" => "xack273551" "titulo" => "Acknowledgements" ] 3 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1067 "Ancho" => 2356 "Tamanyo" => 114005 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Quebec Sleep Questionnaire (QSQ) global score and five health related quality of life domains according to the presence of type 2 diabetes.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0055" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Global assessment of the impact of Type 2 diabetes on sleep through specific questionnaires: a case-control study" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "A. 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Simó" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/1753-0407.12197" "Revista" => array:6 [ "tituloSerie" => "J Diabetes" "fecha" => "2015" "volumen" => "7" "paginaInicial" => "133" "paginaFinal" => "138" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25043292" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] "agradecimientos" => array:1 [ 0 => array:4 [ "identificador" => "xack273551" "titulo" => "Acknowledgements" "texto" => "<p id="par0055" class="elsevierStylePara elsevierViewall">This work was supported by grants from de Instituto de Salud Carlos III ISCIII (Fondo de Investigación Sanitaria, FI12/00803) and Fundación Sociedad Española Endocrinología y Nutrición (FSEEN). CIBER de Diabetes y Enfermedades Metabólicas Asociadas (CIBERDEM) and CIBER de Enfermedades Respiratorias (CIBERES) are an initiative of the Instituto Carlos III.</p>" "vista" => "all" ] ] ] "idiomaDefecto" => "en" "url" => "/25300164/0000006400000003/v1_201703170143/S2530016417300228/v1_201703170143/en/main.assets" "Apartado" => array:4 [ "identificador" => "63843" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Cartas científicas" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/25300164/0000006400000003/v1_201703170143/S2530016417300228/v1_201703170143/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2530016417300228?idApp=UINPBA00004N" ]
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