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Sleep Apnea and Diabetes

Posted on July 17, 2018 | No Comments on Sleep Apnea and Diabetes

The snore is often associated with good sleep after a hard day’s work. However, it may actually indicate partial obstruction of the upper airway.

During sleep, we lose the voluntary control that keeps our airway passages open, predisposing them to obstruction. Increased risk is commonly seen among overweight or obese individuals as the added fat around the neck compresses the airway. Persons who have enlarged tonsils and tongues or small chins have intrinsically narrowed passages that are easily obstructed. If the snore is associated with labored breathing efforts, as evidenced by grunting or stoppage of breathing, this may be considered as obstructive sleep apnea (OSA).

What Does OSA Do To Your Body?
To understand this, let us first talk about normal sleep. This is often mistaken as a period of inactivity. Sleep, in fact, is a restorative process that allows for numerous metabolic processes. One has to have deep sleep (slow wave sleep) in order to feel refreshed in the morning. A patient who has OSA actually undergoes what may be described as repeated strangulations during sleep. This prevents the person from going into deep sleep and is repeatedly moved into a lighter stage of sleep. His oxygen supply is repeatedly cut off and the carbon dioxide is trapped in his body as his breathing is unable to move air in and out of the lungs. This repeated disturbance makes the patient’s stress response (sympathetic nervous system) kick in, making the blood pressure rise.

Upon waking up, the OSA patient feels like he has a bad hangover, complete with headaches, irritability and increased sleepiness. Long-term complications involve increased risk for heart disease and strokes. Added to this is the public health risk, as the untreated OSA sufferer has increased sleepiness, and has vigilance and reflexes that are worse than those of a drunk driver.

The OSA-Diabetes Link
As mentioned earlier, obesity is a risk factor, one that is shared with diabetes. The link between OSA and sugar control goes beyond this. As the body’s fight-or-flight response is activated during episodes of apnea or obstruction of breathing, this triggers a release of a hormone called cortisol that acts contrary to insulin, leading to increased blood sugar levels. A six-year follow-up on 593 OSA patients in the Veterans Administration Health System in Connecticut by the Yale University School of Medicine found these patients to have more than two-and-a-half times the risk of developing diabetes compared to those without sleep apnea.

The lack of deep sleep has also been shown to decrease insulin sensitivity* by as much as 25 percent. A University of Chicago study used sounds loud enough to prevent the subjects from getting deep sleep but not to awaken them. Despite the decreased sensitivity, there was no increase in insulin production among all, save one research subject.

To diagnose OSA and determine a person’s sleep quality, one has to undergo a polysomnography or a sleep study. This is oftentimes done in a laboratory designed to look like a bedroom where wires are attached to the patient and he is observed for at least four hours of sleep. The amount of deep sleep, number of respiratory disturbances, drops in oxygenation and abnormalities in cardiac rhythm can be determined. More than five disturbances per hour are diagnostic of OSA. A score of 30 and above is considered severe.

How to Treat OSA
Treatment begins with lifestyle changes. Weight reduction has been shown to have a direct correlation with a decrease in respiratory disturbances. For those with diabetes, glycemic control is likewise improved. Smoking, alcohol intake and sedative use either irritate the airway or relax the muscles that keep it open, thereby increasing the risk of obstruction. Every effort must then be taken to avoid these. A regular sleep schedule allows for more deep sleep and decreases irregular breathing. These practices taken together are known as sleep hygiene.

Definitive treatment involves keeping the airway open. This may be done with an oral device, much like a mouth guard, that moves the jaw forward to increase the airway diameter. This is applicable for mild OSA. Surgery is an option for enlarged tonsils and anatomic defects. The gold standard treatment however, is the use of continuous positive airway pressure or CPAP. This pushes in air that acts as a pneumatic splint keeping the airway open and preventing it from collapsing. The patient is then allowed to have an unobstructed and undisturbed sleep. The ideal pressure can be determined using a titration study, which is just like a regular sleep study with the addition of a CPAP device. The pressure is progressively raised during the night of testing until the snoring disappears, the oxygenation remains stable and the sleep disturbances are obliterated.

Our energy expenditure normally falls during sleep. With OSA however, the expenditure increases during the episodes of apnea. In a study with CPAP use, this was shown to decrease along with cortisol release. In theory, this should allow for better blood sugar control, but more studies are needed to buttress this claim. Proof of CPAP benefit can be seen with hypertension control, allowing for a reduction in anti-hypertensive medications. Sleepiness is likewise marked improved allowing the patient to lead a more active life, hopefully translating into increased weight loss. In general, a better quality of life is achieved, improving the patient’s activities of daily living and self-esteem.

The Philippines has 25 sleep specialists in 12 recognized sleep centers. Efforts to increase awareness from both the medical practitioner and general public standpoints have been undertaken by the Philippine Society of Sleep Medicine. Sleep disorders differ from the usual diseases, as they need an observer to identify the manifestation such as snoring, because the sufferer is asleep.

So, if your loved one snores and has risk factors, ask your doctor about OSA. For the diabetic with OSA, it may give them sweet sleep without the excess sugar. It may not only improve the quality of his sleep, it may improve yours as well.

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