A Structured Narrative Review of the OSA-T2DM Axis

Abstract

Background/Objectives: Obstructive sleep apnea (OSA) and type 2 diabetes mellitus (T2DM) are two highly prevalent and interconnected conditions with significant implications for morbidity and mortality. Emerging evidence suggests a bidirectional relationship between the two disorders, mediated by shared pathophysiological mechanisms such as intermittent hypoxia, systemic inflammation, and autonomic dysfunction. Methods: A structured narrative review of the literature was conducted using a comprehensive PubMed search of clinical and observational studies published between 2020 and 2024. Studies evaluating the association between OSA and diabetes, including its effects on glycemic control, diabetic complications, and treatment outcomes, were included. Results: Thirty-three studies met our inclusion criteria. OSA is independently associated with impaired glucose metabolism, increased insulin resistance, and a higher risk of diabetic complications, including nephropathy, retinopathy, and neuropathy. Continuous positive airway pressure (CPAP) therapy has shown variable effects on metabolic outcomes, largely dependent on adherence. Traditional OSA severity metrics, such as the apnea-hypopnea index (AHI), did not consistently predict metabolic burden. Factors such as sleep quality, nocturnal hypoxemia, and comorbid insomnia have emerged as the most relevant predictors. Sex-specific differences and the roles of pharmacological and behavioral interventions were also noted. Conclusions: OSA is a modifiable and under-recognized risk factor for poor glycemic control and diabetes complications. Routine screening and individualized treatment strategies are warranted, particularly for patients with T2DM and suboptimal metabolic control. Future research should focus on defining the phenotypes at the greatest risk and developing integrated treatment pathways.

Keywords: OSAS; T2DM; diabetes mellitus; obstructive sleep apnea; sleep disorders.

Figure 1

Flow diagram of the literature selection process. A total of 48 articles were retrieved through a database search. After removing duplicates and screening the titles and abstracts, 33 studies were included in the final analysis.

Figure 2

Schematic representation of the bidirectional relationship between OSA and T2DM. Key mediators include obesity, intermittent hypoxia, sympathetic activation, systemic inflammation, and insulin resistance. Note: This diagram refers exclusively to obstructive sleep apnea (OSA/OSAS).

Figure 3

Summary of Key Discussion Themes: The OSA–T2DM Interplay.