1 Introduction

Diabetes mellitus (DM), originally referred to in the ancient Ebers Papyrus as “wasting thirst” or “honey urine” (c. 1550 BC) [1], is a major global health concern, and DM is categorized as type 1 diabetes mellitus (T1DM) and type 2 diabetes mellitus (T2DM) with β-cell loss accounting for 5–10% of cases and insulin resistance accounting for 90–95% of cases. Both types of diabetes result in hyperglycemia [2]. The International Diabetes Federation estimates that the number of diabetics is 536.6 million (10.5%) worldwide, 73 million in the Middle East and North Africa when combined, and 4.3 million in Saudi Arabia [3]. The complex relationship between T2DM and obstructive sleep apnea (OSA), defined by recurrent airway restrictions during sleep, has been clarified by emerging research [4, 5]. Affecting 936 million people worldwide and at least 8.8% of Saudis [6].

New research has revealed how sleep fragmentation and intermittent hypoxia associated with OSA may worsen insulin resistance, leading to developing T2DM, with shared risk factors including obesity, hypertension, and a sedentary lifestyle [7-10]. For example, studies conducted in Pakistan and Ethiopia have shown that different T2DM participants have varying susceptibilities to OSA, depending on variables like neck circumference, body mass index (BMI), and haemoglobin glycation (HbA1C) levels. These findings also indicate that gender and sociodemographic characteristics like marital status and religion affect risk [9, 11].

Innovative local research in Saudi Arabia has investigated these links in further detail. In addition to confirming the association between OSA and conventional risk factors, research in Taif and Tabuk has added new variables to the diagnostic framework, such as medication history and levels of hyperlipidemia, to provide a more complete picture of the relationship between T2DM and OSA [12, 13]. The overall knowledge was poor for 80.7% of the sample of a study done in Abha [14]. The intricacy of the link between T2DM and OSA is emphasized by these studies, highlighting the necessity of focused therapies that can deal with the diseases' metabolic and sleep-related aspects.

2 Methods

This is an analytical cross-sectional study using nonprobability sampling (convenience), which allows for the assessment of both exposure and outcome simultaneously at a single point in time. It is particularly useful for generating hypotheses and understanding the prevalence of outcomes which fits the awareness-based studies. Convenience sampling was applied due to a lack of access to other hospitals and time constraints. The study was conducted from July 2022 to December 2022 with 386 T2DM participants. However, the study included both men and women, aged 18 and above, from all nationalities, attending the King Khalid University Hospital (KKUH) Diabetes Center outpatient clinic in Riyadh, Saudi Arabia, excluding patients with other metabolic disorders.

Data were collected face-to-face, using an electronic copy of the questionnaire. The first section includes the informed consent and demographic details such as age, gender, education level, and monthly income. The second section of the survey is focused on the state of lifestyle habits and identifying if there are any chronic illnesses with diabetes, such as hypertension, obesity, depression, and asthma. The third and last part of the survey is about specific questions regarding the STOP-BANG questionnaire: snoring, tiredness, observed while snoring, high blood pressure, BMI, age and gender. And also the awareness of the risk of OSA in TD2M participants. The study measured the participants' BMI using their informed weight and height, not measuring the neck circumference due to cultural barriers in women participants. Participants were given an iPad with the electronic form of the questionnaire. This will allow the privacy of the participants and eliminate manual data transferring.

3 Results

Table 1 displays the sociodemographic features of 386 T2DM participants. Most participants were men (52.1%). Educational status and monthly income shared almost the same distribution of population, with high educational and monthly income being less than the rest (13.7% in education and 20.7% in monthly income). Most of the participants sleep 5–8 h/day (81.9%). Over half of the population have little to no weekly based physical activity (57%). Most of them were clinically obese (BMI: 30 or more) (48.7%), and some were clinically overweight (BMI: 25–29.9) (21.8%). Most of the patients were diagnosed with hypertension (50.5%) while only (12.2%) were diagnosed with asthma and (9.3%) with depression. It is worth mentioning that only (19.4%) were smokers, including any type of smoking (hookah, cigarettes, vaping, etc.). Forty-seven participants had unknown recorded BMI due to a lack of knowledge about their weight and/or height.

Table 2A shows the knowledge of OSA found through the survey. Most of them have no knowledge regarding OSA (70.2%), consisting of ≤50 (38.6%), men (38.9%), high school or below (31.9%), BMI of 30–34.9 (18.9%), and not hypertensive (38.9%). There was a significant difference between age groups (p = 0.012), gender groups (p = 0.048), educational status (p = 0.002), BMI groups (p = 0.003), and hypertension groups (p = <0.001).

Table 2B shows participants' awareness of the relationship between T2DM and OSA and found through the survey. Most of them have no awareness of the relationship between T2DM and OSA (81.3%). The only significance found is with the hypertensive group (42.2%).

Table 3 demonstrates the risk of developing OSA in T2DM participants with clinical obesity (measured by BMI) by using a modified form of the STOP-BANG questionnaire. The mean score for BMI of 35 or more was 4.17 (SD = 1.41), age ≤50 was 3.11 (SD = 1.58), men gender 3.15 (SD = 1.51), high school or below, educational status 2.98 (SD = 1.61), less than 150 min/week physical activity 3.09 (SD = 1.56), 5-8 sleep h/day 2.83 (SD = 1.53), and hypertension 3.57 (SD = 1.40). Additionally, it shows a significant difference for BMI of 35 or more (p ≤ 0.001), age (p ≤ 0.001), gender (p ≤ 0.001), educational status (p = 0.005), physical activity (p = 0.002), and hypertension (p ≤ 0.001).

4 Discussion

Our study at KKUH involved 386 participants with T2DM to evaluate their awareness of OSA using a specially modified STOP-BANG questionnaire. This modification was significant: we excluded the neck circumference measurement, a standard component of the original questionnaire. This adjustment was made to respect cultural sensitivities in the Middle Eastern setting, where measuring neck circumference publicly can be seen as inappropriate or uncomfortable. Despite the omission of neck circumference, our modified STOP-BANG questionnaire still identified statistically significant correlations between the risk of OSA symptoms and high BMI, older age, male gender, lower educational status, limited physical activity, and hypertension. This suggests that even without the neck circumference data, the remaining indicators are strong predictors of OSA risk among T2DM patients.

The participant demographic was nearly evenly split between men (52.1%) and women (47.9%), predominantly aged over 50 years. A notable 50.5% of the participants had hypertension, and 57% reported engaging in less than 150 min of physical activity per week, indicating a predominantly sedentary lifestyle. Concerning BMI, which was measured in the clinical setting, 48.7% were clinically obese and 21.8% were overweight. Our study at the KKUH diabetic center used face-to-face electronic questionnaires to reduce the chance of selection bias, compared to another study that utilized an online format and reported a higher percentage of female participants (60.9%). This difference in methodology could affect the accuracy of their findings due to possible selection bias [14].

A critical finding was the low level of OSA awareness: 70.2% of participants had not heard of or understood OSA. Furthermore, 81.3% were unaware of the bidirectional relationship between T2DM and OSA, which is crucial for recognizing symptoms and preventing further complications. Our analysis found statistically significant associations between lack of awareness and factors such as age, gender, educational level (predominantly high school or less), and higher BMI values.

Additionally, a study conducted in Jazan using the STOP-BANG questionnaire revealed that obesity, hypertension, and older age significantly increased the risk of developing OSA among individuals with T2DM. This study found strong statistical evidence linking these conditions to OSA (p ≤ 0.05) [15, 16]. Similarly, a study from the College of Medicine at Qassim University in Buraidah showed that a high BMI, specifically a mean BMI of 32, is associated with clinical obesity and significantly correlated with hypertension (p = 0.0047). The participants were nearly equally divided between men and women, with men making up 50.3% of the sample [17].

These findings highlight the importance of raising awareness regarding the risks of OSA in people with T2DM, particularly those who are obese or have high blood pressure. Increased awareness can lead to earlier detection and better management of OSA, improving health outcomes for those at risk. Ultimately, these findings underscore the need for improved educational efforts regarding OSA in diabetic care settings, particularly given the cultural and logistical challenges of traditional diagnostic tools like the STOP-BANG questionnaire in certain populations. The study's limitations included a potential underestimation of OSA prevalence due to the modified questionnaire and a limited focus on sleep-related questions, which could affect the accuracy of identifying OSA risk.

5 Conclusion/Recommendations

The study reveals a significant lack of understanding among participants diagnosed with T2DM and OSA, a condition that often coexists with diabetes. Given the increased global incidence of diabetes and obesity—two critical health issues that call for rapid attention—this misunderstanding is extremely worrisome. Increased healthcare professional education is necessary due to the link between these disorders and obesity, a prevalent risk factor that raises mortality and health dangers. Increasing research at Riyadh's diabetes clinics, regularly screening for OSA symptoms, and creating OSA education programs are all important efforts. These are crucial initiatives to address the related issues of diabetes and obesity and to enhance overall patient outcomes.

Conflicts of Interest

The authors declare no conflicts of interest.