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Letter to the Editor Regarding: “Association between Metabolic Score for Insulin Resistance (METS-IR) and Risk of Obstructive Sleep Apnea: Analysis of NHANES Database and a Chinese Cohort” [Letter]
Received 29 April 2025
Accepted for publication 9 May 2025
Published 22 May 2025 Volume 2025:17 Pages 987—988
DOI https://doi.org/10.2147/NSS.S536885
Checked for plagiarism Yes
Editor who approved publication: Prof. Dr. Ahmed BaHammam
Qing-qing Shan, Yangke Li
Department of Respiration, Chengdu Integrated TCM & Western Medicine Hospital, Chengdu, 610095, People’s Republic of China
Correspondence: Qing-qing Shan, Department of Respiration, Chengdu Integrated TCM & Western Medicine Hospital, No. 18, Wangxiang North Road, High-Tech Zone, Chengdu, Sichuan, 610041, People’s Republic of China, Tel +86-028-85311622, Email [email protected]
View the original paper by Dr Zhou and colleagues
A Response to Letter has been published for this article.
Dear editor
We read with great interest the article by Zhou et al1 demonstrating a significant association between the Metabolic Score for Insulin Resistance (METS-IR) and obstructive sleep apnea (OSA) risk. While this study provides valuable insights into METS-IR as a potential screening tool for OSA, particularly in metabolically abnormal individuals without elevated BMI, we wish to highlight several methodological considerations that could enhance future research.
First, regarding sample selection, the OSA risk assessment in the NHANES cohort relied on questionnaire-based definitions, yielding a prevalence of 49.8%. This contrasts with polysomnography (PSG)-confirmed prevalence rates of 10–17% among adults aged 30–70 years, with significant gender disparities (24% in males vs 9% in females).2 We recommend incorporating home sleep apnea testing (HSAT) or validated portable monitoring devices to improve diagnostic accuracy.3
Second, concerning covariate control, two key limitations merit attention: Unadjusted sleep parameters: Sleep duration and fragmentation may independently influence the METS-IR-OSA relationship. Reference to standardized sleep variable adjustments, as implemented in the CARDIA study,4 would strengthen the analysis. Medication effects: The impact of glucocorticoids and β-blockers on insulin sensitivity5 warrants consideration in future studies. Recent findings suggest that while certain OSA severity markers correlate with HbA1c, neither OSA severity nor sleep duration is associated with insulin sensitivity or β-cell function indices.6
Third, the cross-sectional design precludes causal inference. The bidirectional relationship between OSA and METS-IR—whereby intermittent hypoxia may exacerbate insulin resistance—necessitates intervention studies examining continuous positive airway pressure (CPAP) effects on metabolic parameters.7
Finally, the observed gender differences in subgroup analyses may reflect sex-specific fat distribution patterns, with reduced visceral adiposity in women potentially attenuating METS-IR’s predictive power.8 Future studies should explore these physiological distinctions.
In conclusion, while Zhou et al present compelling evidence for METS-IR as an OSA risk marker, addressing these methodological considerations would enhance the validity and clinical applicability of findings. We commend the authors for their valuable contribution to this emerging field.
Data Sharing Statement
Data sharing is not applicable to this article as no data were created or analysed in this study.
Author Contributions
Qing-qing Shan: Conceptualization, Writing - original draft. Yangke Li: Conceptualization, Writing - original draft. All authors have agreed on the journal to which the article will be submitted. Reviewed and agreed on all versions of the article before submission, during revision, the final version accepted for publication, and any significant changes introduced at the proofing stage, and agree to take responsibility and be accountable for the contents of the article.
Funding
No funding was received.
Disclosure
The authors reported no potential conflict of interest. There are no relevant financial or non-financial competing interests to report.
References
1. Zhou B, Yao Y, Wang Y, et al. Association between Metabolic Score for Insulin Resistance (METS-IR) and risk of obstructive sleep apnea: analysis of NHANES database and a Chinese cohort. Nat Sci Sleep. 2025;17:607–620. doi:10.2147/NSS.S400125
2. Peppard PE, Young T, Barnet JH, Palta M, Hagen EW, Hla KM. Increased prevalence of sleep-disordered breathing in adults. Am J Epidemiol. 2013;177(9):1006–1014. doi:10.1093/aje/kws342
3. Kapur VK, Auckley DH, Chowdhuri S, et al. Clinical practice guideline for diagnostic testing for adult obstructive sleep apnea: an American Academy of Sleep Medicine clinical practice guideline. J Clin Sleep Med. 2017;13(3):479–504. doi:10.5664/jcsm.6506
4. Cho HJ, Seeman TE, Kiefe CI, Lauderdale DS, Irwin MR. Sleep disturbance and longitudinal risk of inflammation: moderating influences of social integration and social isolation in the Coronary Artery Risk Development in Young Adults (CARDIA) study. Brain Behav Immun. 2015;46:319–326. doi:10.1016/j.bbi.2015.02.023
5. Petersen MC, Shulman GI. Mechanisms of insulin action and insulin resistance. Physiol Rev. 2018;98(4):2133–2223. doi:10.1152/physrev.00063.2017
6. Mokhlesi B, Tjaden AH, Temple KA, et al. Obstructive sleep apnea, glucose tolerance, and β-cell function in adults with prediabetes or untreated type 2 diabetes in the Restoring Insulin Secretion (RISE) Study. Diabetes Care. 2021;44(4):993–1001. doi:10.2337/dc20-2127
7. Sharma SK, Agrawal S, Damodaran D, et al. CPAP for the metabolic syndrome in patients with obstructive sleep apnea. N Engl J Med. 2011;365(24):2277–2286. doi:10.1056/NEJMoa1103944
8. Zhang W, Chen C, Li M, Yan G, Tang C. Sex differences in the associations among insulin resistance indexes with metabolic syndrome: a large cross-sectional study. Int J Endocrinol. 2024;2024:3352531. doi:10.1155/2024/3352531
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