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“O sleep, O gentle sleep, Nature's soft nurse, how have I frighted thee, that thou no more wilt weigh my eyelids down and steep my senses in forgetfulness?”1

Written by: Dr Jay Narainsamy, MBChB (Natal), FRCP (SA), MMed (UKZN), Cert Endocrinology (SA) Specialist Physician/Endocrinologist
Published: 22 March 2024

The fear that life seems to be passing us by at lightning pace is compelling enough to spur us on to milk every second of every day to the fullest. We seem to be working harder, staring at screens for longer, engaging in more activities and generally shortening our nights. This rest that we sacrifice to do more is vital for both mental and physical health. The consequences of little or poor sleep can affect mood, energy levels and cause irritability. In addition, sleep issues can exacerbate, cause and reveal other more ‘serious’ medical conditions.2

Sleep is divided into Rapid Eye Movement (REM) and non-REM sleep which are in-turn divided into 3 stages.3 An individual cycles through these stages around 4 to 6 times during the night. This is an important time for rest but also for upkeep and ‘servicing’ of the brain and its complex neurological links. The National Sleep Foundation in America states that an average individual requires around 7 to 9 hours of sleep daily. However nearly 30 percent of adults only have around 6 hours of sleep per night.4

Sleep disorders can affect quality, timing and amount of sleep.2 There are numerous causes of sleep issues including psychological issues, medical problems, and drugs, but I am not going to delve into the multiple possible causes which are vast and beyond the scope of this article. I want to focus instead on an overview of Obstructive Sleep Apnoea (OSA), a well-known medical condition we encounter frequently in medical practice.

OSA is a common medical condition and affects about 2 - 4% of the adult population.5 It is therefore imperative that health care practitioners are aware of risk factors, ask the right questions and screen timeously. It is also important that non-medical individuals recognise the symptoms and ask their health care practitioners about this condition. OSA occurs when there is repetitive collapse of the upper airways which causes obstruction of the airways resulting in deoxygenated blood perfusing the brain. There is also sleep disruption, hypercapnia, changes in intrathoracic pressures and increased sympathetic system activation.5

The prevalence of OSA increases during adulthood and plateaus during the 6th and 7th decades of life.6 It is more common in males. Overweight individuals are more at risk for OSA with one study reporting moderate to severe OSA in 63% of people with a body mass index (BMI) of more than 30 kg/m2.7 In addition, craniofacial and upper airway abnormalities may also contribute to OSA. Unfortunately, as expected, the usual suspect of smoking is also thought to increase or worsen OSA.8

OSA may be recognised by common symptoms of, snoring, gasping and choking when sleeping, and morning headaches and daytime sleepiness. I have found the partner of the ‘snorer’ is usually very forthcoming with this history! The physical findings of an increased BMI, a large neck circumference and other medical conditions, for example, hypertension, heart failure, pulmonary hypertension, cardiac arrhythmias, ischaemic heart disease, type 2 diabetes mellitus and other metabolic disorders, should increase the index of suspicion.

Formal scales exist to assess OSA but I find these rather cumbersome to use in daily practice. Polysomnography or ‘sleep study’ is considered the gold standard diagnostic test. This is usually done by dedicated companies and fortunately can also be done in the comfort of the person’s home. The sleep study assesses the apnoea-hypopnoea index (AHI), with >15 events/hour for 2 or more hours of testing, and 3 hours or more of sleep usually being diagnostic.

Although OSA should be addressed according to severity, basic lifestyle changes should be implemented across the spectrum. People diagnosed should be encouraged to lose weight, engage in more physical activity, stop smoking, and avoid alcohol and other sedating medications. Healthcare practitioners should also screen and treat co-morbidities. CPAP (continuous positive airways pressure) therapy remains the mainstay of OSA treatment. Clients will usually be given a trial of CPAP, and the equipment is adjusted and titrated to the individual’s needs.

I have attempted to summarise an extensive and complex topic. My main aim is to make both the healthcare client and healthcare practitioners more aware of this silent menace. The more we ask the right questions, the more we screen and the more we treat. I have had clients who have noted that CPAP has changed their lives and improved the overall quality of their day. OSA is not as simple as snoring and an annoyance to an aggrieved and long-suffering partner… this is a high-risk medical condition that needs to be addressed for the holistic management of our clients.

References

  1. Shakespeare W (1600). Henry IV, Part II, Act III, Sc. 1.
  2. American Psychiatric Association (2020). What are Sleep Disorders? Available from: https://www.psychiatry.org/patients-families/sleep-disorders/what-are-sleep-disorders
  3. Patel AK, Reddy V, Shumway KR, et al. (2024). Physiology, Sleep Stages. [Updated 2024 Jan 26]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing.
  4. Hafner M, Stepanek M, Taylor J, Troxel WM, Van Stolk C (2017). Why Sleep Matters—The Economic Costs of Insufficient Sleep - A Cross-Country Comparative Analysis. RAND Health Quarterly, Vol. 6 No. 4. Available from: https://www.rand.org/pubs/periodicals/health-quarterly/issues/v6/n4/11.html
  5. Epstein LJ, et al. (2009). Adult Obstructive Sleep Apnea Task Force of the American Academy of Sleep Medicine. Clinical guideline for the evaluation, management and long-term care of obstructive sleep apnea in adults. J Clin Sleep Med. 5(3):263-76.
  6. Young T, Palta M, Dempsey J et al. (2009). Burden of sleep apnea: rationale, design and major findings of the Wisconsin Sleep Cohort Study. WMJ; 108: 246
  7. Randerath WJ, Verbraecken J, Andreas et al. (2011). Non-CPAP therapies in obstructive sleep apnoea. Eur Respir J: 37:1000.
  8. Dixon JB, Shcachter LM, O’Brien PE et al. (2012). Surgical vs conventional therapy for weight loss treatment of obstructive sleep apnea: a randomized controlled trial. JAMA; 308:1142.