Moderate to severe obstructive sleep apnea during REM sleep as a predictor of metabolic syndrome in a Korean population



Metabolic syndrome is a cluster of metabolic abnormalities including obesity, hypertension, hypertriglyceridemia, low high-density lipoprotein cholesterol, and hyperglycemia. Obstructive sleep apnea (OSA) is known to be associated with metabolic syndrome. However, it remains uncertain which sleep parameters of OSA are associated with metabolic syndrome. We aimed to clarify the relationship between sleep variables and the presence of metabolic syndrome in patients with OSA.


We prospectively recruited patients who visited the institute for the evaluation of sleep-disordered breathing. All patients underwent overnight polysomnography and sleep questionnaires. They were diagnosed with metabolic syndrome according to the 2007 consensus definition by the International Diabetes Federation. We applied multivariate logistic regression models to predict the presence of metabolic syndrome with variables related to sleep parameters.


A total of 85 patients (43 men) were enrolled. The mean age (± standard deviation) was 52.0 ± 14.3 years. Metabolic syndrome was diagnosed in 39 (46%) patients. Patients with metabolic syndrome had a significantly higher apnea-hypopnea index (AHI) compared with patients without metabolic syndrome. An AHI greater than 15/h during REM sleep was a significant independent predictor of metabolic syndrome (adjusted OR, 7.08; 95% CI, 1.60–31.41; p = 0.010) after adjusting for age, body mass index, and non-REM AHI ≥ 15/h. In partial correlation analysis, REM AHI was significantly associated with the presence of metabolic syndrome after adjusting for age and BMI (r = 0.229, p = 0.042).


Korean patients with OSA frequently had comorbid metabolic syndrome. Moderate to severe OSA during REM sleep may be a predictor of metabolic syndrome.

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This research was supported by the Grant from the Seoul National University Hospital Research Fund (16-2014-85).

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Corresponding author

Correspondence to Hyunwoo Nam.

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All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

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Written informed consent was obtained from all individual participants included in the study.

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This study finds an association between the metabolic syndrome and OSA during REM sleep, with an adjusted OR of 7.08, but no significant association with non-REM OSA. This study adds to the growing body of literature finding REM OSA to be associated with cardiometabolic outcomes. A study in a Caucasian population (HypnoLaus cohort) also found an association between REM OSA and metabolic syndrome. The lower OR in that study may have been due to the different ethnicity of participants but also to the population-based rather than clinical-based study design. Several particularities of REM OSA may account for greater impact on outcomes as discussed by authors, notably, often more marked hypoxemia.

Although analyses were adjusted for body mass index, BMI is a poor predictor of metabolic and cardiovascular complications. Rather, waist circumference, which reflects visceral fat, is much more predictive but was not adjusted for and remains a possible confounder in this study. Further studies in different populations will need to more clearly delineate the role of OSA itself, including related intermittent hypoxemia, sleep fragmentation and deprivation, autonomic activation, etc., on metabolic dysregulation. Could an interaction exist between increased visceral fat and intermittent hypoxemia? Treatment studies will be particularly important to help guide clinical practice. Should we be more aggressive in treating patients with lower overall AHI if REM AHI is ≥ 15/h?

Marta Kaminska

Montreal, Canada

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Koo, D., Kim, HR. & Nam, H. Moderate to severe obstructive sleep apnea during REM sleep as a predictor of metabolic syndrome in a Korean population. Sleep Breath 24, 1751–1758 (2020).

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  • Obstructive sleep apnea
  • Apnea-hypopnea index
  • Metabolic syndrome
  • REM sleep