Association between insulin resistance and obstructive sleep apnea in non-diabetic children with obesity

Although several studies have demonstrated an independent association between obstructive sleep apnea (OSA) and insulin resistance, the evidence remains inconsistent. We aimed to investigate the relationship between the presence and severity of OSA and insulin resistance in non-diabetic children with obesity and to explore the potential role of homeostasis model assessment-insulin resistance index (HOMA-IR) in identifying children at higher risk for OSA. Children with obesity aged 6-18 years who underwent polysomnography were retrospectively analyzed. Patients with diabetes, neuromuscular disorders, craniofacial anomalies, or those receiving treatment affecting insulin sensitivity were excluded. Age, sex, BMI, and oral glucose tolerance test (OGTT) results were extracted from medical records, and HOMA-IR was calculated. Patients were divided into two groups based on their obstructive apnea-hypopnea index (OAHI): < 2 and ≥ 2 events/h. ROC analysis was performed for HOMA-IR to determine the optimal cutoff value for identifying patients with OSA. A total of 90 children with obesity were enrolled, among whom 39 (43.3%) had OSA. The groups were comparable in terms of age and sex. Median HOMA-IR values were significantly higher in the OSA group (p = 0.014). Total OAHI showed moderately positive correlation with HOMA-IR (ρ = 0.325, p = 0.002), and baseline insulin levels measured during OGTT (ρ = 0.323, p = 0.002). In multiple linear regression analysis, HOMA-IR remained independently associated with OSA severity after adjustment for age, sex, BMI z-score, sleep efficiency, and pubertal status (β = 0.691, p = 0.025). ROC analysis identified a HOMA-IR cutoff of 3.39, with 72% sensitivity and 59% specificity for OSA.

HOMA-IR was independently associated with OSA severity in children with obesity, suggesting that insulin resistance may serve as a useful adjunct marker for identifying patients at higher risk and prioritizing PSG evaluation.

• Childhood obesity is strongly associated with both obstructive sleep apnea (OSA) and insulin resistance. Whether insulin resistance contributes to OSA risk beyond the effect of obesity remains controversial. • Access to polysomnography (PSG) is limited, creating an unmet need for practical tools to identify children at greatest risk for OSA.

• To our knowledge, this is the first pediatric study to evaluate HOMA-IR as a tool for identifying children with obesity at increased risk of obstructive sleep apnea and to propose a clinically applicable HOMA-IR threshold for prioritizing polysomnography referral. • In non-diabetic children with obesity, insulin resistance was independently associated with OSA severity, regardless of obesity, pubertal status, and other clinically relevant confounders. Children with HOMA-IR ≥ 3.39 had a substantially greater burden of obstructive sleep apnea. These findings support HOMA-IR as a simple, widely available biomarker that could help prioritize children with obesity for PSG evaluation and improve risk stratification in pediatric sleep medicine.