Longitudinal study of moderate weight change and sleep-disordered breathing

Comparative efficacy of non-pharmacological interventions for adults with sleep apnea: A systematic review and network meta-analysis

BACKGROUND

Sleep apnea is associated with cardiovascular risk, work productivity, occupational/traffic accidents, and quality-of-life (QoL); however uncertainty exists regarding optimal treatment. We performed a systematic review on the efficacy of non-pharmacological interventions for adults with sleep apnea.

METHOD

We searched MEDLINE, Scopus, Virtual-Health-Library and Web-of-Science through June 2023 for parallel/cross-over randomized trials on adults with sleep apnea (apnea-hypopnea-index>5 events/hour). Study selection, data extraction and risk-of-bias assessment were performed in duplicate, followed by frequentist network meta-analyses.

RESULTS

Ultimately, 197 unique trials were included (15,931 patients; mean age 51.4 years; 78.9 % male) assessing 25 treatments. Positive Airway Pressure (PAP) (alone or combined with health behaviour modification) consistently improved more apnea-hypopnea-index or daytime sleepiness and physical/mental QoL in obstructive sleep apnea (OSA) patients compared to all other interventions but was not always well-tolerated. Mandibular advancement devices (MAD) yielded the greatest improvement in depression, while also improving objective/subjective apnea-outcomes, and physical/mental QoL-albeit less than PAP and less for moderate/severe cases. Acupuncture, health behaviour modifications, surgical maxillomandibular advancement, minor oral surgery, oropharyngeal training, oxygen supplementation, or electrical neurostimulation might improve apnea-related outcomes, but weak evidence exists. Finally, electrical neurostimulation performed best for central sleep apnea and PAP performed best for positional OSA. Confidence in the network meta-analysis estimates was low due to non-adherence issues that was rarely directly assessed in included trials with objective measures.

CONCLUSION

PAP (alone or with co-interventions) performed best for the treatment of adult OSA patients regardless of disease severity. For patients not tolerating PAP, MADs might be a good alternative, but confer smaller improvements overall. However, adherence issues and the heterogenous response increase the complexity of OSA treatment.

Obesity Management for Patients with Coronary Artery Disease and Heart Failure

Obesity is causally linked to heart disease directly by triggering various adverse pathophysiological changes and indirectly through convergent risk factors such as type 2 diabetes, hypertension, dyslipidemia, and sleep disorder. Weight reduction is an important intervention for obesity-related cardiomyopathy, and antiobesity medications that target both obesity and heart failure (HF), particularly sodium-glucose cotransporter-2 inhibitors and glucagon-like peptide 1 receptor agonists, have a role in treatment. Bariatric surgery offers a viable treatment option for patients with severe obesity associated with coronary artery disease and HF but requires careful patient selection, preoperative optimization, choice of procedure, and postoperative management to minimize risks.

Association between obstructive sleep apnea and migraine: A United States population-based cohort study

OBJECTIVE

To determine the association between obstructive sleep apnea (OSA) and the incidence of migraine using a large population-based dataset, as well as to identify the at-risk target groups.

BACKGROUND

Epidemiological and biochemical studies have provided evidence for the close connection between sleep disorders and migraine. Understanding the connections between OSA and migraine, as well as their shared risk factors, may provide new perspectives on the pathophysiology of both OSA and migraine and novel approaches to managing and treating these conditions.

METHODS

This retrospective cohort study used data from the TriNetX network from 2010 to 2021. We compared 196,864 adult participants with OSA to a group of 196,864 participants who had never been diagnosed with OSA (1:1 propensity score-matching for age, sex, race, comorbidities, and body mass index [BMI] categories) in relation to the risk of incident migraine. We performed subgroup analyses based on age (18-39, 40-59, ≥60 years), sex (female, male), race (White, Black or African American, Asian), BMI categories (<18.5, 18.5-24.9, 25-29.9, ≥30 kg/m2), and the presence of hypoxemia (yes, no). Sensitivity analyses were performed to validate our findings.

RESULTS

During the follow-up period, 12,613 (6.4%) and 6356 participants (3.2%) developed migraine in the OSA and non-OSA cohorts, respectively. Patients with OSA were found to have a 1.85-fold risk (hazard ratio [HR] 1.85; 95% confidence interval [CI] 1.79-1.90) of incident migraine when compared to those without OSA, after accounting for age, sex, race, and baseline comorbidities. The results were consistent in sensitivity analyses (test-negative design: HR 1.39, 95% CI 1.28-1.49) and also cross-validated in a different dataset from TriNetX (Global Collaborative Research Network: HR 1.88, 95% CI 1.82-1.93). The results of subgroup analysis by sex, age, race, BMI categories, and the presence of hypoxemia were generally consistent.

CONCLUSION

We found OSA to be associated with an elevated risk of developing migraine using a large United States nationwide database, and the association was generalizable across sex, age, race, and BMI categories. Our results suggest that awareness of migraine should be increased among patients with OSA. The findings also encourage further research to clarify the role of obesity and overweight in the relationship between OSA and migraine, as well as the potential benefits of body weight control for those with these two comorbid conditions.

Sex Differences in Obesity and Its Treatment

PURPOSE OF REVIEW

Researchers and clinicians have increasingly recognized the importance of investigating and considering sex differences in obesity treatment. In this narrative review, we first summarized sex differences in select obesity-related conditions that have been the focus of studies of second-generation anti-obesity medications (i.e., semaglutide and tirzepatide) including type 2 diabetes, obstructive sleep apnea, knee osteoarthritis, and heart failure. We next described sex differences related to obesity treatments with a focus on the second-generation anti-obesity medications, semaglutide and tirzepatide.

RECENT FINDINGS

Type 2 diabetes, obstructive sleep apnea, knee osteoarthritis, and heart failure demonstrated sex-specific pathways influenced by factors such as hormones and body composition. Lifestyle modification, on average, resulted in larger weight losses in males. In contrast, second-generation AOMs produced higher mean weight losses among females. Females reported more adverse events (e.g., nausea, vomiting) with second-generation anti-obesity medications. The few studies that have performed analyses of changes in obesity-related comorbidities stratified by sex have shown consistent improvements between males and females in heart failure and cardiovascular outcomes. Studies are needed to evaluate the effect of sex on the efficacy of anti-obesity medications including on mental health, investigate the mechanisms underlying these effects, and develop interventions to improve the availability and access of these medications.

Evaluating cystatin-C and monocyte-to-high-density lipoprotein cholesterol ratio as indicators of obstructive sleep apnea severity in male patients

Objectives

This study investigates the association between blood cystatin-C (Cys-C) and monocyte-to-high-density lipoprotein cholesterol ratio (MHR), both established inflammatory markers, with the severity of obstructive sleep apnea (OSA) in male patients.

Methods

A total of 117 male participants who underwent overnight polysomnography (PSG) between February 2019 and December 2022 were included. Based on the apnea-hypopnea index (AHI), participants were categorized into three groups: G1 (AHI < 5 events/hour, n = 9; control group), G2 (5 ≤ AHI < 30 events/hour, n = 32), and G3 (AHI ≥ 30 events/hour, n = 76). Serum Cys-C and MHR levels were measured and analyzed for their correlation with OSA severity. Multivariate logistic regression and receiver operating characteristic (ROC) analyses assessed their diagnostic value, while restricted cubic spline (RCS) analysis examined potential nonlinear relationships.

Results

Cys-C and MHR levels increased with OSA severity and showed significant positive correlations with AHI (Cys-C: r = 0.084, P < 0.05; MHR: r = 0.1286, P < 0.05). In multivariate regression, MHR remained an independent correlate of OSA severity (adjusted OR = 47.130, 95% CI: 1.014-6.692, P = 0.008), whereas Cys-C lost statistical significance after adjusting for confounders. RCS analysis found no significant nonlinear relationship (P > 0.05). ROC analysis showed that combining Cys-C and MHR modestly improved diagnostic accuracy (AUC = 0.6622, 95% CI: 0.554-0.77). Subgroup analysis indicated that severe OSA patients with hypertension had higher Cys-C and MHR levels compared to those without hypertension, though the differences were not statistically significant (P > 0.05).

Conclusions

Cys-C and MHR are positively associated with OSA severity, with MHR emerging as a stronger independent biomarker. Incorporating these markers into OSA risk stratification may enhance clinical assessment and targeted interventions. Future large-scale prospective studies are needed to validate their prognostic value and clinical utility.

Multimodal Treatment of Sleep Apnea

Obstructive sleep apnea (OSA) is a common condition linked with multiple comorbidities. Continuous positive airway pressure (CPAP) devices, though the gold standard for OSA treatment, often do not address the entirety of the disorder. Various treatment strategies exist to address OSA beyond CPAP, each targeting different OSA aspects. These include managing comorbid sleep disorders, anatomic considerations, endotype-directed therapy, and lifestyle interventions. These comprehensive approaches aim to improve the benefits of treatment, and reduce the complications associated with OSA.

Effects of sleeve gastrectomy on populations with obesity and obstructive sleep apnea: a meta-analysis

BACKGROUND

Obstructive sleep apnea (OSA) is highly prevalent in patients with morbid obesity, prompting interest in bariatric surgery as a potential management strategy. Sleeve gastrectomy (SG), being the primary bariatric surgical option, offers simplicity, reduced postoperative complications, and favorable outcomes for obesity and its associated conditions.

OBJECTIVES

This study aims to assess the efficacy of SG in treating populations with obesity and OSA.

SETTING

University-affiliated hospital, China.

METHODS

We conducted a comprehensive literature search across PubMed, Embase, Cochrane Library, and Web of Science databases to identify pertinent studies published up to March 28, 2024. Our review encompassed studies that assessed the effectiveness of SG on primary outcomes, including the apnea-hypopnea index (AHI), as well as secondary outcomes such as forced vital capacity (FVC), forced expiratory volume in the first second (FEV1), nonrapid eye movement sleep stage 3 (NREM 3), rapid eye movement sleep (REM), sleep efficiency (SE), arousal index, Epworth sleepiness scale (ESS), oxygen desaturation index (ODI), apnea index (AI), meanSpO2, body mass index (BMI), weight, neck circumference (NC), waist circumference (WC), waist-to-hip ratio (WHR), subcutaneous fat area (SFA), visceral fat area (VFA), systolic blood pressure(SBP)/diastolic blood pressure(DBP), and measurements related to glucolipid metabolism. A total of 12 eligible studies underwent a systematic screening process and were subsequently subjected to meta-analysis using either randomized effects model or fixed-effect models.

RESULTS

Significant reductions in AHI, BMI, weight, SFA, and VFA were observed following SG. Correspondingly, enhancements in FVC, meanSpO2, NREM 3%, REM%, and SE, were noted after SG. Additionally, the populations with obesity and OSA exhibited decreases in arousal index, ODI, AI, ESS, NC, WC, WHR, and DBP post-SG. Moreover, reductions in HOMA-IR and glycosylated hemoglobin were also observed after SG.

CONCLUSION

SG demonstrates favorable outcomes in the populations with obesity and OSA.

Obesity and Atrial Fibrillation: A Comprehensive Review

Atrial fibrillation (AF) remains the most common arrhythmia worldwide, but its pathophysiology remains complex and multifactorial. As obesity has increased over the past couple of decades, much interest has been generated about its relationship with other diseases. As a result, the interplay between AF and obesity has been rigorously investigated as risk factor modification has become more important for the management of AF. In this review, we discuss the epidemiology of AF and obesity, the pathophysiology connecting these two diseases, and how obesity affects the management of AF.

Obesity and cardiovascular disease: an ESC clinical consensus statement

The global prevalence of obesity has more than doubled over the past four decades, currently affecting more than a billion individuals. Beyond its recognition as a high-risk condition that is causally linked to many chronic illnesses, obesity has been declared a disease per se that results in impaired quality of life and reduced life expectancy. Notably, two-thirds of obesity-related excess mortality is attributable to cardiovascular disease. Despite the increasingly appreciated link between obesity and a broad range of cardiovascular disease manifestations including atherosclerotic disease, heart failure, thromboembolic disease, arrhythmias, and sudden cardiac death, obesity has been underrecognized and sub-optimally addressed compared with other modifiable cardiovascular risk factors. In the view of major repercussions of the obesity epidemic on public health, attention has focused on population-based and personalized approaches to prevent excess weight gain and maintain a healthy body weight from early childhood and throughout adult life, as well as on comprehensive weight loss interventions for persons with established obesity. This clinical consensus statement by the European Society of Cardiology discusses current evidence on the epidemiology and aetiology of obesity; the interplay between obesity, cardiovascular risk factors and cardiac conditions; the clinical management of patients with cardiac disease and obesity; and weight loss strategies including lifestyle changes, interventional procedures, and anti-obesity medications with particular focus on their impact on cardiometabolic risk and cardiac outcomes. The document aims to raise awareness on obesity as a major risk factor and provide guidance for implementing evidence-based practices for its prevention and optimal management within the context of primary and secondary cardiovascular disease prevention.

Associations between mobile phone involvement, BMI levels, and sleep quality among Chinese university students: evidence from a multi-regional large-scale survey

Objective

This study aims to explore the association between mobile phone involvement, body mass index (BMI) levels, and the sleep quality of Chinese university students.

Methods

Using a cluster sampling method, we selected 17,085 university students from three universities in eastern, central, and western China as the study subjects. Demographic information such as age and sex were collected. The Pittsburgh Sleep Quality Index (PSQI) and the Mobile Phone Involvement Questionnaire (MPIQ) were utilized to measure their sleep quality scores and mobile phone involvement scores, respectively. Pearson correlation analysis, two-way ANOVA, and multiple linear regression were employed to examine the relationship between BMI levels, mobile phone involvement, and sleep quality.

Results

The results show that 15.87% (2,712 participants) are classified as overweight, and 18.45% (3,151 participants) are classified as obese. Additionally, 35.87% (6,125 participants) exhibit mobile phone involvement, while 57.94% (9,899 participants) reported poor sleep quality. Pearson correlation analysis indicates a significant negative correlation (p < 0.01) between sleep quality and both BMI levels and mobile phone involvement. Two-way ANOVA shows the significant effect of BMI levels (p < 0.001) and mobile phone involvement (p < 0.001) on sleep quality, and there is no interaction effect between the two. Additionally, the sleep quality of overweight and obese individuals is significantly poorer than that of those with normal weight (p < 0.05), while the sleep quality of overweight individuals is significantly lower than that of obese individuals (p < 0.05). Multiple linear regression analysis indicates that, after controlling for age and gender, both BMI (β = -2.69) levels and mobile phone involvement (β = -1.34) are significantly negatively associated with sleep quality (p < 0.001), accounting for 19% of the variance in poor sleep quality.

Conclusion

This study found that BMI levels and mobile phone involvement are both independently associated with sleep quality among Chinese university students. However, among individuals with excess BMI, although their sleep quality is worse than individuals with normal weight, overweight individuals may have poorer sleep quality than obese individuals. This study also revealed high rates of overweight and obesity, with over half of participants reporting poor sleep quality, highlighting the need for targeted interventions to address weight management and mobile phone usage to improve sleep health in this population.

Assessment of obstructive sleep apnea rate and associated factors among Lebanese adults: a cross-sectional study

Objectives

To estimate the rate of obstructive sleep apnea (OSA) and associated factors among Lebanese adults.

Methods

A cross-sectional study was conducted in February-April 2022; 1,202 Lebanese adults were enrolled. The sample was collected among several Lebanese governorates through an anonymous online self-reported questionnaire. The STOP-BANG questionnaire was used as a screening tool to estimate the OSA risk. "Low OSA risk" is established with 0-2 positive answers, "Intermediate OSA risk" is established by 3-4 positive answers while "High OSA risk" is established by 5-8 positive answers.

Results

This study showed that 743 (62.4%) of the sample had low risk for OSA, 357 (30.0%) had moderate, and 90 (7.6%) had high risk for OSA. Older age (aOR = 1.05) and having hypertension (aOR = 7.80) were associated with higher odds of moderate OSA. Female sex (aOR = 0.04) was significantly associated with lower odds of moderate OSA compared to males. Older age (OR = 1.17), higher BMI (OR = 1.14), hypertension (OR = 18.55), and having severe COVID-19 infection compared to mild (OR = 4.30) were significantly associated with higher odds of high OSA, whereas female sex (OR = 0.002) and being married compared to single (aOR = 0.23) were associated with lower odds of high OSA.

Conclusion

This study showed that most Lebanese adults have low risk for OSA. It also confirmed that sex, age, obesity, hypertension, and severe COVID-19 were associated with high OSA risk. These associated factors call for future research exploring the causes including the potential effect of social, economic, and political instability, local customs, and environmental factors. Moreover, future health campaigns should be assigned to increase awareness among Lebanese population regarding the prevention of OSA through lifestyle modifications.

Weight-adjusted-waist index is associated with increased risk of sleep disturbances in the U.S. adult population: an analysis of NHANES 2007-2012

OBJECTIVE

The weight-adjusted-waist index (WWI) is a novel measure of central adiposity, potentially linked to various sleep disturbances. This study explores the relationship between WWI and sleep outcomes, such as trouble sleeping, sleep disorder, and sleep duration.

METHODS

Data from the National Health and Nutrition Examination Survey 2007-2012 were analyzed, including 13,494 participants. The analysis focused on individuals aged 20 years and older who provided information on WWI and sleep. Sleep status was determined based on responses to the following questions: (1) "How many hours do you sleep?"; (2) if they reported trouble sleeping; and (3) if they had physician-diagnosed sleep disorders. Regression models assessed the association between WWI and sleep outcomes across the entire population and within subgroups. Restricted cubic spline (RCS) analysis was conducted to examine potential non-linear relationships between WWI and sleep outcomes.

RESULTS

A higher WWI was significantly correlated with an increased likelihood of trouble sleeping (OR = 1.26, 95% CI: 1.16, 1.36; p < 0.001) and sleep disorder (OR = 1.71, 95% CI: 1.50, 1.95; p < 0.001) in the overall population. RCS analysis indicated a linear relationship between WWI and these sleep outcomes. Subgroup analysis identified that the connection between WWI and trouble sleeping was most pronounced among Non-Hispanic Blacks and individuals with lower educational levels. For sleep disorder, the association was stronger in males and Non-Hispanic Blacks. A slight negative association between WWI and sleep duration was found, especially among non-drinkers (β = - 0.13, 95% CI: - 0.24, - 0.02; p = 0.028).

CONCLUSION

The findings highlight a significant and linear relationship between elevated WWI and an increased likelihood of experiencing trouble sleeping and sleep disorder, with variations observed across different demographic and lifestyle subgroups. These results imply that central adiposity, as measured by WWI, plays an important role in sleep health.

LEVEL OF EVIDENCE

Level III: Evidence obtained from well-designed cohort or case-control analytic studies.

Prevalence of symptoms suggestive of sleep apnea among children and its impact on academic performance

BACKGROUND

Obstructive sleep apnea (OSA) is a common condition in pediatrics that requires prompt recognition and management to minimize its negative impact on their health and development. Data on the prevalence of OSA among school-age minors in Jordan is scarce. This study aims to estimate the prevalence of OSA in children and adolescents and identify factors that make them more likely to have OSA and its impact on academic achievement.

METHODS

This school-based cross-sectional study was conducted from January to March 2023. A questionnaire including information on demographic variables, school performance, and a validated sleep-related breathing disorder (SRBD) scale for pediatrics was distributed to 1798 students in schools all over Amman. The prevalence of OSA (defined as SRBD score > 33%) was reported as a proportion along with its 95% confidence interval.

RESULTS

Out of the 2000 questionnaires distributed, 1798 were analyzed. Among these, 1079 (60%) were from children aged 5 to 10 years, and 719 (40%) were from adolescents aged 11 to 18 years. The prevalence of high risk for OSA (HR-OSA) was higher among adolescents than in children (25.6% vs. 20.8%). Adolescents with unemployed fathers were more likely to be HR-OSA (33.70 vs 17.57%, p < 0.001). In contrast, paternal employment did not affect the prevalence of HR-OSA in children. Sleep talking, bruxism, and sweating during sleep were more common among children with positive SRBD. Nocturnal enuresis (NE) was associated with positive SRBD in children and adolescents. HR-OSA was associated with poor academic performance in both study groups.

CONCLUSION

HR-OSA is highly prevalent in Jordanian children and adolescents. HR-OSA can occur alongside other sleep disorders, and it significantly impairs the academic performance of affected individuals. This study found an association between high risk for OSA and other sleeping disorders (sleep talking, sleep bruxism, and sweat during sleeping) and nocturnal enuresis which needs to be confirmed in larger studies.

The MC4R agonist, setmelanotide, is associated with an improvement in hypercapnic chemosensitivity and weight loss in male mice

Obesity increases the risk of respiratory diseases that reduce respiratory chemosensitivity, such as Obesity Hypoventilation Syndrome and sleep apnea. Recent evidence suggests that obesity-related changes in the brain, including alterations in melanocortin signaling via the melanocortin-4 receptor (MC4R), may underly altered chemosensitivity. Setmelanotide, an MC4R agonist, causes weight loss in both humans and animal models. However, it is unknown the extent to which setmelanotide affects respiratory chemosensitivity independent of body weight loss. The present study uses diet-induced obese, male C57bl/6 J mice to determine the extent to which acute setmelanotide treatment affects the hypercapnic ventilatory response (HCVR). We find that ten days of daily setmelanotide treatment at 1 mg/kg, but not 0.2 mg/kg, is sufficient to cause weight loss and increase HCVR. In a separate group of animals, we find that we can emulate setmelanotide's effect on weight loss by restricting daily calories to match the hypophagia triggered by setmelanotide. These pair-fed animals exhibit improvements in HCVR similar to those who receive setmelanotide. We conclude that acute treatment with setmelanotide is as effective as weight loss at improving respiratory hypercapnic chemosensitivity.

Assessment of the Potential Clinical and Economic Impact of Weight Loss in the Adult Population with Obesity and Associated Comorbidities in Spain

INTRODUCTION

Obesity and its complications are associated with high morbidity/mortality and a significant healthcare cost burden in Spain. It is therefore essential to know the potential clinical and economic benefits of reducing obesity. The objective of this study is to predict the decrease in rates of onset of potential complications associated with obesity and the cost savings after a weight loss of 15% over 10 years in Spain.

METHODS

Data were combined in an adapted version of a weight loss benefit simulation model. Sources with demographic information on the Spanish population and the distribution of obesity and type 2 diabetes mellitus (T2DM) were used to obtain the data for the model. In addition, use was made of prevalence data on obesity-associated complications from a cohort of patients with obesity in the United Kingdom (UK). These data were combined by age and sex to create a Spanish synthetic cohort.

RESULTS

The simulation showed that, for a cohort of 100,000 individuals with a body mass index (BMI) of 30-50 kg/m2, a weight loss of 15% is estimated to lead to relevant relative risk reductions in obstructive sleep apnoea (OSA) (- 56.4%), T2DM (- 39.2%), asthma (- 20.2%) and arterial hypertension (- 18.7%). The estimated overall savings were €105 million for a cohort of 100,000 individuals, mainly resulting from the decrease in T2DM and arterial hypertension (23% and 22% of the total savings at year 10, respectively), as well as osteoarthritis and chronic kidney disease (CKD) (16% and 13%, respectively).

CONCLUSIONS

Sustained weight loss could significantly reduce the burden derived from future complications associated to obesity in Spain, as well as the excess economic cost associated with its treatment.

Beyond the mouth: An overview of obstructive sleep apnea in adults for dentists

Obstructive sleep apnea (OSA) is a common and complex medical sleep condition in adults that is associated with chronic medical and mental health conditions. Left undiagnosed and untreated it can decrease quality of life and increase morbidity and mortality. Dentists are at the forefront for screening OSA in their role to maintain the health of the oral cavity. Clinical experience in the management of OSA in dentists is limited. The aim of this article is to provide dentists with foundational knowledge about OSA to empower them to play an active role in the care management of screening and treating OSA.

Exploring the therapeutic potential of GLP-1 receptor agonists in the management of obstructive sleep apnea: a comprehensive review

Obstructive Sleep Apnea (OSA) is a prevalent sleep disorder marked by repeated episodes of partial or complete upper airway obstruction during sleep, which leads to intermittent hypoxia and fragmented sleep. These disruptions negatively impact cardiovascular health, metabolic function, and overall quality of life. Obesity is a major modifiable risk factor for OSA, as it contributes to both anatomical and physiological mechanisms that increase the likelihood of airway collapse during sleep. While continuous positive airway pressure (CPAP) therapy remains the gold standard for OSA treatment, its limitations - particularly issues with patient adherence - underscore the need for alternative or adjunct therapeutic options. One such option is the use of glucagon-like peptide-1 receptor agonists (GLP-1 RAs), which are widely recognized for their ability to reduce body weight and improve metabolic health. Emerging evidence suggests that GLP-1 RAs may offer therapeutic benefits in managing OSA, particularly by addressing obesity, a key contributor to the condition. This narrative review seeks to explore the role of GLP-1 RAs in the treatment of OSA, evaluating their efficacy in reducing OSA severity and discussing their broader clinical implications for future research and practice.

Association between weight-adjusted waist index and obstructive sleep apnea among adults in the United States: data from NHANES (2005-2008 and 2015-2018)

OBJECTIVE

We aimed to examine the relationship between the weight-adjusted waist index (WWI) and obstructive sleep apnea (OSA), a condition often caused by obesity, which remains unclear.

METHODS

In this cross-sectional study, we analyzed data from the National Health and Nutrition Examination Survey among adults in the United States (US) aged 20 to 65 years, covering the periods 2005 to 2008 and 2015 to 2018. The study included 8278 participants; we used multivariate logistic regression, restricted cubic splines, and subgroup analyses to explore the relationship between WWI and OSA.

RESULTS

After adjusting for all covariates, each unit increase in WWI was associated with a 30% increase in OSA prevalence (odds ratio = 1.30, 95% confidence interval: 1.20-1.40).

CONCLUSIONS

These findings suggest that WWI, an index reflecting abdominal obesity, can provide important insights into OSA risk assessment. Its strong association with OSA highlights its potential utility in predicting OSA prevalence, particularly among diverse subpopulations. The WWI was associated with a higher prevalence of OSA among US adults and may serve as a valuable tool for risk assessment, early screening, and intervention strategies in clinical practice.

The Impact of Living in a Low Food Access/Low Income Area on Obstructive Sleep Apnea

OBJECTIVE

To assess differences in obstructive sleep apnea (OSA)-related health parameters between residents of low income/low access (LILA) census tracts-food deserts-and non-LILA residents STUDY DESIGN: Retrospective review.

SETTING

Single institution serving a large region in Southern California from 2017 to 2023.

METHODS

Census tracts are defined as LILA if a significant proportion of residents live below the poverty threshold and far from healthy food vendors. Adults newly diagnosed with OSA on polysomnography were included. Food access status was determined by searching patient addresses in the US Department of Agriculture Food Access Research Atlas. Baseline and 1-year follow-up body mass index (BMI) and vitals were collected and compared based on food access and other demographic variables.

RESULTS

A total of 379 patients in the LILA+ group and 2281 patients in the LILA- group met inclusion criteria. BMI was higher in the LILA group (36.6 ± 9.4 vs 35.2 ± 8.9; P = .006). The effect of food access was most significant in certain demographic groups: patients aged < 65, males, Asian/Pacific Islanders, Hispanics, and patients with Medicaid coverage all had a higher BMI when in the LILA+ group compared to the LILA- group. When considering insurance, LILA+ patients with Medicaid coverage had a significantly higher BMI than LILA- patients with non-Medicaid coverage (40.4 ± 10.3 vs 34.2 ± 8.4, P < .001. Blood pressure, heart rate, and apnea-hypopnea index were also significantly higher in LILA+/Medicaid group. BMI change across all demographic groups was minimal at 1-year follow-up.

CONCLUSION

Living in a LILA census tract may result in worse OSA-related health parameters. When accounting for insurance status, the effects are even more profound. Intensive counseling on the importance of weight management should begin at the diagnosis of OSA.

Sleep apnea is a common and dangerous cardiovascular risk factor

Sleep apnea involves almost one billion individuals throughout the world, including 40 million Americans. Of major medical concern is the fact that the prevalence of sleep apnea is significantly increasing due to the epidemic of obesity, physical inactivity, and diabetes mellitus which are important risk factors for the development and persistence of sleep apnea in individuals. Sleep apnea is characterized by multiple episodes of apnea or hypopnea during sleep, which cause nocturnal arousals, gasping for breath during the night, daytime sleepiness, irritability, forgetfulness, fatigue and recurrent headaches. Obstructive sleep apnea occurs when upper airway obstruction occurs in an individual during sleep with absent or markedly reduced airflow in the presence of continued activity of inspiratory thoracic and diaphragmatic muscles. Central sleep apnea is defined as the absence or the significant reduction of naso-oral airflow due to the withdrawal during sleep of ponto-medullary respiratory center stimulation of the nerves of the inspiratory thoracic and diaphragmatic muscles and absence of contraction of these muscles during apnea. Complex sleep apnea occurs when an individual exhibits characteristics of both obstructive and central sleep apnea. The severity of sleep apnea is measured by polysomnography and the apnea hypopnea index (AHI), which is the average number of apneas and hypopneas per hour of sleep measured by polysomnography. Sleep apnea is mild if the AHI is 5-14/h with no or mild symptoms, moderate if the AHI is 15 to 30/h with occasional daytime sleepiness, and severe if the AHI is >30/h with frequent daytime sleepiness that interferes with the normal activities of daily life. Chronic sleep apneas and hypopneas followed by compensatory hyperpneas are associated with significant adverse cardiovascular consequences including: 1) recurrent hypoxemia and hypercarbia; 2) Increased sympathetic nerve activity and decreased parasympathetic nerve activity; 3) oxidative stress and vascular endothelial dysfunction; and 4) cardiac remodeling and cardiovascular disease. Moderate or severe sleep apnea significantly increases the risk of coronary artery disease, congestive heart failure, cerebral vascular events (strokes), and cardiac dysrhythmias, and also increase the morbidity and mortality of these diseases. Nevertheless, sleep apnea is currently underdiagnosed and untreated in many individuals due to the challenges in the prediction and detection of sleep apnea and a lack of well-defined optimal treatment guidelines. Chronic continuous positive airway pressure for ≥4 h/night for >70% of nights is beneficial in the treatment of patients with sleep apnea. CPAP Improves sleep quality, reduces the AHI, augments cardiac output and increases oxygen delivery to brain and heart, reduces resistant hypertension, decreases cardiac dysrhythmias, and reduces daytime sleepiness. The present article discusses the diagnosis of obstructive sleep apnea, central sleep apnea, and complex apnea. Thereafter the important pathophysiologic mechanisms in sleep apnea and the relationship of these pathophysiologic mechanics to atherosclerotic vascular disease are reviewed. Guidelines are then provided for the treatment of mild, moderate and severe sleep apnea. In order to reduce the cardiovascular morbidity and mortality caused by sleep apnea and facilitate the diagnosis and the long-term, effective treatment of sleep apnea in patients, the close cooperation is necessary of cardiovascular specialists, pulmonary specialists, and respiratory therapy/rehabilitation specialists.

Postnatal Growth Trajectories and Risk of Obstructive Sleep Apnea in Middle Age: A Cohort Study

STUDY OBJECTIVES

Rapid growth in childhood predisposes to obesity and cardiometabolic diseases in adulthood. While obstructive sleep apnea (OSA) is bidirectionally linked to obesity, its developmental origins are sparsely studied. We examined associations between postnatal growth and the risk of OSA in adulthood.

METHODS

We included adults whose childhood anthropometric data was collected in the New Delhi Birth Cohort study. The risk of OSA was defined by the Berlin Questionnaire (BQ) with and without the obesity criterion. Using logistic regression, we studied associations of OSA risk with conditional growth parameters, which are statistically independent measures of gain in height, weight, and body mass index (BMI), during infancy (0-2 years), early childhood (2-5 years), and late childhood (5-11 years).

RESULTS

Among 521 subjects (58.9% males) with a mean (SD) age of 40.9 (1.7) years, 30.9% had a high risk of OSA. On multivariate analysis, a high risk of OSA was associated with a higher conditional BMI in infancy (odds ratio: 1.25; 95% confidence interval: 1.00-1.57; p = 0.048) and early childhood (1.35; 1.07-1.69; p = 0.011). Higher risk of OSA was associated with greater conditional weight in early childhood (1.34; 1.06-1.68; p = 0.013). Using the modified BQ definition without obesity, adult risk of OSA was significantly associated with a higher adult BMI instead of childhood conditional BMIs.

CONCLUSIONS

Greater gain in conditional BMI or weight in early childhood is associated with a high risk of OSA in middle age, which is mediated by a higher attained adult BMI.

Influence of Obstructive Sleep Apnea on the Risk of Dental Caries: Insights from a 13-Year Population-Based Retrospective Study

KNOWLEDGE TRANSFER STATEMENT

Obstructive sleep apnea has been proven to have a great negative impact on patients, and the relationship between sleep apnea and dental caries is still inconclusive. Our study shows that patients with sleep apnea and those older than 45 y have a significant risk of dental caries.

Sleep Health Disparities

Sleep is an important and potentially modifiable determinant of many severe health outcomes. Sleep health disparities exist and are exemplified by reported differential rates of prevalence, severity, and outcomes among minority groups and low-socioeconomic-status backgrounds. In this review we highlight the concept of sleep health, review the evidence for disparities in sleep health, examine risk factors and consequences of poor sleep health, and discuss policy implications.

Beyond continuous positive airway pressure for cardiovascular risk reduction in patients with obstructive sleep apnea

An accumulating body of evidence suggests a bidirectional relationship between sleep and cardiovascular (CV) health. A high level of evidence has linked obstructive sleep apnea (OSA) with cardiovascular disease (CVD). Accordingly, clinical sleep medicine emphasizes the diagnosis and treatment of OSA in the context of promoting CV health. While continuous positive airway pressure (CPAP), the mainstay treatment for OSA, is effective in improving several sleep-related quality-of-life outcomes and leads to modest reductions in blood pressure, there is currently insufficient evidence to justify using CPAP alone for improving CVD outcomes in OSA. Sleep physicians are uniquely positioned to expand their focus beyond the evaluation of OSA and administering CPAP, in efforts to enhance the CV health of sleep patients. Herein, we suggest the role of sleep physicians as CV preventionists. Key focus areas for managing CV risk beyond CPAP therapy in OSA include identifying comorbid disorders that are vital for optimizing CV health. This involves risk-stratifying patients and providing appropriate counseling, referrals, and treatment as appropriate for comorbid sleep conditions such as insomnia and insufficient sleep, comorbid CV risk factors including hypertension, dyslipidemia, metabolic dysfunction-associated steatohepatitis, as well as counseling for weight management programs, smoking, and alcohol cessation. We urge sleep clinicians to play an active and integral role in optimizing the CV health of patients with sleep disorders.

The impact of comprehensive healthy lifestyles on obstructive sleep apnea and the mediating role of BMI: insights from NHANES 2005-2008 and 2015-2018

OBJECTIVE

In this study, the associations between healthy lifestyles and obstructive sleep apnea (OSA) in middle-aged and elderly adults were investigated via data from the National Health and Nutrition Examination Survey (NHANES) for the periods of 2005-2008 and 2015-2018.

METHODS

A total of 6,406 participants aged 40 years and older were included in the analysis. Healthy lifestyle behaviors were assessed through diet quality, physical activity, sleep duration, alcohol consumption, smoking status, and body mass index (BMI). A composite healthy lifestyle score (ranging from 0 to 6) was created and categorized into insufficient (0-2), intermediate (3-4), and optimal (5-6) health groups. Weighted logistic regression models were used to examine the association between these lifestyle scores and OSA, adjusting for some demographic, socioeconomic, and clinical covariates. Additionally, mediation analysis was conducted to evaluate the role of BMI as a mediator in the relationship between the composite healthy lifestyle score and OSA, determining the proportion of the total effect mediated by BMI.

RESULTS

Participants were classified into insufficient (17.81%), intermediate (56.82%), and optimal (25.37%) lifestyle groups. Higher dietary quality (OR: 0.81, 95% CI: 0.66-0.99) and adequate weight (OR: 0.09, 95% CI: 0.07-0.11) were statistically associated with reduced OSA odds after adjustments, whereas the variables were not. Each one-point increase in the healthy lifestyle score was linked to a 33% reduction in OSA odds (OR: 0.67, 95% CI: 0.63-0.71). A significant linear trend was observed, with better adherence to healthy lifestyle correlating with lower odds of OSA (p for trend < 0.001). Compared with insufficient lifestyle, intermediate lifestyle was linked to a 27% reduction in OSA (OR: 0.73, 95% CI: 0.58-0.91), whereas optimal lifestyle was associated with a 74% reduction (OR: 0.26, 95% CI: 0.21-0.33). Mediation analysis revealed that BMI significantly mediated the relationship between healthy lifestyle score and OSA, accounting for approximately 59.2% of the total effect (P < 0.001). The direct effect of the healthy lifestyle score on OSA remained significant even when controlling for BMI (P < 0.001). Subgroup analyses confirmed consistent benefits across different demographic groups.

CONCLUSIONS

This study revealed that adherence to healthy lifestyles significantly reduces the odds of OSA, with optimal lifestyles leading to a marked decrease in the odds of OSA. Notably, BMI plays a critical mediating role in this relationship. These findings emphasize the importance of promoting healthy lifestyle interventions as a key strategy for the prevention and management of OSA.

Obstructive sleep apnea and obesity: A review of epidemiology, pathophysiology and the effect of weight-loss treatments

Despite the commonly-accepted paradigm that patients with obstructive sleep apnea (OSA) also invariably have obesity, OSA prevalence extends beyond obesity. This necessitates a reevaluation of screening strategies, biomarkers of increased OSA risk, and heightened awareness among healthcare providers about the array of OSA treatments for diverse adult populations. While obesity contributes importantly to OSA pathogenesis, there is substantial evidence that non-anatomical factors also play a crucial role, especially in patients who do not have obesity. In recent years, notwithstanding the recognition of diverse contributors to OSA pathogenesis, research has frequently focused on weight reduction to address OSA. Insights from past experiences with bariatric surgery in OSA serve as a lens to anticipate potential outcomes of emerging anti-obesity pharmacotherapies. Pharmacological alternatives, particularly incretin agonists, exhibit promise in weight reduction and OSA improvement, but encounter obstacles such as potential side effects and high costs. With this comprehensive narrative review, we delve into the complex epidemiological and pathophysiological connections between OSA and obesity. Additionally, we emphasize the importance of a multifaceted approach to OSA treatment, recognizing that while weight management is crucial, there is a need for comprehensive strategies that go beyond traditional weight-centric perspectives.

Estimating Cardiovascular Benefits of Tirzepatide in Sleep Apnea and Obesity: Insight from the SURMOUNT-OSA Trials

PURPOSE OF COMMENTARY

This commentary aims to offer a perspective on the effect of tirzepatide on hypoxic burden and provide indirect evidence of cardiovascular risk reduction after tirzepatide for the treatment of obstructive sleep apnea and obesity. It also discusses the role of tirzepatide-induced weight loss in the management of obstructive sleep apnea.

RECENT FINDINGS

In the SURMOUNT-OSA phase 3 trials, tirzepatide, a new GIP/GLP-1 receptor co-agonist, reduced the apnea-hypopnea index, hypoxic burden, and body weight in adults with moderate-to-severe obstructive sleep apnea and obesity. The change in apnea-hypopnea index is clinically relevant, but its impact on cardiovascular mortality remains unclear. Conversely, hypoxic burden predicts cardiovascular mortality across populations independent of AHI. We attempted to postulate the magnitude of cardiovascular benefits of tirzepatide based on the reduction in hypoxic burden. Tirzepatide treatment for obstructive sleep apnea and obesity seems to result in hypoxic burden values associated with a lower cardiovascular mortality rate and thus might attenuate the negative cardiovascular impact of hypoxic burden.

Endoscopic duodenal-jejunal bypass liner treatment of moderate obstructive sleep apnoea-A pilot study

We aimed to assess the extent to which people with type 2 diabetes or pre-diabetes, obesity (BMI 30-45 kg/m2) and moderate obstructive sleep apnoea (OSA) requiring continuous positive airway pressure ventilation (CPAP) were able to discontinue CPAP following EndoBarrier-related weight loss. We assessed sleep and metabolic parameters before, during and after EndoBarrier in 12 participants with moderate OSA requiring CPAP (75% female, 8/12 [66%] type 2 diabetes, 4/12 [34%] prediabetes, mean ± SD age 52.6 ± 9.7 years, BMI 37.4 ± 3.5 kg/m2, median duration of OSA while on CPAP 9.0 [7.0-15.0] months). With EndoBarrier in-situ, mean ± SD Apnoea Hypopnoea Index (AHI) fell by 9.1 ± 5.0 events/h from 18.9 ± 3.8 to 9.7 ± 3.0 events/h (p < .001) with an associated reduction in symptoms of daytime sleepiness (mean Epworth Sleepiness Score) such that all the 12 participants no longer required CPAP according to National Institute for Health and Care Excellence criteria. After EndoBarrier removal, 10/12 (83%) patients attended follow-up and at 12 months after removal, AHI remained below 15 in 5/10 (50%) patients but in other five the AHI rose above 15 such that restarting CPAP was recommended as justified by their symptoms. Rather than restart CPAP, two patients lost the regained weight and their AHI dropped below 15 again. Thus, 7/10 (70%) of patients were able to remain off CPAP 12 or more months after EndoBarrier removal. These results demonstrate major benefit of EndoBarrier in moderate OSA, allowing all patients to discontinue CPAP during treatment, and with maintenance of improvement at follow-up in 70%. They confirm previously demonstrated metabolic improvements in diabetes and obesity.

Outcome Reporting in Prospective Studies Evaluating Neurostimulation for Obstructive Sleep Apnea

OBJECTIVE

Due to the controversy surrounding the appropriate outcomes in neurostimulation, we sought to systematically describe ways in which polysomnography and apnea-hypopnea index are reported in prospective studies involving unilateral hypoglossal nerve stimulation.

DATA SOURCES

MEDLINE (Ovid), Embase (Ovid), Cochrane Library, and Scopus.

REVIEW METHODS

Following the Preferred Reporting items of Systematic Reviews and Meta-analysis (PRISMA) Statement guidelines, a systematic two-reviewer system was used for study screening and quality assessment. Articles that met inclusion criteria were included. Quality was evaluated with either the Newcastle-Ottawa Quality Assessment Scale or the Covidence risk-of-bias tool.

RESULTS

Fifteen studies met the inclusion criteria, which included 14 prospective cohort studies and one randomized controlled trial. Titration polysomnography was the primary sleep study used to acquire data in five of the studies compared to only three studies employing exclusively non-titration polysomnography to report outcomes. Three studies compiled data from two or more sleep studies to report a single apnea-hypopnea index. Within the 15 studies, non-titration apnea-hypopnea index was the most reported type (five studies). Titration apnea-hypopnea index was used to report outcomes in one study. Five studies did not specify what type of apnea-hypopnea index was employed to report treatment effectiveness.

CONCLUSION

The reported sleep studies and corresponding apnea-hypopnea indices were highly variable across the studies. Because of the high degree of heterogeneity, future research would benefit from consistent use of a standardized apnea-hypopnea index to report outcomes related to hypoglossal nerve stimulation.

LEVEL OF EVIDENCE

NA Laryngoscope, 134:4873-4881, 2024.

A comparative analysis of anthropometric indices for diagnosing obstructive sleep apnea among American Adults

The occurrence of obstructive sleep apnea (OSA) syndrome is related to not only the overall obesity, but also the local distribution of fat. Therefore, we introduced anthropometric indicators to comprehensively assess the risks associated with obesity, including body mass index (BMI), which is used to assess the overall obesity, together with waist circumference (WC), body roundness index (BRI), visceral adiposity index (VAI) and lipid accumulation product (LAP), all of which reflect fat distribution. This cross-sectional study analyzed data from the 2005-2008 and 2015-2018 NHANES cycles, comprising 8966 participants. Logistic regression models were used to examine the associations between anthropometric indices and OSA, adjusting for relevant covariates. Receiver operating characteristic (ROC) curves were constructed, and values of the area under the curve (AUC) were calculated to assess diagnostic performance. AUC comparisons between men and women were conducted using the DeLong's test. After adjusting for covariates, WC and BMI emerged as the strongest diagnostic indicators of OSA risk. A ROC analysis revealed that WC and BMI had higher diagnostic performance performance among women (AUC: WC: 0.651, BMI: 0.653) than men (AUC: WC: 0.616, BMI: 0.619). Other indices demonstrated weaker diagnostic abilities. Both WC and BMI demonstrated a strong diagnostic ability for OSA across both sexes, with slightly better performance observed among women. These findings suggest that WC and BMI are practical and effective tools for the early detection, risk stratification and management of OSA in clinical practices.

Obstructive sleep apnoea and lung function, and their association with nocturnal hypoxemia: results from the Swedish CArdioPulmonary bioimage Study (SCAPIS) - a cross-sectional study

Obstructive sleep apnoea (OSA) and its associations with lung function.

BACKGROUND

OSA is highly prevalent and characterised by abnormal respiration during sleep. This large, population-based study aimed to investigate the associations between OSA and lung function in subjects aged 50-64 years.

METHOD

The population-based Swedish CArdioPulmonary bioimage Study includes information on anthropometry, comorbidities and spirometry. The current analysis included data from three centres (Gothenburg, Umeå and Uppsala) on whole-night respiratory polygraphy as a meta-analysis examining the overall effect size of lung function on sleep apnoea severity, expressed as ß-coefficient after stratifying for sex and adjusting for age, waist circumference and smoking status.

RESULTS

Data from 9016 participants (54% women, age 58±4 years, body mass index 27±4 kg/m2 ) with sleep recordings of good quality were included in the final analysis. Forced expiratory volume during 1 s (FEV 1 ) (ß=-0.10 (95% CI -0.16 to -0.03)), forced vital capacity (FVC) (-0.15 (-0.21 to -0.10)) and diffusion capacity for carbon monoxide (DLCO ) (-0.08 (-0.10 to -0.05)) were all negatively associated with the oxygen desaturation index (ODI) and also with per cent of registration with nocturnal oxygen saturation <90% FVC (-0.44 (-0.87 to -0.01)), FEV 1 (-0.86 (-1.36 to -0.36)) and DL CO (-0.47 (-0.60 to -0.35)). Additionally, a positive association was observed between FEV 1 (0.13 (0.05 to 0.22)) and DL CO (0.07 (0.04 to 0.09)) with the mean nocturnal saturation. There was a negative association between DL CO and apnoea-hypopnoea index, AHI, (ß=-0.04 (95% CI-0.06 to -0.03)), while no associations were found between FEV 1 or FVC and AHI.

CONCLUSION

In OSA, lower lung function is more distinctly associated with the nocturnal hypoxic burden than AHI. Potential lung function impairment should be investigated in OSA patients with a high ODI relative to AHI.

The Great Controversy of Obstructive Sleep Apnea Treatment for Cardiovascular Risk Benefit: Advancing the Science Through Expert Consensus. An Official American Thoracic Society Workshop Report

The prevalence of obstructive sleep apnea (OSA) is on the rise, driven by various factors including more sensitive diagnostic criteria, increased awareness, enhanced technology through at-home testing enabling easy and cost-effective diagnosis, and a growing incidence of comorbid conditions such as obesity. Treating symptomatic patients with OSA syndrome to enhance quality of life remains a cornerstone approach. However, there is a lack of consensus regarding treatment to improve cardiovascular disease (CVD) outcomes, particularly in light of overall negative results from several randomized controlled trials (RCT) indicating no benefit of positive airway pressure (PAP) therapy on primary and secondary CVD events. These RCTs were limited by suboptimal PAP adherence, use of composite CVD outcomes, and limited diversity and generalizability to Sleep Clinic patients. As such, this workshop assembled clinical experts, as well as researchers in basic and translational science, epidemiology, clinical trials, and population health to discuss the current state, and future research directions to guide personalized therapeutic strategies and future research directions in OSA. There was overall consensus among workshop participants that OSA represents a heterogeneous disease with variable endotypes and phenotypes, and heterogeneous responses to treatment. Future research should prioritize employing multi-modal therapeutic approaches within innovative and adaptive trial designs, focusing on specific subgroups of OSA patients hypothesized to benefit from a CVD perspective. Future work should also be inclusive of diverse populations and consider the life-course of OSA to better comprehend treatment strategies that can address the disproportionate impact of OSA on racially minoritized groups. Further, a more holistic approach to sleep must be adopted to include broader assessments of symptoms, sleep duration, and comorbid sleep and circadian disorders. Finally, it is imperative to establish a sleep research consortium dedicated to collecting raw data and biospecimens categorized by OSA subtypes. This will facilitate mechanistic determinations, foster collaborative research, and help bolster the pipeline of early-career researchers.

Effects of aerobic exercise and resistance training on obstructive sleep apnea: a systematic review and meta-analysis

STUDY OBJECTIVES

We investigated the therapeutic effects of exercise in patients with obstructive sleep apnea, aiming to identify the subgroups that benefit the most and determine the optimal exercise protocol.

METHODS

Major databases were searched for randomized controlled trials involving patients with obstructive sleep apnea performing aerobic exercise and/or resistance training. The investigated outcomes included apnea-hypopnea index (AHI), Epworth Sleepiness Scale, body mass index, and peak oxygen consumption during exercise (VO2peak). The pre- and postintervention unstandardized mean difference (USMD) of these parameters was compared between the exercise and control groups.

RESULTS

Twelve studies involving 526 patients were included. Exercise training significantly reduced AHI (USMD = -7.08 events/h, 95% confidence interval: -9.98 to -4.17, P < .00001), Epworth Sleepiness Scale (USMD = -2.37, 95% confidence interval: -3.21 to -1.54, P < .00001), and body mass index (USMD = -0.72 kg/m2, 95% confidence interval: -1.22 to -0.22, P = .005) and enhanced VO2peak (USMD = 3.46 ml·kg-1·min-1, 95% confidence interval: 1.20 to 5.71, P = .003). Subgroup analyses revealed that in continuous positive airway pressure-adherent patients, exercise significantly improved VO2peak but did not reduce AHI and Epworth Sleepiness Scale. A trend was observed that combining resistance training with aerobic exercise resulted in greater AHI reduction and VO2peak enhancement. Notably, exercise improved AHI, Epworth Sleepiness Scale, body mass index, and VO2peak regardless of the baseline AHI or body mass index.

CONCLUSIONS

Exercise, including resistance and aerobic training, should be part of treatment for patients with obstructive sleep apnea of all severities, regardless of obesity status, and even for those who are already under continuous positive airway pressure.

CITATION

Lin C-F, Ho N-H, Hsu W-L, Lin C-H, Wang Y-H, Wang Y-P. Effects of aerobic exercise and resistance training on obstructive sleep apnea: a systematic review and meta-analysis. J Clin Sleep Med. 2024;20(11):1839-1849.

Computational analysis on 3D airway model of obstructive sleep apnea patient for optimal maxillomandibular advancement

Obstructive sleep apnea (OSA) can have many adverse effects on people's health, including cognitive decline and high blood pressure. Typical surgical treatment methods include the commonly performed uvulopalatopharyngoplasty and the highly successful maxillomandibular advancement (MMA). These surgical methods are more effective than non-surgical methods because they widen the airway where a collapse has occurred through direct treatment. However, few studies has shown that moving the upper and lower jaws in a specific manner is the most efficient way to treat OSA during an MMA surgery. In this study, the airway of an OSA patient was reproduced digitally, and computational fluid dynamics analysis was performed on various models with changed airway shapes, including the original model based on an actual CT image and three resizing models of the retropalatal (RP) and retroglossal (RG) regions of the airway. Consequently, it was possible to provide more quantitative predicted flow data, which could be helpful in performing sophisticated OSA surgery. Among the four airway models of the OSA patient, a reduction in the epiglottis regional pressure difference of up to 40.2% was evident in the model with an expanded RG region, and a reduction in the wall shear stress of up to 25.8% was confirmed. The proposed process could be an important aid for surgeons in determining the optimal surgical method suitable for an individual patient's uniquely-shaped airway.

Study of the upper airway anatomy using magnetic resonance imaging in Indian obese patients with obstructive sleep apnea - A pilot study

BACKGROUND

Obstructive sleep apnea (OSA) is very common in obese patients. However, why some obese patients have severe OSA while others do not is unclear. Research is limited regarding which structures contribute to upper airway narrowing, especially in Asian patients where bony restrictions is thought to be important.

METHODS

Nineteen consecutive patients with BMI ≥35 kg/m2, and newly diagnosed with OSA based on overnight polysomnography were studied using non-contrast magnetic resonance imaging (MRI) of the upper airway during wakefulness.

RESULTS

Patients were divided into two groups, one with severe OSA comprising 11 patients and one without severe OSA having 8 patients. The retro-palatal airway was narrowest in both groups. Patients with severe OSA had a significantly narrower retroglossal airway (0.99 ± 0.48 cm2 vs 2.61 ± 2.02 cm2, p = 0.02), primarily due to a narrower anteroposterior diameter at this level (p = 0.03). The tongue volume (p = 0.91), lateral pharyngeal wall volume (p = 0.26), tongue length (p = 0.93), soft palate length (p = 0.13), and dynamic change of upper airway with inspiration (p = 0.31) were not significantly different between the two groups.

CONCLUSIONS

While the retro-palatal airway is equally narrow in both groups of patients, patients with severe OSA also have a significantly narrower retro-glossal airway. This finding could represent either a generalized reduction in airway area in whole of the oropharynx or multiple-level obstruction; probably aggravating upper airway collapse during sleep, predisposing some Asian obese patients to develop severe OSA.

Time-Restricted Eating Versus Daily Calorie Restriction: Effect on Sleep in Adults with Obesity over 12 Months

Objective: The aim of this secondary analysis was to compare the effects of time-restricted eating (TRE) versus daily calorie restriction (CR) on sleep quality, duration, insomnia severity, and risk of obstructive sleep apnea in adults with obesity over one year. Methods: A total of 90 participants were randomized to one of three groups for 12 months: 8 h TRE (eating only between 12 p.m. and 8 p.m.); CR (25% daily calorie restriction) or a no-intervention control group. Results: By the end of the study, weight loss was 4.61 kg (95% CI; 7.37 to 1.85 kg; p ≤ 0.01) for the TRE group and 5.42 kg (CI; 9.13 to 1.71 kg; p ≤ 0.01) for the CR group, with no statistically significant difference between TRE and CR (0.81 kg [CI; 3.07 to 4.69]; p = 0.68]). Self-reported sleep quality, sleep duration, insomnia severity, and risk of obstructive sleep apnea did not change in the TRE or CR groups versus controls by month 12. Conclusions: These findings suggest that the weight loss produced by TRE and CR does not have any impact on various sleep parameters in adults with obesity over one year.

Metabolic and bariatric surgery for obstructive sleep apnoea syndrome: bibliometric analysis and visualisation from 1999 to 2023

OBJECTIVES

Metabolic and bariatric surgery (MBS) for obstructive sleep apnoea syndrome (OSAS) has garnered significant research interest. The main aim of this study was to analyse the unique characteristics of publications centred around MBS for OSAS. We aimed to provide valuable insights into the present status of the field and offer predictions regarding future trends.

DESIGN

Bibliometric analysis through science mapping and performance analysis methods.

DATA SOURCES

Scientific articles.

DATA EXTRACTION AND SYNTHESIS

A comprehensive search was conducted in the Web of Science database to retrieve publications on MBS for OSAS within the time frame of 1999-2023. The search was performed using keywords such as "Obstructive Sleep Apnea syndrome", "OSAS", "metabolic surgery" and "bariatric surgery" to identify relevant papers. To analyse the bibliometric characteristics of these publications, VOSviewer and R software were used. This analysis encompassed various aspects, including the number of publications, contributions by different countries and institutions, the most cited author, journal publications, citation frequency and the identification of keywords related to popular scientific fields.

RESULTS

1264 papers on MBS for OSAS were identified and are currently in a stage of rapid growth. The relevant study involved 1230 institutions from 53 different countries, with the USA topping the field with 465 publications contributed. Assistance Publique Hopitaux Paris proved to be the most productive institution, with De Vries N posting the highest number of papers (n=24). The most prolific journal was Obesity Surgery, with 241 publications. Keywords "Bariatric surgery", "Obstructive sleep apnea", "Obesity", "Weight loss" and "Morbid obesity" have the highest frequency of occurrence.

CONCLUSIONS

The relationship between obesity and OSAS, various metabolic surgical techniques, and the mechanism of MBS for OSAS will continue to be related areas of frontiers. Furthermore, while there has been a gradual increase in basic research, the mechanisms involved and the long-term efficacy of bariatric MBS for OSAS still require further investigation. It is anticipated that these research areas may emerge as potential hot topics in the future.

Obesity and cardiovascular disease: an ESC clinical consensus statement

The global prevalence of obesity has more than doubled over the past four decades, currently affecting more than a billion individuals. Beyond its recognition as a high-risk condition that is causally linked to many chronic illnesses, obesity has been declared a disease per se that results in impaired quality of life and reduced life expectancy. Notably, two-thirds of obesity-related excess mortality is attributable to cardiovascular disease. Despite the increasingly appreciated link between obesity and a broad range of cardiovascular disease manifestations including atherosclerotic disease, heart failure, thromboembolic disease, arrhythmias, and sudden cardiac death, obesity has been underrecognized and sub-optimally addressed compared with other modifiable cardiovascular risk factors. In the view of major repercussions of the obesity epidemic on public health, attention has focused on population-based and personalized approaches to prevent excess weight gain and maintain a healthy body weight from early childhood and throughout adult life, as well as on comprehensive weight loss interventions for persons with established obesity. This clinical consensus statement by the European Society of Cardiology discusses current evidence on the epidemiology and aetiology of obesity; the interplay between obesity, cardiovascular risk factors and cardiac conditions; the clinical management of patients with cardiac disease and obesity; and weight loss strategies including lifestyle changes, interventional procedures, and anti-obesity medications with particular focus on their impact on cardiometabolic risk and cardiac outcomes. The document aims to raise awareness on obesity as a major risk factor and provide guidance for implementing evidence-based practices for its prevention and optimal management within the context of primary and secondary cardiovascular disease prevention.

Associations between Type of Bariatric Surgery and Obstructive Sleep Apnoea, Employment Outcomes, and Body Image Satisfaction: A Systematic Review and Meta-Analysis

INTRODUCTION

Bariatric surgery has been shown to provide significant patient benefits in terms of weight loss and mitigation of obesity-linked comorbidities, as well as providing improvements in occupational productivity and patient quality of life. However, the choice of which bariatric surgery procedure provides the most patient benefit in each of these cases is still in question. In this review, we provide a systematic review, with the objective of evaluating associations between different bariatric surgery procedures and mitigation of obesity-linked comorbidities, improvement in occupational productivity, and patient quality of life, concentrating on three areas: obstructive sleep apnoea (OSA), employment prospects, and body image.

METHODS

The CINAHL, PubMed, Web of Science, and CENTRAL databases were searched for eligible studies. Summary risk ratio (RR) and 95% confidence intervals were estimated using random-effects models. Thirty-three studies were included in this review, including 29 cohort studies and 4 randomised clinical trials (RCTs).

RESULTS

Pooled analysis of the observational studies showed significantly lower OSA remission in sleeve gastrectomy (SG) compared to Roux-en-Y gastric bypass (RYGB) across both short-term (1-2 years) and longer term (3+ years) follow-up periods (RR = 0.91, 95% CI = 0.84-0.99, p = 0.02; and RR = 0.88, 95% CI = 0.65-0.99, p = 0.03, respectively). In contrast, a meta-analysis of the RCT studies found no difference in OSA remission between SG and RYGB (RR = 1.01, 95% CI = 0.81-1.25, p = 0.93). An analysis of four studies showed significantly higher OSA remission for SG versus adjustable gastric banding (RR = 1.83, 95% CI = 1.57-2.14, p < 0.001). No significant difference was observed regarding improvement in employment status between SG and RYGB (RR = 0.77, 95% CI = 0.32-1.87, p = 0.57). A narrative synthesis of studies on body image reported no significant differences between body image scores and surgery types.

CONCLUSION

This review found significantly lower OSA remission in SG as compared to RYGB across different follow-up periods, while no significant statistical difference was observed in RCT studies. Further studies are recommended to assess the effectiveness of the various bariatric surgeries in relation to improving employment status and body image, where primary studies are lacking.

State of the art: Alternative overlap syndrome-asthma and obstructive sleep apnea

In the general population, Bronchial Asthma (BA) and Obstructive Sleep Apnea (OSA) are among the most prevalent chronic respiratory disorders. Significant epidemiologic connections and complex pathogenetic pathways link these disorders via complex interactions at genetic, epigenetic, and environmental levels. The coexistence of BA and OSA in an individual likely represents a distinct syndrome, that is, a collection of clinical manifestations attributable to several mechanisms and pathobiological signatures. To avoid terminological confusion, this association has been named alternative overlap syndrome (vs overlap syndrome represented by the chronic obstructive pulmonary disease-OSA association). This comprehensive review summarizes the complex, often bidirectional links between the constituents of the alternative overlap syndrome. Cross-sectional, population, or clinic-based studies are unlikely to elucidate causality or directionality in these relationships. Even longitudinal epidemiological evaluations in BA cohorts developing over time OSA, or OSA cohorts developing BA during follow-up cannot exclude time factors or causal influence of other known or unknown mediators. As such, a lot of pathophysiological interactions described here have suggestive evidence, biological plausibility, potential or actual directionality. By showcasing existing evidence and current knowledge gaps, the hope is that deliberate, focused, and collaborative efforts in the near-future will be geared toward opportunities to shine light on the unknowns and accelerate discovery in this field of health, clinical care, education, research, and scholarly endeavors.

Targeted single cell expression profiling identifies integrators of sleep and metabolic state

Animals modulate sleep in accordance with their internal and external environments. Metabolic cues are particularly potent regulators of sleep, allowing animals to alter their sleep timing and amount depending on food availability and foraging duration. The fruit fly, Drosophila melanogaster, suppresses sleep in response to acute food deprivation, presumably to forage for food. This process is dependent on a single pair of Lateral Horn Leucokinin (LHLK) neurons, that secrete the neuropeptide Leucokinin. These neurons signal to insulin producing cells and suppress sleep under periods of starvation. The identification of individual neurons that modulate sleep-metabolism interactions provides the opportunity to examine the cellular changes associated with sleep modulation. Here, we use single-cell sequencing of LHLK neurons to examine the transcriptional responses to starvation. We validate that a Patch-seq approach selectively isolates RNA from individual LHLK neurons. Single-cell CEL-Seq comparisons of LHLK neurons between fed and 24-hr starved flies identified 24 genes that are differentially expressed in accordance with starvation state. In total, 12 upregulated genes and 12 downregulated genes were identified. Gene-ontology analysis showed an enrichment for Attacins, a family of anti-microbial peptides, along with several transcripts with diverse roles in regulating cellular function. Targeted knockdown of differentially expressed genes identified multiple genes that function within LHLK neurons to regulate sleep-metabolism interactions. Functionally validated genes include an essential role for the E3 ubiquitin Ligase insomniac, the sorbitol dehydrogenase Sodh1, as well as AttacinC and AttacinB in starvation-induced sleep suppression. Taken together, these findings provide a pipeline for identifying novel regulators of sleep-metabolism interactions within individual neurons.

Obstructive Sleep Apnea Syndrome Exacerbates NASH Progression via Selective Autophagy-Mediated Eepd1 Degradation

Obstructive sleep apnea syndrome (OSAS), characterized by chronic intermittent hypoxia (CIH), is an independent risk factor for aggravating non-alcoholic steatohepatitis (NASH). The prevailing mouse model employed in CIH research is inadequate for the comprehensive exploration of the impact of CIH on NASH development due to reduced food intake observed in CIH-exposed mice, which deviates from human responses. To address this issue, a pair-feeding investigation with CIH-exposed and normoxia-exposed mice is conducted. It is revealed that CIH exposure aggravates DNA damage, leading to hepatic fibrosis and inflammation. The analysis of genome-wide association study (GWAS) data also discloses the association between Eepd1, a DNA repair enzyme, and OSAS. Furthermore, it is revealed that CIH triggered selective autophagy, leading to the autophagic degradation of Eepd1, thereby exacerbating DNA damage in hepatocytes. Notably, Eepd1 liver-specific knockout mice exhibit aggravated hepatic DNA damage and further progression of NASH. To identify a therapeutic approach for CIH-induced NASH, a drug screening is conducted and it is found that Retigabine dihydrochloride suppresses CIH-mediated Eepd1 degradation, leading to alleviated DNA damage in hepatocytes. These findings imply that targeting CIH-mediated Eepd1 degradation can be an adjunctive approach in the treatment of NASH exacerbated by OSAS.

Overnutrition in persons with cystic fibrosis on modulator therapy and the relationship to obstructive sleep apnea

Cystic fibrosis (CF) care is evolving with the ubiquitous use of modulator therapy and resultant increase in lifespan. It is important for CF clinicians to monitor the pathologic weight gain that is concomitantly being seen as obesity is a known risk factor for multiple other diseases. In this review we focus on obesity in CF, discuss screening and lifestyle considerations, outline CF-specific concerns with weight loss medications, and describe the vicious cycle of obesity and obstructive sleep apnea (OSA). We discuss screening and treatment for OSA, as it directly correlates with weight fluctuation. We offer interim recommendations for CF teams as they continue to care for this population.

Weight reduction and the impact on apnea-hypopnea index: A systematic meta-analysis

Obstructive sleep apnea (OSA) is strongly associated with obesity. While the relationship between weight reduction and apnea-hypopnea index improvement has been documented, to our knowledge, it has not been quantified adequately. Therefore, this study aimed to quantify the relationship between weight reduction and AHI change.

METHODS

A systematic literature search was performed using meta-analyses (PRISMA) guidelines for studies reporting AHI and weight loss in people with obesity/overweight and OSA between 2000 and 2023. A linear and quadratic model (weighted by treatment arm sample size) predicted percent change from baseline AHI against mean percent change from baseline weight. The quadratic term was statistically significant (P < 0.05), so the quadratic model (with 95 % prediction interval) was used.

RESULTS

The literature search identified 27 studies/32 treatment arms: 15 using bariatric surgery and lifestyle intervention each and 2 using pharmacological interventions. Included studies were ≥3 months with weight intervention and participants had AHI ≥15/h. Weight reduction in people with OSA and obesity was associated with improvements in the severity of OSA. BMI reduction of 20 % was associated with AHI reduction of 57 %, while further weight reduction beyond 20 % in BMI was associated with a smaller effect on AHI. As the prediction intervals are relatively wide, a precise relationship could not be conclusively established.

CONCLUSION

The degree of AHI index improvement was associated with the magnitude of weight reduction. The model suggests that with progress in weight reduction beyond 20 %, the incremental decrease in BMI appeared to translate to a smaller additional effect on AHI.

The Association Between Obesity and the Development and Severity of Obstructive Sleep Apnea: A Systematic Review

Obesity has reached epidemic proportions globally, accompanied by a parallel rise in the incidence of obstructive sleep apnea (OSA). The systematic study aims to assess the association between obesity and the onset and severity of OSA. A comprehensive computerized search of pertinent databases was done to find studies that fit the inclusion requirements. A comprehensive search was carried out on PubMed, SCOPUS, Science Direct, Systematic Library, and Web of Science to locate relevant material. Our data included 12 trials with 4095 participants, and 1456 (35.6%) were men. In individuals who were obese, the prevalence of OSA varied from 12.6% to 88.9%, with a total prevalence of 1291 (31.5%). One major factor that determined the level of OSA was obesity. It was consistently discovered by studies that there was a positive correlation between body mass index (BMI), and measures such as the Apnea-Hypopnea Index (AHI) are crucial in determining the extent of OSA. Besides, it was also observed that these comorbid conditions made OSA more severe and difficult to manage. Variability in findings suggests the influence of additional factors such as age, sex, and ethnicity on the obesity-OSA relationship. This comprehensive study offers strong evidence that OSA development and severity are significantly influenced by fat. The results emphasize the significance of weight control, especially for obese people, in treating and preventing OSA.