Effect of an Interdisciplinary Weight Loss and Lifestyle Intervention on Obstructive Sleep Apnea Severity: The INTERAPNEA Randomized Clinical Trial

Effects of high-intensity interval training on subjective sleep quality and daytime sleepiness in patients with obstructive sleep apnea: A secondary analysis from a randomized controlled trial

This study aimed to verify the effect of 12 weeks of HIIT on the perceived sleep quality and excessive daytime sleepiness in patients with obstructive sleep apnea (OSA). For this, a secondary analysis of a randomized controlled trial, including 36 adults with moderate-severe OSA (19 males; 52.2 ± 9.8 years; body mass index = 34.2 ± 5.8; AHI = 42.0 ± 22.9 e/h) was performed. Participants were randomly assigned to HIIT [5 periods of 4 min of walking or running on a treadmill at 90-95 % of maximum heart rate (HRmax) interspersed with 3 min of walking at 50-55 % of HRmax performed three times per week for 12 weeks] or a control group (CG; stretching exercises performed two times per week for 12 weeks). Specific domains of subjective sleep quality and EDS were assessed at baseline and post 12 weeks. Generalized estimated equation were used to verify between groups and times differences. There were no group × time interactions for the domains sleep duration (0.416), sleep efficiency (0.198), sleep disturbance (0.523), and sleep medications (0.915). However, significant group × time interactions were observed for global sleep score (0.022), and for the domains sleep quality (0.001), sleep latency (0.029), and daytime dysfunction (0.012). In addition, there was a significant group × time interaction for EDS (HIIT = -3.4 ± 0.9; CG change = -1.0 ± 1.0; p = 0.023). Thus, in patients with OSA, 12 weeks of HIIT improves perceived sleep quality and daytime sleepiness.

Impacts of conservative treatment on the clinical manifestations of obstructive sleep apnea-systematic review and meta-analysis

INTRODUCTION

Obstructive sleep apnea (OSA) is a chronic disease with a high populational prevalence that is characterized as airway closure during sleep. Treatment is multidisciplinary and varies according to each case. Continuous positive airway pressure (CPAP), oral appliances, and surgery are the primary therapeutic options. Non-invasive conservative treatments such as sleep hygiene, positional therapy, physical exercises, and weight loss aim to reduce the worsening of the disease while being complementary to the invasive primary treatment.

OBJECTIVE

To analyze the impact of non-invasive conservative therapies on the clinical manifestations of OSA syndrome (OSA), compared with other interventions.

METHOD

This was a systematic review with meta-analysis. The searches were performed without filters for the time period, type of publication, or language. Randomized clinical trials on subjects over 18 years of age diagnosed with untreated OSA were included. Responses to non-invasive conservative treatment were compared with responses to the primary intervention. Primary outcomes were assessed using the Epworth Sleepiness Scale and/or Functional Outcomes of Sleep Questionnaire (FOSQ).

RESULTS

A total of eight studies were included in the review. The heterogeneity of the effect was estimated at 89.77%. Six studies compared conservative treatment with CPAP, one with oral appliances, and one with oropharyngeal exercises. Using the Epworth Sleepiness Scale measurements, the standardized difference in the estimated means, based on the random-effects model, was 0.457 (95% CI (1.082 to 0.169)) and the mean result did not differ significantly from zero (z = 1.43; p = 0.153). The conservative therapies assessed in this study improved the subjective quality of sleep, although the post-treatment ESE scores did not show significant results. The reduction in AHI and better outcomes in the evaluated domains, as well as in cognition and mood, were superior in the groups that received CPAP and IOD.

CONCLUSION

The most commonly used treatments of choice for OSA are invasive, including the use of CPAP, oral appliances, and surgeries, being the most utilized options. This study demonstrated that non-invasive conservative treatments, such as sleep hygiene, yield results as effective as invasive treatments. Further studies are needed to confirm this result and to predict whether invasive treatment can be used as the primary treatment or only as a supplement.

Obstructive sleep apnea: Overlooked comorbidity in patients with diabetes

In this review article, we explore the interplay between obstructive sleep apnea (OSA) and type 2 diabetes mellitus (T2DM), highlighting a significant yet often overlooked comorbidity. We delve into the pathophysiological links between OSA and diabetes, specifically how OSA exacerbates insulin resistance and disrupts glucose metabolism. The research examines the prevalence of OSA in diabetic patients and its role in worsening diabetes-related complications. Emphasizing the importance of comprehensive management, including weight control and positive airway pressure therapy, the study advocates integrated approaches to improve outcomes for patients with T2DM and OSA. This review underscores the necessity of recognizing and addressing OSA in diabetes care to ensure more effective treatment and better patient outcomes.

Association of healthy lifestyle with self-reported sleep disordered breathing: A cross-sectional study

Some healthy lifestyle components have been linked with sleep disordered breathing (SDB), yet little is known about the relationship between comprehensive lifestyle factors and SDB. This study aimed to examine the healthy lifestyle with SDB in community-dwelling adults. We conducted a cross-sectional analysis of the Suzhou Food Consumption and Health Survey in China between 2018 and 2020. The healthy lifestyle index (HLI) was created by combining smoking, alcohol drinking, diet, physical activity, and body mass index (BMI). Its association with SDB was assessed by multiple logistic regression analysis. Subgroup analysis and sensitivity analysis were conducted to assess the robustness of our results. The final analysis included 3788 participants (2859 without SDB and 929 with SDB). In multivariable-adjusted analyses, non-smoking (OR: 0.58, 95 % CI: 0.47-0.71), non-drinking (OR: 0.55, 95 % CI: 0.45-0.68), healthy diet (OR: 0.79, 95 % CI: 0.65-0.95), and healthy BMI (OR: 0.72, 95 % CI: 0.6-0.86) were associated with SDB. Compared with participants with HLI score of 0-1, participants with HLI score of 2, 3, 4, and 5 had OR of 0.68 (95 % CI: 0.51-0.91), 0.49 (95 % CI: 0.37-0.64), 0.29 (95 % CI: 0.21-0.38), and 0.22 (95 % CI: 0.15-0.33), respectively, after adjustment for confounding factors (P-trend<0.001). An inverse dose-response relationship between HLI and SDB was also observed. The association was similar in subgroups stratified by sex, marital status, diabetes and dyslipidemia. A higher score of HLI was associated with reduced odds of SDB in Chinese adults. Our findings suggest the potential of addressing five modifiable lifestyle factors for the prevention of SDB.

Exploring the Shared Genetic Architecture Between Obstructive Sleep Apnea and Body Mass Index

Purpose

The reciprocal comorbidity of obstructive sleep apnea (OSA) and body mass index (BMI) has been observed, yet the shared genetic architecture between them remains unclear. This study aimed to explore the genetic overlaps between them.

Methods

Summary statistics were acquired from the genome-wide association studies (GWASs) on OSA (Ncase = 41,704; Ncontrol = 335,573) and BMI (Noverall = 461,460). A comprehensive genome-wide cross-trait analysis was performed to quantify global and local genetic correlation, infer the bidirectional causal relationships, detect independent pleiotropic loci, and investigate potential comorbid genes.

Results

A positive significant global genetic correlation between OSA and BMI was observed (r g = 0.52, P = 2.85e-122), which was supported by three local signal. The Mendelian randomization analysis confirmed bidirectional causal associations. In the meta-analysis of cross-traits GWAS, a total of 151 single-nucleotide polymorphisms were found to be pleiotropic between OSA and BMI. Additionally, we discovered that the genetic association between OSA and BMI is concentrated in 12 brain regions. Finally, a total 134 expression-tissue pairs were observed to have a significant impact on both OSA and BMI within the specified brain regions.

Conclusion

Our comprehensive genome-wide cross-trait analysis indicates a shared genetic architecture between OSA and BMI, offering new perspectives on the possible mechanisms involved.

Sleep apnoea, gut dysbiosis and cognitive dysfunction

Sleep disorders are becoming increasingly common, and their distinct effects on physical and mental health require elaborate investigation. Gut dysbiosis (GD) has been reported in sleep-related disorders, but sleep apnoea is of particular significance because of its higher prevalence and chronicity. Cumulative evidence has suggested a link between sleep apnoea and GD. This review highlights the gut-brain communication axis that is mediated via commensal microbes and various microbiota-derived metabolites (e.g. short-chain fatty acids, lipopolysaccharide and trimethyl amine N-oxide), neurotransmitters (e.g. γ-aminobutyric acid, serotonin, glutamate and dopamine), immune cells and inflammatory mediators, as well as the vagus nerve and hypothalamic-pituitary-adrenal axis. This review also discusses the pathological role underpinning GD and altered gut bacterial populations in sleep apnoea and its related comorbid conditions, particularly cognitive dysfunction. In addition, the review examines the preclinical and clinical evidence, which suggests that prebiotics and probiotics may potentially be beneficial in sleep apnoea and its comorbidities through restoration of eubiosis or gut microbial homeostasis that regulates neural, metabolic and immune responses, as well as physiological barrier integrity via the gut-brain axis.

Development and application of a machine learning-based predictive model for obstructive sleep apnea screening

Objective

To develop a robust machine learning prediction model for the automatic screening and diagnosis of obstructive sleep apnea (OSA) using five advanced algorithms, namely Extreme Gradient Boosting (XGBoost), Logistic Regression (LR), Support Vector Machine (SVM), Light Gradient Boosting Machine (LightGBM), and Random Forest (RF) to provide substantial support for early clinical diagnosis and intervention.

Methods

We conducted a retrospective analysis of clinical data from 439 patients who underwent polysomnography at the Affiliated Hospital of Xuzhou Medical University between October 2019 and October 2022. Predictor variables such as demographic information [age, sex, height, weight, body mass index (BMI)], medical history, and Epworth Sleepiness Scale (ESS) were used. Univariate analysis was used to identify variables with significant differences, and the dataset was then divided into training and validation sets in a 4:1 ratio. The training set was established to predict OSA severity grading. The validation set was used to assess model performance using the area under the curve (AUC). Additionally, a separate analysis was conducted, categorizing the normal population as one group and patients with moderate-to-severe OSA as another. The same univariate analysis was applied, and the dataset was divided into training and validation sets in a 4:1 ratio. The training set was used to build a prediction model for screening moderate-to-severe OSA, while the validation set was used to verify the model's performance.

Results

Among the four groups, the LightGBM model outperformed others, with the top five feature importance rankings of ESS total score, BMI, sex, hypertension, and gastroesophageal reflux (GERD), where Age, ESS total score and BMI played the most significant roles. In the dichotomous model, RF is the best performer of the five models respectively. The top five ranked feature importance of the best-performing RF models were ESS total score, BMI, GERD, age and Dry mouth, with ESS total score and BMI being particularly pivotal.

Conclusion

Machine learning-based prediction models for OSA disease grading and screening prove instrumental in the early identification of patients with moderate-to-severe OSA, revealing pertinent risk factors and facilitating timely interventions to counter pathological changes induced by OSA. Notably, ESS total score and BMI emerge as the most critical features for predicting OSA, emphasizing their significance in clinical assessments. The dataset will be publicly available on my Github.

Sleep-disordered breathing in heart failure

PURPOSE OF REVIEW

This review addresses the evolving intersection of sleep-disordered breathing (SDB) and heart failure, a topic of increasing clinical significance due to the high prevalence of SDB in heart failure patients and its impact on morbidity and mortality. It reflects recent advancements in diagnostic methodologies and therapeutic strategies. It emphasizes the need for heightened awareness among healthcare providers about the complex relationship between SDB and various forms of heart failure.

RECENT FINDINGS

Recent studies underscore the high incidence of SDB in heart failure patients, varying with the cause of heart failure. Emerging diagnostic tools, including home sleep tests and advanced inpatient screening methods, have improved the early detection and accurate diagnosis of SDB. Novel treatment modalities, like hypoglossal and phrenic nerve stimulation, are promising, especially where conventional therapies are inadequate. The review also discusses the complexities of managing SDB in the context of different heart failure subtypes.

SUMMARY

Findings from recent literature suggest that improved screening, diagnosis, and innovative treatment of SDB in heart failure patients can reduce morbidity, mortality, and healthcare costs. This review emphasizes the need for personalized treatment approaches tailored to individual patient profiles, highlighting the potential of new technologies and multidisciplinary strategies in clinical practice.

Weight loss and lifestyle intervention for cardiorespiratory fitness in obstructive sleep apnea: The INTERAPNEA trial

INTRODUCTION

Although recent trials have shown benefits of weight loss and lifestyle interventions on obstructive sleep apnea (OSA) severity and comorbidities, the effect of these interventions on cardiorespiratory fitness (CRF) remains unknown. This study aimed to investigate the effects of an interdisciplinary weight loss and lifestyle intervention on CRF and self-reported physical fitness in adults with OSA.

METHODS

Eighty-nine men aged 18-65 years with moderate-to-severe OSA and a body mass index ≥25 kg/m2 were randomly assigned to a usual-care group or an 8-week interdisciplinary weight loss and lifestyle intervention. CRF was assessed through the 2-km walking test, and the International Fitness Scale (IFIS) was used to assess self-reported physical fitness.

RESULTS

As compared with usual-care, the intervention group had greater improvements at intervention endpoint in objective CRF (6% reduction in 2-km walking test total time, mean between-group difference, -1.7 min; 95% confidence interval, -2.3 to -1.1), and self-reported overall physical fitness (18% increase in IFIS total score, mean between-group difference, 2.3; 95% CI 1.2 to 3.3). At 6 months after intervention, the intervention group also had greater improvements in both 2-km walking test total time (10% reduction) and IFIS total score (22% increase), with mean between-group differences of -2.5 (CI 95%, -3.1 to -1.8) and 3.0 (CI 95%, 1.8 to 4.1), respectively.

CONCLUSIONS

An 8-week interdisciplinary weight loss and lifestyle intervention resulted in significant and sustainable improvements in CRF and self-reported physical fitness in men with overweight/obesity and moderate-to-severe OSA.

STUDY REGISTRATION

ClinicalTrials.gov registration (NCT03851653).

Plant-based and vegetarian diets are associated with reduced obstructive sleep apnoea risk

Introduction

Obstructive sleep apnoea (OSA) and obesity commonly coexist. Weight loss and exercise are recommended management options for OSA. However, most of the current evidence on diet and OSA is focused on calorie restriction rather than diet quality. The aim of the present study was to determine the association of plant-based dietary indices (PDI) with OSA risk.

Methods

Cross-sectional data from 14 210 participants of the National Health and Nutrition Examination Survey who provided dietary information using the 24-hour recall method were used. PDI - including healthy (hPDI), unhealthy (uPDI) and pro-vegetarian diet index (PVDI) - were determined. OSA risk was determined using the STOP-BANG questionnaire. Logistic regression was used to determine the relationship between dietary indices and OSA risk.

Results

Higher adherence to PDI (odds ratio (OR)Q5 versus Q1=0.81; 95% confidence interval (CI): 0.66-1.00), hPDI (OR=0.83; 95% CI: 0.69-1.01) and PVDI (OR=0.84; 95% CI: 0.68-1.05) was inversely associated with OSA risk, whereas higher consumption of an unhealthy plant-based diet (OR=1.22; 95% CI: 1.00-1.49) was positively associated with OSA. Sex differences in estimates were observed for PDI in males (OR=0.71; 95% CI: 0.56-0.90) versus females (OR=0.93; 95% CI: 0.68-1.28), hPDI in males (OR=0.90; 95% CI: 0.68-1.18) versus females (OR=0.77; 95% CI: 0.54-1.09) and uPDI in males (OR=1.13; 95% CI: 0.89-1.44) versus females (OR=1.42; 95% CI: 1.03-1.97) but not for PVDI.

Conclusions

Higher adherence to a healthy plant-based diet is associated with reduced OSA risk, while an unhealthy plant-based diet has a positive association. The magnitude of these associations differs by sex. Further longitudinal studies are warranted.

ERS International Congress 2023: highlights from the Sleep Disordered Breathing Assembly

The topic of sleep-related breathing disorders is always evolving, and during the European Respiratory Society (ERS) International Congress 2023 in Milan, Italy, the latest research and clinical topics in respiratory medicine were presented. The most interesting issues included new diagnostic tools, such as cardiovascular parameters and artificial intelligence, pathophysiological traits of sleep disordered breathing from routine polysomnography or polygraphy signals, and new biomarkers and the diagnostic approach in patients with excessive daytime sleepiness. This article summarises the most relevant studies and topics presented at the ERS International Congress 2023. Each section has been written by early career members of ERS Assembly 4.

Continuous Positive Airway Pressure but Not GLP1-mediated Weight Loss Improves Early Cardiovascular Disease in Obstructive Sleep Apnea: A Randomized Proof-of-Concept Study

Rationale: Obstructive sleep apnea (OSA) is an independent risk factor for cardiovascular (CV) morbidity and mortality, but the benefit of continuous positive airway pressure (CPAP) is uncertain. However, most randomized controlled trials have focused on the role of CPAP in secondary prevention, although there is growing evidence of a potential benefit on early CV disease. Weight loss in combination with CPAP may be superior but is difficult to achieve and maintain with conventional measures alone. Objectives: The aim of this study was to gain insights into the effect of CPAP on early atherosclerotic processes and to compare it with a glucagon-like peptide (GLP)-1-mediated weight loss regimen in patients with OSA. Methods: We performed a randomized proof-of-concept study comparing CPAP, a GLP1-mediated weight-loss regimen (liraglutide [Lir]), and both in combination for 24 weeks in 30 consecutive patients with OSA (apnea-hypopnea index >15 events/h; body mass index 30-40 kg/m2; and no history of diabetes, heart failure, or unstable CV disease). In addition to extensive evaluation for CV risk factors and endothelial function at baseline and end of study, subjects underwent 18F-fluoro-2-deoxy-D-glucose positron emission tomography-computed tomography (18F-FDG PET-CT) for the measurement of aortic wall inflammation (target-to-background ratio) and coronary computed tomography angiography for semiautomated coronary plaque analysis. Results: Baseline characteristics were similar between groups. CPAP alone and in combination resulted in greater reduction in apnea-hypopnea index than Lir alone (mean difference, -45 and -43 events/h, respectively, vs. -12 events/h; P < 0.05). Both Lir and combination treatment led to significant weight loss, but only CPAP alone resulted in significant decrease in vascular inflammation (aortic wall target-to-background ratio from 2.03 ± 0.34 to 1.84 ± 0.43; P = 0.010), associated with an improvement in endothelial function and a decrease in C-reactive protein. Low-attenuation coronary artery plaque volume as a marker of unstable plaque also decreased with CPAP (from 571 ± 490 to 334 ± 185 mm3) and with combination therapy (from 401 ± 145 to 278 ± 126 mm3) but not with Lir. Conclusions: These data suggest that CPAP therapy, but not GLP1-mediated weight loss, improves vascular inflammation and reduces unstable plaque volume in patients with OSA. Further large randomized controlled studies are warranted to assess the benefit of CPAP therapy in modifying early CV disease. Clinical trial registered with www.clinicaltrials.gov (NCT04186494).

Application Value of Cardiometabolic Index for the Screening of Obstructive Sleep Apnea with or Without Metabolic Syndrome

Background

Obstructive sleep apnea (OSA) is a common chronic disease with various comorbidities. The cardiometabolic index (CMI) reflects visceral fat tissue distribution and function, assessing the risk of obesity-related conditions such as metabolic syndrome (MetS) and stroke, which are strongly connected to OSA. The relationship between CMI with OSA and OSA combined with MetS (OMS) remains unclear. This study aims to evaluate the screening value of CMI for OSA and OMS, compared to the lipid accumulation product (LAP).

Methods

A total of 280 participants who underwent polysomnography were finally included, with the measurements of metabolic-related laboratory test results such as total cholesterol and triglyceride. Receiver operating curve (ROC) analysis and calculation of the area under the curve (AUC) were conducted to assess the screening potential of CMI, LAP, and the logistic regression models established based on them for OSA and OMS. The Youden index, sensitivity, and specificity were used to determine the optimal cutoff points.

Results

ROC curve analysis revealed that the AUCs for CMI in screening OSA and OMS were 0.808 and 0.797, and the optimal cutoff values were 0.71 (sensitivity 0.797, specificity 0.776) and 0.89 (sensitivity 0.830, specificity 0.662), respectively, showing higher Youden index than LAP. The AUCs of screening models based on CMI for OSA and OMS were 0.887 and 0.824, respectively.

Conclusion

CMI and LAP can effectively screen for OSA and OMS, while CMI has more practical cutoff values for identifying the diseased states. Screening models based on CMI demonstrate a high discriminatory ability for OSA and OMS, which needs verification in a large-scale population.

[Obstructive sleep apnea in cardiology clinical practice. Epidemiology, diagnosis, and treatment. Observational, cross-sectional, retrospective study]

Objective

To determine the clinical-epidemiological characteristics, diagnostic feasibility of home respiratory polygraphy and treatment of patients with suspected obstructive sleep apnea (OSA) at cardiovascular risk.

Methods

An observational, cross-sectional, descriptive study was conducted in patients seen in a cardiology outpatient service with suspected OSA, from January 2015 to December 2019. The information was obtained from medical records, and a descriptive statistical analysis was applied to this information.

Results

138 files were reviewed; only 8% of the home respiratory polygraphs were discarded, because they did not meet the required quality standards. It was demonstrated that 89% suffered from OSA, 60% moderate to severe; in men after 50 years of age. The main cardiovascular risk factors was hypertension (89%). The most prevalent heart disease was hypertension (52%). Cardiovascular pharmacological treatment was improved in 82% of the cases. Cardiac rehabilitation in 30%, noninvasive mechanical ventilation 41%, fixed modality 33%, and self-adjustable 9%, all with telemetry.

Conclusions

The prevalence and severity of OSA is higher in the presence of risk or established cardiovascular disease. In the presence of clinical suspicion, it is feasible to confirm the diagnosis with home respiratory poligrafy due to the level of precision and the lower infrastructure required. Greater involvement of the cardiologist in the diagnosis and treatment of this disorder is necessary due to the significant risk of cardiovascular disease it represents.

Recommended assessment and management of sleep disordered breathing in patients with atrial fibrillation, hypertension and heart failure: Taiwan Society of Cardiology/Taiwan Society of sleep Medicine/Taiwan Society of pulmonary and Critical Care Medicine joint consensus statement

Sleep disordered breathing (SDB) is highly prevalent and may be linked to cardiovascular disease in a bidirectional manner. The Taiwan Society of Cardiology, Taiwan Society of Sleep Medicine and Taiwan Society of Pulmonary and Critical Care Medicine established a task force of experts to evaluate the evidence regarding the assessment and management of SDB in patients with atrial fibrillation (AF), hypertension and heart failure with reduced ejection fraction (HFrEF). The GRADE process was used to assess the evidence associated with 15 formulated questions. The task force developed recommendations and determined strength (Strong, Weak) and direction (For, Against) based on the quality of evidence, balance of benefits and harms, patient values and preferences, and resource use. The resulting 11 recommendations are intended to guide clinicians in determining which the specific patient-care strategy should be utilized by clinicians based on the needs of individual patients.

Time-restricted eating and supervised exercise for improving hepatic steatosis and cardiometabolic health in adults with obesity: protocol for the TEMPUS randomised controlled trial

INTRODUCTION

Metabolic dysfunction-associated steatotic liver disease is a major public health problem considering its high prevalence and its strong association with extrahepatic diseases. Implementing strategies based on an intermittent fasting approach and supervised exercise may mitigate the risks. This study aims to investigate the effects of a 12-week time-restricted eating (TRE) intervention combined with a supervised exercise intervention, compared with TRE or supervised exercise alone and with a usual-care control group, on hepatic fat (primary outcome) and cardiometabolic health (secondary outcomes) in adults with obesity.

METHODS AND ANALYSIS

An anticipated 184 adults with obesity (50% women) will be recruited from Granada (south of Spain) for this parallel-group, randomised controlled trial (TEMPUS). Participants will be randomly designated to usual care, TRE alone, supervised exercise alone or TRE combined with supervised exercise, using a parallel design with a 1:1:1:1 allocation ratio. The TRE and TRE combined with supervised exercise groups will select an 8-hour eating window before the intervention and will maintain it over the intervention. The exercise alone and TRE combined with exercise groups will perform 24 sessions (2 sessions per week+walking intervention) of supervised exercise combining resistance and aerobic high-intensity interval training. All participants will receive nutritional counselling throughout the intervention. The primary outcome is change from baseline to 12 weeks in hepatic fat; secondary outcomes include measures of cardiometabolic health.

ETHICS AND DISSEMINATION

This study was approved by Granada Provincial Research Ethics Committee (CEI Granada-0365-N-23). All participants will be asked to provide written informed consent. The findings will be disseminated in scientific journals and at international scientific conferences.

TRIAL REGISTRATION NUMBER

NCT05897073.

Novel Approaches to Sleep Apnea in Heart Failure

Sleep apnea is a serious comorbid condition affecting patients with heart failure. Present in 50% to 75% of heart failure patients, it is often underrecognized, underdiagnosed, and undertreated. Patients with sleep apnea and heart failure are at increased risk of adverse cardiovascular events and sudden death. Treatment of sleep apnea has shown mixed results in reduction of adverse outcomes by sleep apnea type and intervention strategy. Evolving home-based technologies and device therapies present an exciting frontier for patients with sleep apnea and heart failure and an opportunity to improve outcomes. This article reviews novel approaches to sleep apnea in heart failure.

Association of modifiable risk factors with obstructive sleep apnea: a Mendelian randomization study

BACKGROUND

The risk factors involved in obstructive sleep apnea (OSA) have not been clearly identified yet. We attempted to systematically investigate genetically predicted modifiable risk factors and lifestyle behaviors associated with OSA.

METHODS

The association between 34 risk factors and OSA was evaluated using the two-sample Mendelian randomization (MR). Genetic variants for risk factors were acquired from European-descent genome-wide studies. Data sources for OSA were extracted from FinnGen study with 16,761 cases and 201,194 controls. The primary analysis chosen was the inverse-variance weighted method.

RESULTS

MR analyses provide evidence of genetically predicted poor overall health rating (odds ratio (OR), 2.82; 95% confidence interval (CI), 1.95-4.08), nap during day (OR, 2.01; 95% CI, 1.37-2.93), high body mass index (BMI) (OR, 1.14; 95% CI, 1.09-1.19), increased body fat mass (OR, 1.83; 95% CI, 1.83-2.05), elevated body water mass (OR, 1.50; 95% CI, 1.31-1.70) and hypertension (OR, 1.81; 95% CI, 1.34-2.45) were associated with higher OSA risk, while high education level (OR, 0.55; 95% CI, 0.40-0.75) correlated with reduced OSA risk. Suggestive evidence was obtained for smoking and waist-to-hip ratio (WHR) with higher OSA odds, and vigorous physical activity, and HDL cholesterol with lower OSA odds. After adjusting for BMI using multivariable MR analysis, the effects of smoking, WHR, vigorous physical activity, and HDL-cholesterol were fully attenuated.

CONCLUSIONS

This MR study indicates that overall health rating, nap during day, BMI, body fat mass, body water mass, hypertension, and education are causally associated with the risk of OSA, which means that these modifiable risk factors are key targets for OSA prevention.

Comprehensive home-based telerehabilitation in a morbidly obese male patient with severe obstructive sleep apnea. A case report

BACKGROUND

Rehabilitation may be an effective additional treatment method in patients with obstructive sleep apnea (OSA). Physical exercise, weight reduction, pulmonary rehabilitation, and myofunctional therapy (MT) represent beneficial components of rehabilitation recommended as a possible adjunct to standard OSA treatment.

METHODS AND RESULTS

A 54-year-old man with morbid obesity, long-lasting snoring, breathing pauses, frequent waking, as well as persistent drowsiness and fatigue during the day underwent polysomnography (PSG) to investigate suspected OSA. Severe OSA was confirmed by PSG and a 12-week comprehensive, home-based telerehabilitation program (tele-RHB program) along with continuous positive airway pressure (CPAP) therapy was implemented. The tele-RHB program included regular teleconsultations, aerobic-endurance training, MT, inspiratory and expiratory muscle training, as well as recommendations on proper nutrition, a healthy lifestyle, and behavioral changes. Following the treatment, the patient's quality of life (QoL), exercise capacity, lung function, and OSA severity significantly improved. The patient achieved an overall 19.9 kg reduction in weight, of which 16.2 kg was body fat, and his apnea-hypopnea index decreased by 42.6 episodes/hour.

CONCLUSION

Our case report suggests that the comprehensive home-based tele-RHB program adjunct to CPAP therapy may be a novel approach for improving OSA severity, a patient's QoL, exercise capacity, lung function and body composition. It is important to note that such a program should be optional, however it may be needed to achieve the highest possible overall improvement in a patient's life. Further clinical investigations are needed to determine the therapeutic efficacy and clinical potential of this tele-RHB program.

Impact of 8-hour time-limited eating on sleep in adolescents with obesity

STUDY OBJECTIVES

The relationship between time-limited eating (TLE) and sleep quality is a topic of growing interest in the field of chronobiology. Data in adult cohorts shows that TLE may improve sleep quality, but this has not been evaluated in adolescents. The aim of this secondary analysis was to (1) examine the impact of 8-hour TLE on sleep parameters in youth with obesity and (2) explore if there was any association between sleep patterns and glycemic profiles.

METHODS

Adolescents with obesity were randomized into one of three groups: 8-hour TLE (participants self-selected their eating window) + real-time continuous glucose monitor, 8-hour TLE + blinded continuous glucose monitor, or a prolonged eating window. In the primary analysis, it was found that participants in the real-time continuous glucose monitor group + 8-hour TLE group did not access their continuous glucose monitor data and thus for this analysis the two TLE groups were combined and only completers who had available Pittsburgh Sleep Quality Index (PSQI) data at all three time points were included. Participants completed the PSQI at baseline, week 4, and week 12. Mixed-effects generalized linear regression models were utilized to examine the change in PSQI score and assess association between glycemic variability and PSQI total score overtime by intervention arm.

RESULTS

The median PSQI total score for the TLE groups (n = 27) was 6 at week 0 (interquartile range = 5 to 10) and 5 at week 12 (interquartile range = 2 to 7). There was no significant difference in the change in total PSQI score or sleep latency between TLE and control over the study period (P > .05). There was no association between PSQI score and change in weight or glycemic profile between groups (all P values > 0.05).

CONCLUSIONS

These results suggest that in adolescents with obesity, an 8-hour TLE approach did not negatively impact sleep quality or efficiency when compared to a prolonged eating window. The potential effects of TLE on sleep should be further investigated in larger randomized trials.

CITATION

Jayakumr A, Gillett ES, Wee CP, Kim A, Vidmar AP. Impact of 8-hour time-limited eating on sleep in adolescents with obesity. J Clin Sleep Med. 2023;19(11):1941-1949.

No Changes in Body Composition and Adherence to the Mediterranean Diet after a 12-Week Aerobic Training Intervention in Women with Systemic Lupus Erythematosus: The EJERCITA-LES Study

Systemic Lupus Erythematosus (SLE) is a chronic autoimmune disease linked to high cardiovascular risk. To reach an adequate body composition status while maintaining proper dietary habits are effective strategies for reducing cardiovascular risk, both being potentially modified through exercise. This study aimed to evaluate the effects of a 12-week aerobic training intervention on anthropometry, body composition and adherence to the Mediterranean diet in women with SLE. A total of 58 women with SLE were assigned to either an exercise group (EG; n = 26) or a comparison group (CG; n = 32) in this non-randomized controlled trial. The EG comprised 12 weeks of aerobic exercise (two sessions/week) between 40-75% of the individual's heart rate reserve (calculated as maximum heart rate - resting heart rate) and the CG received usual care. At baseline and after the intervention, the anthropometry (i.e., weight, waist circumference, waist-to-hip ratio, and body mass index) and body composition (i.e., fat mass and lean mass) were assessed using a stadiometer, an anthropometric tape, and a bioimpedance device, respectively. Dietary habits were assessed with the Mediterranean Diet score. There were no between-group differences in neither anthropometric nor body composition parameters (all p > 0.05). Similarly, no between-group differences were obtained in the adherence to the Mediterranean diet after the exercise intervention (all p > 0.05). Contrary to the initial hypothesis, these results suggest that the 12-week aerobic training intervention performed in this study did not improve anthropometry, body composition or adherence to the Mediterranean diet in women with SLE.

Evaluation of thyroid functions and obesity in obstructive sleep apnea syndrome

OBJECTIVE

Obstructive sleep apnea syndrome is associated with many chronic diseases.

METHODS

Obesity and thyroid function tests were evaluated retrospectively and cross-sectionally for 782 obstructive sleep apnea syndrome patients.

RESULTS

The mean patient age was 49.3±11.5 years, and the majority were obese (67.9%) or overweight (26.6%). The mean age of the patients in Group 2 (moderate/severe obstructive sleep apnea syndrome) was higher than that of Group 1 (simple snoring/mild obstructive sleep apnea syndrome). The rate of severe obstructive sleep apnea syndrome among obese patients (35.2%) was significantly higher than that of normal-weight (11.6%) and overweight (18.3%) patients (p=0.001). The oxygen desaturation index/apnea-hypopnea index and levels of leukocytes and C-reactive protein were significantly higher, while mean/minimum saturation values and hemoglobin, hematocrit, and free triiodothyronine levels were significantly lower among obese patients compared with overweight and normal-weight patients (p=0.001). Leukocytes, C-reactive protein, and apnea-hypopnea index/oxygen desaturation index values were higher, and mean/minimum saturation values were lower in Group 2 than in Group 1.

CONCLUSION

There were relationships between obstructive sleep apnea syndrome severity and body mass index. Obesity could be a critical predisposing factor for sleep disturbances. The prevention and control of obesity is important while being treated for obstructive sleep apnea syndrome.

A Dietary and Lifestyle Intervention Improves Treatment Adherence and Clinical Outcomes in Overweight and Obese Patients with Obstructive Sleep Apnea: A Randomized, Controlled Trial

The study's objective was to assess the impact of Mediterranean diet/lifestyle interventions for weight loss on positive airway pressure (PAP) adherence, body mass index (ΒΜΙ), sleepiness, and blood pressure measurements (BP) in patients with obstructive sleep apnea (OSA). We designed a randomized, controlled trial, including overweight and obese patients with moderate to severe OSA, randomized to standard care (SCG, n = 37) or a Mediterranean diet group (MDG, n = 37). The SCG received healthy lifestyle advice, while the MDG underwent a 6-month behavioral intervention aiming to enhance weight loss and adherence to a Mediterranean diet. PAP adherence, BMI, Epworth Sleepiness Scale (ESS), and BP measurements were evaluated pre- and post-intervention. Post-intervention PAP use was higher in the MDG compared to the SCG (6.1 vs. 5.4, p = 0.02). Diet/lifestyle intervention was one of the most significant predictive factors for PAP adherence (OR = 5.458, 95% CI = 1.144-26.036, p = 0.03). The SCG demonstrated a rise in BMI, while the MDG displayed a decline (0.41 vs. -0.75, p = 0.02). The MDG also demonstrated a substantial reduction in adjusted SBP (-5.5 vs. 2.8, p = 0.014) and DBP (-4.0 vs. 2.5, p = 0.01). Ultimately, incorporating a dietary/lifestyle intervention with standard care yields superior PAP adherence, BMI, and BP measurements in contrast to standard care alone, emphasizing the advantages of dedicating more time and support within the MDG.

Whole-food plant-based diet reduces daytime sleepiness in patients with OSA

Consumption of a diet high in saturated fat has been associated with daytime sleepiness. A whole-food plant-based (WFPB) dietary pattern, which is low in saturated fat, has been shown to be beneficial in a variety of health conditions. We assessed the effect of a short-term (21 days) WFPB diet intervention on daytime sleepiness in 14 patients with obstructive sleep apnea (OSA). We found a mean decrease of 3.8 points (SD = 3.3, p = 0.003) on the Epworth Sleepiness Scale (ESS) after switching from a standard Western diet to a WFPB diet. Our results suggest that a WFPB diet could be a viable dietary intervention to reduce symptom of daytime sleepiness.

Comparison of ocular surface assessment outcomes between healthy controls and patients with obstructive sleep apnea-hypopnea syndrome: a meta-analysis of the literature

Objective: This meta-analysis aims to determine whether ocular surface alterations are associated with disease severity in patients with obstructive sleep apnea-hypopnea syndrome (OSAHS). Methods: The protocol for this systematic review and meta-analysis was registered in PROSPERO. We conducted the search in six electronic databases (China National Knowledge Infrastructure, EMBASE, Cochrane Library, Web of Science, Wanfang, and PubMed) from since the construction of the databases to 30 December 2022. The standard mean difference (SMD) and correlation coefficients are reported as measures of the effect size in the presence of retrieved data. In addition, the random effects model or fixed effects model was used in a combined analysis. Stata 11.0 and R 3.6.1 were used for statistical analyses of the data. Results: A total of 15 studies satisfied the inclusion criteria for this study. The prevalence of floppy eyelid syndrome (FES) and dry eye syndrome in patients with obstructive sleep apnea-hypopnea syndrome was 40 and 48%, respectively. In addition, the Schirmer 1 value and tear break-up time (TBUT) were remarkably reduced in patients with OSAHS when compared to that of the controls. The ocular surface disease index (OSDI) scores, Oxford corneal staining scores, and the rates of loss in the meibomian glands were elevated in patients with obstructive sleep apnea-hypopnea syndrome when compared to that of the controls, especially those with severe disease. Moreover, the Schirmer 1 value and tear break-up time exhibited a negative correlation with the apnea-hypopnea index (AHI), and the OSDI showed a positive association with the apnea-hypopnea index. Conclusion: Patients with OSAHS had a greater prevalence of FES than the healthy controls. They also showed lower Schirmer 1 value and tear break-up time but had a higher OSDI, Oxford corneal staining scores, and rates of loss in the meibomian glands than the healthy controls. Clinical Trial Registration: (https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=392527).

Shorter sleep duration is associated with greater visceral fat mass in US adults: Findings from NHANES, 2011-2014

Habitual declines in sleep duration and increased rates of obesity are public health concerns worldwide. Accumulating evidence suggests a prominent link between reduced sleep duration and weight gain. Our cross-sectional study investigated the relationship between sleep duration and body fat distribution in US adults. We extracted data for 5151 participants (2575 men and 2576 women) aged 18-59 years from the US National Health and Nutrition Examination Survey 2011-2012 and 2013-2014. Weekday or workday night-time sleep duration was estimated using an in-home interview questionnaire. Dual-energy x-ray absorptiometry scans were used to determine regional body fat mass (arms, legs, trunk [android and gynoid], and abdominal [subcutaneous and visceral]). Multiple linear regression and restricted cubic spline analyses were performed after adjusting for several demographic, anthropometric, and nutritional covariates. There was a significant negative association between sleep duration and visceral fat mass overall (β: -12.139, P < 0.001) and by sex (men: β: -10.096, P < 0.001; women: β: -11.545, P = 0.038), after adjusting for age, ethnicity, body mass index, total body fat mass, daily energy and alcohol intake, sleep quality and sleep disorder status. Sleep duration and visceral fat appeared to plateau at ≥ 8 h of daily sleep. Sleep duration is negatively associated with visceral fat mass accumulation during adulthood with possibly no benefits beyond 8 h of sleep per day. Mechanistic and prospective studies are required to confirm the effect of sleep duration on visceral adiposity and determine its causes.

Impact of Nocturnal Polyuria and Sleep Quality in Kidney Transplant Recipients With Nocturia

BACKGROUND

To investigate the quality of life (QOL) of patients with nocturia after kidney transplantation (KT) and the association between nocturnal polyuria and sleep quality.

METHODS

In a cross-sectional study, a patient who consented was evaluated using the following items: international prostate symptom QOL score, nocturia-quality of life score, overactive bladder symptom score, Pittsburgh sleep quality index, bladder diary, uroflowmetry, and bioimpedance analysis. Clinical and laboratory data were obtained from medical charts.

RESULTS

Forty-three patients were included in the analysis. Approximately 25% of patients urinated once at night, and 58.1% had nocturia twice. Nocturnal polyuria was observed in 86.0% of patients, and overactive bladder was observed in 23.3% of patients. According to the Pittsburgh sleep quality Index, 34.9% of patients had poor sleep quality. Multivariate analysis revealed that patients with nocturnal polyuria tended to have a high estimated glomerular filtration rate (P = .058). On the other hand, multivariate analysis for poor sleep quality revealed that high body fat percentage and low nocturia-quality of life total score were independently correlated factors (P = .008 and P = .012, respectively). Furthermore, the patients with nocturia ≥3/night were significantly older than those with nocturia ≤2/night (P = .022).

CONCLUSION

Nocturnal polyuria, poor sleep quality, and aging may decrease the QOL of patients with nocturia after KT. Further investigations, including optimal water intake and interventions, can lead to better management after KT.

Is obstructive sleep apnea a circadian rhythm disorder?

Obstructive sleep apnea is the most common sleep-related breathing disorder worldwide and remains underdiagnosed. Its multiple associated comorbidities contribute to a decreased quality of life and work performance as well as an increased risk of death. Standard treatment seems to have limited effects on cardiovascular and metabolic aspects of the disease, emphasising the need for early diagnosis and additional therapeutic approaches. Recent evidence suggests that the dysregulation of circadian rhythms, processes with endogenous rhythmicity that are adjusted to the environment through various cues, is involved in the pathogenesis of comorbidities. In patients with obstructive sleep apnea, altered circadian gene expression patterns have been demonstrated. Obstructive respiratory events may promote circadian dysregulation through the effects of sleep disturbance and intermittent hypoxia, with subsequent inflammation and disruption of neural and hormonal homeostasis. In this review, current knowledge on obstructive sleep apnea, circadian rhythm regulation, and circadian rhythm sleep disorders is summarised. Studies that connect obstructive sleep apnea to circadian rhythm abnormalities are critically evaluated. Furthermore, pathogenetic mechanisms that may underlie this association, most notably hypoxia signalling, are presented. A bidirectional relationship between obstructive sleep apnea and circadian rhythm dysregulation is proposed. Approaching obstructive sleep apnea as a circadian rhythm disorder may prove beneficial for the development of new, personalised diagnostic, therapeutic and prognostic tools. However, further studies are needed before the clinical approach to obstructive sleep apnea includes targeting the circadian system.

An Updated Approach to Antiobesity Pharmacotherapy: Moving Beyond the 5% Weight Loss Goal

Despite professional society guidelines recommending that obesity be treated as a chronic disease by emphasizing the use of lifestyle modification in conjunction with pharmacotherapy, antiobesity medications are uncommonly prescribed in most clinical practices. The recent Food and Drug Administration approval of semaglutide 2.4 mg weekly to treat obesity-as well as other forthcoming advancements in diabetes and antiobesity medications-highlights the potential of pharmacotherapy to significantly augment weight loss efforts. In this Expert Endocrine Consult, we review the evolving role of antiobesity pharmacotherapy in clinical practice and suggest a framework for the use of these medications.

Obstructive sleep apnea: a review for the orthodontist

INTRODUCTION

Obstructive sleep apnea (OSA) affects an important part of the population and is characterized by recurrent total or partial obstruction of the upper airway (UA) during sleep, negatively affecting the quality of life of patients in the short and long terms, and constituting an important public health problem for the society. The field of expertise of orthodontists is closely related to the UA, placing them in a strategic position to diagnose air passage failures and intervene when necessary. Orthodontists, as health professionals, must know how to recognize respiratory problems and manage them appropriately, when indicated.

OBJECTIVE

Thus, this paper aims to review and critically evaluate the related literature, to provide orthodontists with updated knowledge on the diagnosis and therapy related to OSA. Science and technology are constantly evolving; thus, the literature was also reviewed considering new technologies available in consumer-targeted applications and devices for the diagnosis, monitoring, and treatment of sleep-disordered breathing.

Impact of a Weight-Loss Rehabilitation Program on Sleep Apnea Risk and Subjective Sleepiness in Patients with Overweight/Obesity: The DietSleep Study

Obstructive sleep apnea (OSA) is one of the most frequent chronic diseases, and comorbid obesity occurs in more than 60% of cases. Variations in body weight influence both OSA severity and OSA-related symptoms. We prospectively assessed the impact of a weight-loss program using the Berlin score to reflect OSA risk, and we also used the Epworth Sleepiness Scale (ESS) to assess daytime sleepiness. DietSleep was a prospective multicentric cohort study investigating OSA risk and daytime sleepiness before and after weight-loss intervention. One hundred and twenty-seven patients were included (initial OSA risk 36%), most of whom were women (85.8%) with a median body mass index (BMI) of 29.7 kg/m2, and the interquartile range was (27.6; 34). The diet-based weight-loss program induced a median decrease in BMI of 3.7 kg/m2 (−5; −2.9) (body weight~12.1% (−16.0; −8.8)) over a period of 171 days (114; 269). Changes in anthropometric values were similar regarding OSA risk after adjusting for initial values. Berlin scores significantly improved from 3 (1; 5) to 1 (0; 2), p < 0.01; the proportion of patients with a Berlin score ≥2 decreased from 36% to 7% after the intervention. The proportion of patients with ESS ≥11 decreased from 13% to 2%. These results confirm that a weight-loss program produces clinically relevant weight loss and a significant improvement in both OSA and subjective daytime sleepiness.

New pharmacologic agents for obstructive sleep apnoea: what do we know and what can we expect?

PURPOSE OF REVIEW

This review provides a condensed description of pharmacological remedies explored in patients with obstructive sleep apnoea (OSA) as well as projections of what we might expect in terms of clinical performance of these drugs.

RECENT FINDINGS

Conventional drug therapies explored in OSA have generally produced disappointing results and there is a shortage of pharmacological treatment alternatives in this disorder. Recent insights into pathophysiological mechanisms potentially involved in OSA suggest that the condition may be divided into distinct subgroups based on clusters or defined by means of unique functional endotypic criteria. In fact, positive outcomes in clinical trials have now resulted in several drug candidates that show a convincing reduction of sleep disordered breathing in both short and intermediate term. Such drugs may be particularly useful in certain variants of OSA but not in others. These insights have also raised the ambition to create personalized therapies in OSA. Another recent development is the insight that OSA-linked conditions such as obesity, daytime somnolence and various forms of cardiovascular/metabolic disease may provide drug-based targets. For instance, pharmacological obesity therapy may provide not only positive metabolic effects but may also be a way to eliminate the anatomic component in obese OSA patients.

SUMMARY

Recent insights into the pathophysiology of OSA have opened possibilities to develop personalized therapy. Drugs addressing fundamental aspects of the sleep and breathing disorder provide a particularly promising avenue for development of novel forms of treatment in OSA.

The Case for Early Use of Glucagon-like Peptide-1 Receptor Agonists in Obstructive Sleep Apnea Patients with Comorbid Diabetes and Metabolic Syndrome

Patients with obstructive sleep apnea (OSA) have high rates of co-occurring type 2 diabetes, hypertension, obesity, stroke, congestive heart failure, and accelerated atherosclerotic cardiovascular diseases. These conditions frequently require multiple medications, raising the risk of polypharmacy, adverse drug-drug and drug-disease interactions, decreased quality of life, and increased healthcare cost in these patients. The current review of extant literature presents evidence supporting glucagon-like peptide-1 receptor agonists (GLP-1RA) as one pharmacologic intervention that provides a "one-stop shop" for OSA patients because of the multiple effects GLP-1RA has on comorbidities (e.g., hypertension, diabetes, obesity, metabolic syndrome, and atherosclerotic cardiovascular diseases) that commonly co-occur with OSA. Examples of glucagon-like peptide-1 receptor agonists approved by the FDA for diabetes (some of which are also approved for obesity) are liraglutide, exenatide, lixisenatide, dulaglutide, semaglutide, and albiglutide. Prescribing of GLP-1RAs to address these multiple co-occurring conditions has enormous potential to reduce polypharmacy, cost, and adverse drug events, and to improve quality of life for patients living with OSA and diabetes. We thus strongly advocate for increased and early use of GLP-1RA in OSA patients with co-occurring diabetes and other cardiometabolic conditions common in OSA.

Effect of a Weight Loss and Lifestyle Intervention on Dietary Behavior in Men with Obstructive Sleep Apnea: The INTERAPNEA Trial

This study investigated the effects of an eight-week interdisciplinary weight loss and lifestyle intervention on dietary behavior in men who were overweight/had obesity and moderate-to-severe obstructive sleep apnea (OSA). It was based on data from INTERAPNEA (ClinicalTrials.gov ID: NCT03851653); a randomized clinical trial conducted from April 2019 to April 2020. Men aged 18–65 years with moderate-to-severe OSA and a body mass index ≥25 kg/m2 were randomly assigned to a usual-care group or an eight-week interdisciplinary weight loss and lifestyle intervention combined with usual-care. Dietary behavior was assessed through the Food Behavior Checklist (FBC) and the Mediterranean Diet Adherence Screener (MEDAS). Of the 89 participants who underwent randomization, 75 completed the intervention endpoint assessment, 89 participants being therefore included in the intention-to-treat analyses, and 75 in the per-protocol approach. As compared with usual-care, the intervention group had greater improvements at intervention endpoint in dietary behavior, as measured by the FBC total score (20% increase in FBC total score, mean between-group difference, 8.7; 95% confidence interval, 5.7 to 11.7), and MEDAS total score (33% increase in MEDAS total score, mean between-group difference, 2.1; 95% CI 1.3 to 2.9). At 6 months after intervention, the intervention group also had greater improvements in both the FBC total score (15% increase) and MEDAS total score (25% increase), with mean between-group differences of 7.7 (CI 95%, 4.4 to 10.9) and 1.7 (CI 95%, 0.9 to 2.6), respectively. An eight-week interdisciplinary weight loss and lifestyle intervention resulted in meaningful and sustainable improvements in dietary behavior, including adherence to the Mediterranean diet in men who were overweight/ had obesity and CPAP-treated moderate-to-severe OSA.