Special Edition: Obstructive Sleep Apnea, Part 1 – May 2025

Podcast: Diabetes Core Update
Hosts: Dr. Neil Skolnick & Dr. John J. Russell
Guest Expert: Dr. Paul Dugramji
Date: May 20, 2025
Episode Focus: Introduction to Obstructive Sleep Apnea (OSA)—Definition, Pathophysiology, Epidemiology, Clinical Presentation, and Consequences

Episode Overview

This special episode launches a four-part series on Obstructive Sleep Apnea (OSA), an underdiagnosed yet highly prevalent condition, particularly among individuals with diabetes. Dr. Neil Skolnick and featured guest, Dr. Paul Dugramji, delve into OSA's definition, pathophysiology, severity classification, epidemiology, clinical clues, risk stratification tools, and the profound impact untreated OSA can have on a patient’s quality of life and comorbidity profile. The discussion is tailored to help primary care providers enhance their clinical suspicion and improve early identification and management of OSA.

Key Discussion Points & Insights

1. Defining OSA and Its Pathophysiology

• Definition: OSA (Obstructive Sleep Apnea) is characterized by recurrent episodes of either complete (apnea) or partial (hypopnea) obstruction of the upper airway during sleep, leading to reduced or entirely blocked airflow for at least 10 seconds at a time.
  • “Obstructive sleep apnea, as the name suggests, is a condition in sleep where the person actually stops breathing...this is a decreased airflow that occurs during sleep and this is repetitive.” — Dr. Paul Dugramji [01:59]
• Pathophysiology: The human pharynx and hypopharynx are uniquely pliable, making them susceptible to collapse, particularly with increased fat deposition or unfavorable anatomy. OSA is strongly linked to obesity due to increased fat around the airway.
  • “The more weight that a person carries, the more likely they are to develop obstructive sleep apnea...the more fat deposition there is, the lesser or smaller the airway, and as a result...more collapsibility.” — Dr. Paul Dugramji [05:50]

2. Severity: How OSA Is Measured

• Apnea-Hypopnea Index (AHI): Average number of apneas and hypopneas per hour of sleep during a sleep study.
  • Mild: 5–15
  • Moderate: 16–30
  • Severe: over 30
  • “What we currently have our settings on is 5 to 15 apnea hypopnea index...is considered mild OSA, 16 to 30 is considered moderate OSA, and over 30 is considered severe.” — Dr. Paul Dugramji [04:09]

3. Epidemiology: How Common Is OSA?

• General Population: Prevalence in men was ~24% and women ~9% (1994 NEJM study), with more recent estimates putting moderate to severe OSA at ~15% for men and ~5% for women. Prevalence is increasing, fueled by rising obesity rates.
  • “It was estimated...in a recent article in JAMA to be about 15% for men and 5% for women with moderate to severe OSA accounting for a large proportion of that number.” — Dr. Neil Skolnick [08:02]
• Special Populations:
  • Pacific Islanders and some Asians have greater anatomical risk.
  • 70% of patients with OSA are obese; conversely, obese individuals have a ~40% chance of having OSA.
  • Diabetics are three times more likely to have OSA.
  • “If the person is obese, they have about a 40% chance that they will have obstructive sleep apnea. But if you take people who have obstructive sleep apnea, 70% are obese.” — Dr. Paul Dugramji [09:07]
  • “Diabetics are three times more likely to have obstructive sleep apnea. But also, if you have obstructive sleep apnea, it is a risk factor for diabetes in and of itself.” — Dr. Paul Dugramji [10:53]

4. The Diagnosis Gap

• Undiagnosis: 80–90% of OSA cases remain undiagnosed, even in patients with regular healthcare, due to lack of overt symptoms and insufficient provider attention.
  • “Most recent evidence is suggesting that, unfortunately, 80 to 90% of people with OSA remain undiagnosed...” — Dr. Paul Dugramji [11:28]

5. Clinical Presentation & Clues for Diagnosis

• Symptoms:
  • Loud snoring (often reported by bed partners)
  • Witnessed apneas or gasping/choking during sleep
  • Morning symptoms: headaches, dry mouth, sore throat
  • Insomnia (frequent nighttime awakenings)
  • Nocturia and enuresis (bedwetting)
  • Most notably: excessive daytime sleepiness/fatigue
  • “Choking or gasping during sleep is a glaring problem. If a patient says to you, sometimes I wake up in the middle of night because of choking and gasping, that person has obstructive sleep apnea until proven otherwise.” — Dr. Paul Dugramji [13:14]
  • “Daytime fatigue or tiredness, specifically what we call excessive daytime sleepiness...can be a serious, hazardous problem.” — Dr. Paul Dugramji [14:38]
• High-Risk Contexts:
  • Resistant hypertension
  • Difficult-to-control diabetes
  • Heart failure, coronary artery disease, stroke, atrial fibrillation (50% have OSA)
  • Resistant depression
  • “When we talk about clinical symptoms...there are many medical conditions that we should have our antennas going up to think about obstructive sleep apnea. One of them is in fact resistant hypertension...depression, coronary artery disease, stroke, atrial fibrillation...” — Dr. Paul Dugramji [16:25]

6. Screening & Stratification Tools

• Epworth Sleepiness Scale (ESS): Assesses risk of excessive daytime sleepiness.
• STOP-BANG Questionnaire:
  • S: Snoring
  • T: Tiredness
  • O: Observed apnea
  • P: high blood Pressure
  • B: BMI (>35)
  • A: Age (>50)
  • N: Neck (>17” M; >16” F)
  • G: Gender (male)
  • “If anybody has three or more of these positive, the probability of obstructive sleep apnea is around 85%...with 5 or more positive...95% probability.” — Dr. Paul Dugramji [18:38]
• Mallampati Score: Assesses pharyngeal anatomy via oral exam.

7. Consequences of Untreated OSA

• Quality of Life & Safety:
  • Daytime sleepiness leads to increased risk of car or industrial accidents.
  • Cognitive impairment and decreased interpersonal, romantic relationships.
  • “OSA degrades quality of life. It degrades interpersonal relationships, romantic relationships. These people don’t really feel like doing anything. They’re tired throughout the day.” — Dr. Paul Dugramji [21:20]
• Medical Comorbidities:
  • Hypertension (especially resistant), heart failure, stroke, heart attack, type 2 diabetes, depression (particularly resistant), atrial fibrillation, intractable reflux.
  • “50% of patients with atrial fibrillation have obstructive sleep apnea...nowadays a lot of cardiologists are sending patients...to the sleep center...” — Dr. Paul Dugramji [22:12]
  • Decreased life expectancy.

8. Does Treatment Make a Difference?

• Definitive YES:
  • CPAP, BiPAP, and autoPAP improve symptoms, quality of life, comorbidities, and life expectancy.
  • Recent studies (tirzepatide) show weight loss interventions, including some diabetes medications, can improve OSA.
  • “Is intervening going to make any difference at all? And the answer to that is yes, a big difference. We know that...when we intervene with relieving the obstruction, people feel better, their comorbidities improve and they live longer.” — Dr. Paul Dugramji [23:31]

Notable Quotes & Memorable Moments

• On the silent epidemic:
  • “Most recent evidence is suggesting that, unfortunately, 80 to 90% of people with OSA remain undiagnosed despite receiving adequate access to healthcare.” — Dr. Paul Dugramji [11:28]
• On key presenting clues:
  • “Choking or gasping during sleep is a glaring problem. If a patient says to you, sometimes I wake up in the middle of night because of choking and gasping, that person has obstructive sleep apnea until proven otherwise.” — Dr. Paul Dugramji [13:14]
• On the impact of intervention:
  • “We know that when we intervene with relieving the obstruction, people feel better, their comorbidities improve and they live longer.” — Dr. Paul Dugramji [23:44]

Timestamps for Major Segments

• [00:02] Opening and episode overview
• [01:52] Defining OSA and its basic pathophysiology
• [03:11] How OSA severity is classified (AHI, mild-moderate-severe)
• [04:42] Pathophysiology: Why OSA develops
• [06:35] Epidemiology and historical prevalence data
• [08:58] Prevalence in high-risk groups (obesity, diabetes, ethnicity)
• [11:28] The diagnosis gap: High rates of undiagnosed OSA
• [12:27] Clinical presentation—Symptoms and clues for suspicion
• [16:25] Associated/secondary conditions that should raise suspicion
• [18:38] Tools for screening: ESS, STOP-BANG, Mallampati
• [21:20] Consequences: Quality of life, safety, and comorbidities
• [23:31] Evidence that treatment makes a tangible difference
• [25:01] Final thoughts and summary

Final Thoughts

Dr. Dugramji underscores the urgency for clinicians to proactively identify and treat OSA, given its prevalence and pervasive consequences. Incorporating routine sleep histories and validated questionnaires (STOP-BANG, ESS) can dramatically improve identification rates, intervening with therapies that offer substantial improvements in patient well-being and long-term outcomes.

“We need to identify them, stratify them, treat them and get them better. We’re all about helping our patients to reduce towards better quality of life and longevity. And by diagnosing sleep apnea, by remedying it, we can make a significant difference...” — Dr. Paul Dugramji [25:01]

Next Episode Teaser:
The series continues with a stepwise approach to diagnosis and interpretation of sleep studies, followed by treatment modalities and real-world patient cases in upcoming episodes.