The reciprocal interaction between obesity and obstructive sleep apnoea. Sleep Med Rev. 2013;17:123-131. [PMID: 22818968 DOI: 10.1016/j.smrv.2012.05.002]

Oral Health Implications of Obstructive Sleep Apnea: A Literature Review

BACKGROUND

Obstructive sleep apnea (OSA) is a prevalent sleep disorder characterized by repeated episodes of partial or complete obstruction of the upper airway during sleep. While the systemic implications of OSA are well documented, the dental consequences are less frequently discussed yet equally significant. This review aims to elucidate the oral health impacts of OSA, emphasizing the importance of interdisciplinary care.

METHODS

A comprehensive literature search was conducted across several databases to identify studies examining the relationship between OSA and various oral health parameters. The review included observational studies, clinical trials, and systematic reviews published in English up to January 2024.

RESULTS

OSA was significantly associated with heightened risks of bruxism, dry mouth, periodontal disease, temporomandibular joint disorders, palatal and dental changes, and alterations in taste sensation. Mouth breathing associated with OSA was a critical factor in exacerbating xerostomia and dental caries. Furthermore, the systemic inflammation induced by OSA appeared to correlate with the severity of periodontal disease. Patients using oral appliance therapy for OSA also showed notable changes in dental occlusion and required ongoing dental monitoring.

CONCLUSIONS

The findings underscore the bidirectional relationship between OSA and oral health, highlighting the need for dental professionals to be integral participants in the management of OSA. Early dental evaluation and intervention can contribute to the overall health and quality of life of individuals with OSA. The review advocates for the development of clinical guidelines to facilitate the early identification and management of OSA-related oral health issues within dental practice and encourages a collaborative approach to patient care.

Cardio-metabolic health effects of CPAP treatment for sleep apnoea during weight loss: A randomised controlled pilot trial

BACKGROUND AND AIMS

This study assessed whether the addition of continuous positive airway pressure (CPAP) during weight loss would enhance cardiometabolic health improvements in patients with obesity and Obstructive Sleep Apnoea (OSA).

METHODS AND RESULTS

Patients with overweight or obesity, pre-diabetes and moderatesevere OSA were randomised to receive CPAP therapy with a weight loss programme (CPAP+WL) or a weight loss programme alone (WL alone).

PRIMARY OUTCOME

2-hour glucose assessed by an oral glucose tolerance test.

SECONDARY OUTCOMES

24 hr blood pressure, body composition (DEXA) and fasting blood markers. 17 patients completed 3-month follow-up assessments (8 CPAP+WL and 9 WL alone). Overall, participants in both groups lost ∼12 kg which reduced polysomnography determined OSA severity by ∼45 %. In the CPAP+WL group, CPAP use (compliance 5.29 hrs/night) did not improve any outcome above WL alone. There was no improvement in 2-hour glucose in either group. However, in the pooled (n = 17) analysis there were overall improvements in most outcomes including insulin sensitivity (.000965 units, p = .008), sleep systolic BP (- 16.2 mmHg, p = .0003), sleep diastolic BP (-9.8 mmHg, p = 0.02), wake diastolic BP (- 4.3 mmHg, p = .03) and sleepiness (Epworth Sleepiness Score -3.2, p = .0003). In addition, there were reductions in glucose area under the curve (-230 units, p = .009), total (-0.86 mmol/L, p = 0.006) and LDL cholesterol (-0.58 mmol/L, p = 0.007), triglycerides (-0.75 mmol/L, p = 0.004), fat mass (-7.6 kg, p < .0001) and abdominal fat (-310 cm3, p < .0001).

CONCLUSION

Weight loss reduced OSA and improved sleepiness and cardiometabolic health. These improvements were not further enhanced by using CPAP. Results suggest weight loss should be the primary focus of treatment for patients with OSA and obesity.

Scanning of obstructive sleep apnea syndrome using smartwatch: A comparison of smartwatch and polysomnography

BACKGROUND

Obstructive Sleep Apnea Syndrome (OSAS), which significantly impairs nighttime sleep quality and causes excessive daytime sleepiness, not only reduces the quality of life of patients, but also increases the social and socioeconomic burden. Wearable-noninvasive devices can provide faster OSAS screening and follow-up. Smartwatches as an objective, non-invasive, practical and relatively inexpensive method, they are attractive candidates for pre-evaluation of OSAS and referral to a physician. In this study, it was aimed to evaluate the effectiveness of a smart watch in detecting OSAS findings compared to the gold standard polysomnograhy (PSG).

METHODS

PSG data of the study group were compared with data such as SpO2, heart rate and saturation obtained by smartwatch from both sides, and the Cohen's kappa was used to measure for two methods and predictive values were evaluated.

RESULTS

A total of 115 participants [44 female (38.3%), mean age (SD): 49.24 (11.39)] were enrolled. 75 (65.22%) of the participants were diagnosed with OSAS, of which 29 (25.22%) participants have severe OSAS. The smartwatch showed good sensitivity (75% to 96%), specificity (79% to 91%), and diagnostic accuracy (AUC: 0.84 to 0.93) in predicting apnea and severe apnea, respectively. The highest agreement between PSG and smartwatch and the diagnostic ability of smartwatch were found in persons with severe OSAS.

CONCLUSION

The high PPV-NPV values in our study and the good compatibility coefficient of the smart watch with the PSG device can contribute to the expansion of the usage areas of smart watches that come into the lives of many people in daily practice.

The Influence of CPAP Therapy on Basal Metabolic Rate and Physical Activity in Obese Patients with Obstructive Sleep Apnea

BACKGROUND

Energy balance in Obstructive Sleep Apnea (OSA), a disease closely related to obesity, is disturbed, and physical activity levels are impaired. The role of Continuous Positive Airway Pressure treatment (CPAP) in alleviating the disruptions mentioned above is questioned. The objective of this study is to explore changes in energy expenditure (EE) and physical activity (PA) in obese patients with OSA after CPAP treatment.

METHODS

An assessment of Basal Metabolic Rate (BMR) via indirect calorimetry (IC) was performed on 24 obese patients (male in the majority (87.5%), mean age of 52.4 ± 9.8 years), newly diagnosed with moderate-severe OSA by polysomnography, at 4-time points: at baseline, at CPAP titration, at the 1-month and the 3-month follow up. Physical activity levels were subjectively estimated using the International Questionnaire of Physical Activity (IPAQ) before and after 3 months of adherent CPAP application.

RESULTS

BMR significantly decreased after CPAP treatment (1926 ± 537.8 kcal/d at baseline, 1790 ± 493.7 kcal/d at CPAP initiation, 1680.3 ± 600.8 kcal/d at 1 month, and 1581.3 ± 478.9 kcal/d at 3 months follow up (p < 0.001)). No significant changes in IPAQ were observed over time: baseline median IPAQ: 3894 (1487.5-11,755.5) total MET·min·wk-1, 3-month median IPAQ: 3900 (1512-11,824.5) total MET·min·wk-1.

CONCLUSIONS

CPAP has an appreciable time effect on the BMR of obese patients with moderate-severe OSA. However, this change is not accompanied by a significant increase in physical activity levels.

Associations between body mass index, sleep-disordered breathing, brain structure, and behavior in healthy children

Pediatric overweight/obesity can lead to sleep-disordered breathing (SDB), abnormal neurological and cognitive development, and psychiatric problems, but the associations and interactions between these factors have not been fully explored. Therefore, we investigated the associations between body mass index (BMI), SDB, psychiatric and cognitive measures, and brain morphometry in 8484 children 9-11 years old using the Adolescent Brain Cognitive Development dataset. BMI was positively associated with SDB, and both were negatively correlated with cortical thickness in lingual gyrus and lateral orbitofrontal cortex, and cortical volumes in postcentral gyrus, precentral gyrus, precuneus, superior parietal lobule, and insula. Mediation analysis showed that SDB partially mediated the effect of overweight/obesity on these brain regions. Dimensional psychopathology (including aggressive behavior and externalizing problem) and cognitive function were correlated with BMI and SDB. SDB and cortical volumes in precentral gyrus and insula mediated the correlations between BMI and externalizing problem and matrix reasoning ability. Comparisons by sex showed that obesity and SDB had a greater impact on brain measures, cognitive function, and mental health in girls than in boys. These findings suggest that preventing childhood obesity will help decrease SDB symptom burden, abnormal neurological and cognitive development, and psychiatric problems.

Body composition changes and their relationship with obstructive sleep apnoea symptoms, severity: The Sleeping Well Trial

BACKGROUND & AIMS

Obstructive sleep apnoea (OSA) and obesity share a complex bi-directional relationship as location of body fat and changes in regional body composition may be more important for OSA improvement than changes in total body weight only. The aim of this study was to evaluate the impact of a 6-month weight loss intervention for adults newly diagnosed with moderate-severe OSA and obesity on regional body composition. The secondary aims evaluated the relationship between changes in OSA symptoms and severity and anthropometry and regional body composition during the first 12-months after commencing CPAP and explored differences in outcomes between males and females.

METHODS

Participants (n = 59) received CPAP overnight at home alongside a 6-month modified fasting intervention with 12-months follow up. Regional body composition was measured by Dual X-ray absorptiometry, (DXA) and anthropometry before and after the lifestyle intervention. OSA severity was measured using the apnoea hypopnea index via overnight polysomnography and OSA symptoms were measured using the Epworth Sleepiness scale.

RESULTS

Forty-seven adults (74% male) had complete measures available with a mean age of 50.0 y (SD 11.0) and BMI 34.1 kg/m2 (SD 5.0). Following the intervention average fat mass changed by -5.27 kg (5.36), p < 0.001) and visceral adipose tissue (-0.63 kg (0.67), p < 0.001) significantly decreased in males only with a maintenance of fat-free mass (mean -0.41 kg (1.80), p = 0.18). Females (n = 12) had significant decreases in waist circumference (mean -3.36 cm (3.18) p < 0.01), android lean (-0.12 kg (0.04), p < 0.05) and android total mass (-0.28 kg (0.39), p < 0.05) only. Regional body composition changes in males were positively associated with improvements in OSA severity (p < 0.01) but not OSA symptoms.

CONCLUSION

Improvements in regional body composition were seen in males only which were related to improvements in OSA severity but not OSA symptoms. Females may exhibit different OSA pathophysiology and may require different treatment approaches.

TRIAL REGISTRATION

https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=369975&isReview=trueAACTRN12616000203459 ACTRN12616000203459.

Obstructive sleep apnea and orofacial myofunctional aspects in obesity

PURPOSE

This study aimed to evaluate the quality of sleep, presence of obstructive sleep apnea (OSA), and its relationship with the presence of snoring, cephalometric characteristics, degree of collapse of the upper airways, and orofacial myofunctional profile in obese and overweight individuals.

METHODS

All participants completed polysomnography, as well as sleep and snoring questionnaires. We further performed orofacial, otorhinolaryngological, and anthropometric evaluations on all participants.

RESULTS

A total of 102 adults, comprising 29 obese, 21 overweight, and 52 eutrophic individuals of both sexes participated in this study. We observed a high prevalence of snoring in both obese and overweight (100%), and in 65% of eutrophic individuals. Among the obese subjects 58% had a severe degree of OSA, whereas 4% of eutrophic subjects presented a risk for OSA development. Sleep quality was related to body mass index (BMI) and cervical and abdominal circumference. All obese and overweight individuals presented with orofacial myofunctional alterations such as facial asymmetry, alteration of the maxilla-jaw relationship, inadequate tongue posture, changes in masticatory pattern and swallowing, and inadequate general orofacial myofunctional condition. Airway obstructions at the retropalatal and retrolingual levels > 75% were observed in at least 48% of the individuals.

CONCLUSION

Obese and overweight individuals presented a higher risk for the development of OSA compared with eutrophic patients, and obese individuals presented a greater severity of OSA. The higher the BMI and greater the cervical and abdominal circumferences, the higher the prevalence of OSA, worse the quality of sleep, and more serious orofacial myofunctional characteristics in this population.

Relationship of obstructive sleep apnea with periodontal condition and its local and systemic risk factors

OBJECTIVE

Obstructive sleep apnea (OSA) and periodontitis share risk factors, such as age, obesity, stress, and cardiovascular events, which have a bidirectional cause-effect relationship through systemic inflammation. Our objective was to determine the relationship between OSA and the periodontal condition and its associated local and systemic risk factors.

MATERIAL AND METHODS

This was an observational case-control study involving 60 patients. Local oral risk factors and the systemic condition of each patient were evaluated. All patients underwent polysomnography for the diagnosis of OSA. Chi-squared, one-way ANOVA, and Bonferroni's tests were performed.

RESULTS

A higher percentage of patients with periodontitis had severe OSA (66.66%); however, no statistically significant association was found between the two pathologies (p = 0.290). In terms of systemic risk factors, an association was found between arterial hypertension and severe OSA (p = 0.038), and in terms of local factors, an association was found between the use of removable prostheses and severe OSA (p = 0.0273).

CONCLUSION

In the general population, patients with periodontitis showed a higher prevalence of severe OSA. Obesity and hypothyroidism were the most prevalent systemic findings in patients with OSA and periodontitis. Arterial hypertension and osteoarthritis were found to be associated with severe OSA. The local risk factors associated with periodontitis and severe OSA were removable partial dentures and misfit resins.

CLINICAL RELEVANCE

To study the factors that can facilitate the progression of OSA and periodontitis, physicians and dentists should be advised to provide comprehensive care for patients with both pathologies.

Depression, Insomnia, and Obesity Among Post-9/11 Veterans: Eating Pathology as a Distinct Health Risk Behavior

INTRODUCTION

Understanding the interrelationships between co-occurring chronic health conditions and health behaviors is critical to developing interventions to successfully change multiple health behaviors and related comorbidities. The objective of the present study was to examine the effects of depression, insomnia, and their co-occurrence on risk of obesity and to examine the role of health risk behaviors as potential confounders of these relationships with an emphasis on eating pathologies.

METHODS

Iraq and Afghanistan conflict era veterans (n = 1,094, 51.2% women) who participated in the Women Veterans Cohort Study between July 2014 and September 2019 were categorized as having depression, insomnia, both, or neither condition. Logistic regression models were used to examine group differences in the risk of obesity. Health risk behaviors (i.e., eating pathology, physical activity, smoking, and hazardous drinking) were then assessed as potential confounders of the effects of depression and insomnia on the likelihood of obesity.

RESULTS

Obesity was most prevalent in individuals with co-occurring insomnia and depression (53.2%), followed by depression only (44.6%), insomnia only (38.5%), and neither condition (30.1%). Importantly, maladaptive eating behaviors confounded the depression-obesity association but not the insomnia-obesity association. There was no evidence that insufficient physical activity, smoking, or hazardous drinking confounded the effects of insomnia or depression on obesity.

CONCLUSIONS

These findings exemplify the complex relationships between multiple health conditions and behaviors that contribute to obesity. Elucidating these associations can enhance the precision with which interventions are tailored to efficiently allocate resources and reduce the severe health impact of obesity among veterans.

Investigating the Relationship between Obstructive Sleep Apnoea, Inflammation and Cardio-Metabolic Diseases

Obstructive sleep apnoea (OSA) is a prevalent underdiagnosed disorder whose incidence increases with age and weight. Uniquely characterised by frequent breathing interruptions during sleep-known as intermittent hypoxia (IH)-OSA disrupts the circadian rhythm. Patients with OSA have repeated episodes of hypoxia and reoxygenation, leading to systemic consequences. OSA consequences range from apparent symptoms like excessive daytime sleepiness, neurocognitive deterioration and decreased quality of life to pathological complications characterised by elevated biomarkers linked to endocrine-metabolic and cardiovascular changes. OSA is a well-recognized risk factor for cardiovascular and cerebrovascular diseases. Furthermore, OSA is linked to other conditions that worsen cardiovascular outcomes, such as obesity. The relationship between OSA and obesity is complex and reciprocal, involving interaction between biological and lifestyle factors. The pathogenesis of both OSA and obesity involve oxidative stress, inflammation and metabolic dysregulation. The current medical practice uses continuous positive airway pressure (CPAP) as the gold standard tool to manage OSA. It has been shown to improve symptoms and cardiac function, reduce cardiovascular risk and normalise biomarkers. Nonetheless, a full understanding of the factors involved in the deleterious effects of OSA and the best methods to eliminate their occurrence are still poorly understood. In this review, we present the factors and evidence linking OSA to increased risk of cardiovascular conditions.

Impact of a telerehabilitation programme combined with continuous positive airway pressure on symptoms and cardiometabolic risk factors in obstructive sleep apnea patients

Background

Obstructive sleep apnea syndrome is a common sleep-breathing disorder associated with adverse health outcomes including excessive daytime sleepiness, impaired quality of life and is well-established as a cardiovascular risk factor. Continuous positive airway pressure is the reference treatment, but its cardiovascular and metabolic benefits are still debated. Combined interventions aiming at improving patient's lifestyle behaviours are recommended in guidelines management of obstructive sleep apnea syndrome but adherence decreases over time and access to rehabilitation programmes is limited. Telerehabilitation is a promising approach to address these issues, but data are scarce on obstructive sleep apnea syndrome.

Methods

The aim of this study is to assess the potential benefits of a telerehabilitation programme implemented at continuous positive airway pressure initiation, compared to continuous positive airway pressure alone and usual care, on symptoms and cardiometabolic risk factors of obstructive sleep apnea syndrome. This study is a 6-months multicentre randomized, parallel controlled trial during which 180 obese patients with severe obstructive sleep apnea syndrome will be included. We will use a sequential hierarchical criterion for major endpoints including sleepiness, quality of life, nocturnal systolic blood pressure and inflammation biological parameters.

Discussion

m-Rehab obstructive sleep apnea syndrome is the first multicentre randomized controlled trial to examine the effectiveness of a telerehabilitation lifestyle programme in obstructive sleep apnea syndrome. We hypothesize that a telerehabilitation lifestyle intervention associated with continuous positive airway pressure for 6 months will be more efficient than continuous positive airway pressure alone on symptoms, quality of life and cardiometabolic risk profile. Main secondary outcomes include continuous positive airway pressure adherence, usability and satisfaction with the telerehabilitation platform and medico-economic evaluation.

Trial registration

Clinicaltrials.gov Identifier: NCT05049928. Registration data: 20 September 2021.

Intermittent Hypoxia and Diet-Induced Obesity on the Intestinal Wall Morphology in a Murine Model of Sleep Apnea

This work analyzes the impact of two conditions, intermittent hypoxia exposure and high-fat diet in rats as models of sleep apnea. We studied the autonomic activity and histological structure of the rat jejunum and whether the overlapping of both conditions, as often observed in patients, induces more deleterious effects on the intestinal barrier. We found alterations in jejunum wall histology, predominantly in HF rats, based on increased crypt depth and submucosal thickness, as well as decreased muscularis propria thickness. These alterations were maintained with the IH and HF overlap. An increase in the number and size of goblet cells in the villi and crypts and the infiltration of eosinophils and lymphocytes in the lamina propria suggest an inflammatory status, confirmed by the increase in plasma CRP levels in all experimental groups. Regarding the CAs analysis, IH, alone or combined with HF, causes a preferential accumulation of NE in the catecholaminergic nerve fibers of the jejunum. In contrast, serotonin increases in all three experimental conditions, with the highest level in the HF group. It remains to be elucidated whether the alterations found in the present work could affect the permeability of the intestinal barrier, promoting sleep apnea-induced morbidities.

A 12-month weight loss intervention in adults with obstructive sleep apnoea: is timing important? A step wedge randomised trial

BACKGROUND/OBJECTIVES

Continuous positive airway pressure (CPAP) concomitant with weight loss is a recommended treatment approach for adults with moderate-severe obstructive sleep apnoea (OSA) and obesity. This requires multiple synchronous behaviour changes. The aim of this study was to examine the effectiveness of a 6-month lifestyle intervention and to determine whether the timing of starting a weight loss attempt affects weight change and trajectory after 12 months in adults newly diagnosed with moderate-severe OSA and treated at home with overnight CPAP.

METHODS

Using a stepped-wedge design, participants were randomised to commence a six-month lifestyle intervention between one and six-months post-enrolment, with a 12-month overall follow-up. Adults (n = 60, 75% males, mean age 49.4 SD 10.74 years) newly diagnosed with moderate-severe OSA and above a healthy weight (mean BMI 34.1 SD 4.8) were recruited.

RESULTS

After 12 months, exposure to the intervention (CPAP and lifestyle) resulted in a 3.7 (95% CI: 2.6 to 4.8, p < 0.001) kg loss of weight compared to the control condition (CPAP alone). Timing of the weight loss attempt made no difference to outcomes at 12 months. When exposed to CPAP only (control period) there was no change in body weight (Coef, [95% CI] 0.03, [-0.3 to 0.36], p = 0.86).

CONCLUSIONS

The lifestyle intervention resulted in a modest reduction in body weight, while timing of commencement did not impact the degree of weight loss at 12 months. These findings support the recommendation of adjunctive weight-loss interventions within six-months of starting CPAP.

Management of non-alcoholic fatty liver disease patients with sleep apnea syndrome

Nonalcoholic fatty liver disease (NAFLD) is strongly associated with sleep apnea syndrome (SAS). Many NAFLD patients have SAS, and obstructive sleep apnea hypopnea syndrome is also considered to be an independent risk factor for NAFLD, as it contributes to the progression of NAFLD via oxidative stress, lipid peroxidation, inflammation, and insulin resistance. This review aims to provide some recommendations for the management of NAFLD patients with SAS, including diet, exercise, weight loss, and continuous positive airway pressure. This review also highlights the importance of effective strategies in NAFLD prevention and treatment.

Elevated body mass index increases the risk of cardiovascular events in hypertensive patients accompanied with obstructive sleep apnea: A cohort study

BACKGROUND

Effects of body mass index (BMI) on cardiovascular events are inconsistent. We aimed to investigate the association of BMI with cardiovascular events in hypertensives with obstructive sleep apnea (OSA).

METHODS

Hypertensives with OSA diagnosed with polysomnography between 2011 and 2013 in UROSAH cohort were followed up till Jan 2021. Outcomes were non-fatal cardiovascular events and cardiac death. Cox regression was used to estimate the relationship of continuous and categorical BMI with total and specific outcomes. Sensitivity analyses were performed by excluding those on OSA treatment or underweight patients. Stratified analyses were conducted by parameters including sex and age.

RESULTS

2239 hypertensives with OSA were included with 405 normal weight (BMI<25 kg/m²), 1164 overweight (25-29.9 kg/m²) and 670 obesity (≥30 kg/m²). 206 non-fatal cardiovascular events and 18 cardiac death were recorded during 6.6 years follow-up. Compared with normal weight group, overweight (HR=1.53, 95%CI: 1.01-2.32, P = 0.047) and obesity groups (1.85, 1.19-2.86, P = 0.006) showed increased risk for cardiovascular events, significant in obesity group and marginal in overweight group in fully-adjusted model. In specific events, obesity showed significantly elevated HR for non-fatal cardiovascular events (1.64, 1.04-2.60, P = 0.035). Continuous BMI showed significantly increased HR for total and specific events in all models. Sensitivity analysis yielded consistent results. In stratification analysis, stronger association between obesity and cardiovascular events was observed in the young (HR=5.97, P interaction=0.030).

CONCLUSIONS

BMI is in positive association with cardiovascular events in hypertensives with OSA, emphasizing importance of maintaining healthy BMI for prevention of adverse events in this population, on the basis of guideline-recommended treatment.

Electrophysiological complexity in the rat dorsomedial hypothalamus and its susceptibility to daily rhythms and high-fat diet

The dorsomedial hypothalamus (DMH) in amongst the most important brain structures involved in the regulation of feeding behaviour and metabolism. In contrast to other hypothalamic centres, its main role is related to the circadian rhythmicity of food intake and energy homeostasis; both reported to be disrupted in obesity. In modern world, overweight and obesity reached global epidemic proportions. Thus, not only is it important to study their negative implications but also the mechanism responsible for their development. Here, we exposed rats to short-term (2-4 weeks) high-fat diet (HFD)-not long enough to induce obesity. Next, we performed electrophysiological patch-clamp recordings ex vivo from neurons in the DMH either during the day or at night. Our results showed a day-to-night change in the firing frequency of DMH cells, with higher activity during the dark phase. This was abolished by HFD consumption, resulting in a decreased threshold for action potential generation during the day and therefore increased electrical activity at this phase. We propose this electrophysiological disturbance as a mechanism for the induction of abnormal daytime feeding, previously observed for HFD-fed animals, which might in turn contribute to the development of obesity. In addition, we provide an electrophysiological characteristic of DMH neurons with a separation into three anatomically and functionally distinct subpopulations, namely, the compact part, separating the structure into the ventral and dorsal divisions. Our study is the first to show electrophysiological complexity of the DMH with its sensitivity to diet and daily rhythms.

Biomechanical properties of the cornea in Floppy eyelid syndrome

Background: Floppy eyelid syndrome (FES) is a frequently underdiagnosed disorder of unknown pathogenesis. FES has been associated with ocular conditions such as keratoconus. At present, despite the frequent combination of FES and keratoconus, there are almost no data on the biomechanical properties of the cornea in these patients. Aims: to determine the corneas biomechanical properties in patients with floppy eyelid syndrome. Methods: The study included 40 patients (54 eyes) with hyper-extensible eyelid syndrome. The average age was 53.96.7 years. The central corneal thickness averaged 55125 m. All the patients underwent a standard ophthalmological examination, including pneumotonometry. The intraocular pressure (IOP) and biomechanical properties of the cornea were measured using dynamic bidirectional applanation. Results: The study of the corneas biomechanical properties in patients with floppy eyelid syndrome showed a decrease in the corneal hysteresis (CH) indices to 9.960.61 mm Hg on the average, in the corneal resistance factor (CRF) to 9.540.64 mm Hg. Moreover, their value varied depending on the severity of the syndrome. The mean value of the corneal compensated IOP (IOPcc) in the entire sample was 15.51.0 mm Hg, Goldman IOP (IOPg) 15.12.0 mm Hg, pneumotonometric IOP 11.612.9 mm Hg. Regardless of the severity, the pneumotonometric IOP indices did not have statistically significant differences, while as this syndrome progressed, the IOPcc and IOPg indices showed a steady decrease in the mean values. Conclusions: It was found that, in floppy eyelid syndrome, the biomechanical parameters of the cornea were reduced. At the same time, the value of these indicators varied significantly with the severity. The largest and the smallest decrease were observed in the corneal hysteresis index and the corneal-compensated IOP, respectively.

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.

Association between laryngopharyngeal reflux and obstructive sleep apnea in adults

Background

Obstructive sleep apnea syndrome (OSAS) and laryngopharyngeal reflux (LPR) have been found to coexist in the population. OSAS and LPR also share obesity as an important risk factor. However, the relationship between LPR and OSAS remains unclear. This study aimed to correlate LPR as measured by the Reflux Symptom Index (RSI) and the Reflux Finding Score (RFS) with OSAS.

Methods

This cross-sectional study included sixty-four subjects who underwent anamnesis to complete the RSI and the Epworth Sleeping Scale (ESS). The subjects were then divided into the OSAS and non-OSAS groups based on the Apnea-Hypopnea Index (AHI) obtained through a polysomnography examination. Both groups underwent a flexible fiberoptic nasopharyngolaryngoscopy examination to determine the RFS. LPR was identified based on the RSI and RFS.

Results

The mean BMI of the OSAS group significantly was higher than the non-OSAS group (p < 0.05). Most of the subjects in the OSAS group exhibited mild-moderate OSAS (AHI 10-29), and severe OSAS occurred in only seven subjects. The mean RSI and RFS values in the OSAS group did not differ significantly from the non-OSAS group (p = 0.34 and p = 0.36, respectively). The proportion of LPR between the mild-moderate OSAS group, the severe OSAS group, and the non-OSAS group did not differ significantly (p = 1.00). RSI and RFS did not significantly correlate with AHI. Based on RSI, the proportion of LPR between the ESS (+) and ESS (-) groups did not significantly differ (adjusted p = 0.062). The proportion of LPR based on RFS was almost equal between the ESS (+) and ESS (-) groups (p = 0.817).

Conclusions

The BMI of the OSAS group was significantly higher than the non-OSAS group. There was no significant difference in RSI and RFS between the OSAS and non-OSAS groups. There was no significant correlation between RSI and AHI, or between RFS and AHI. There was no significant difference in the proportion of RSI between the ESS (+) and the ESS (-) groups.

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

IMPORTANCE

Obesity is the leading cause of obstructive sleep apnea (OSA); however, the effects of weight loss and lifestyle interventions on OSA and comorbidities remain uncertain.

OBJECTIVE

To evaluate the effect of an interdisciplinary weight loss and lifestyle intervention on OSA and comorbidities among adults with moderate to severe OSA and overweight or obesity.

DESIGN, SETTING, AND PARTICIPANTS

The Interdisciplinary Weight Loss and Lifestyle Intervention for OSA (INTERAPNEA) study was a parallel-group open-label randomized clinical trial conducted at a hospital-based referral center in Granada, Spain, from April 1, 2019, to October 23, 2020. The study enrolled 89 Spanish men aged 18 to 65 years with moderate to severe OSA and a body mass index (calculated as weight in kilograms divided by height in meters squared) of 25 or greater who were receiving continuous positive airway pressure (CPAP) therapy. The sole inclusion of men was based on the higher incidence and prevalence of OSA in this population, the differences in OSA phenotypes between men and women, and the known effectiveness of weight loss interventions among men vs women.

INTERVENTIONS

Participants were randomized to receive usual care (CPAP therapy) or an 8-week weight loss and lifestyle intervention involving nutritional behavior change, aerobic exercise, sleep hygiene, and alcohol and tobacco cessation combined with usual care.

MAIN OUTCOMES AND MEASURES

The primary end point was the change in the apnea-hypopnea index (AHI) from baseline to the intervention end point (8 weeks) and 6 months after intervention. Secondary end points comprised changes in other OSA sleep-related outcomes, body weight and composition, cardiometabolic risk, and health-related quality of life.

RESULTS

Among 89 men (mean [SD] age, 54.1 [8.0] years; all of Spanish ethnicity; mean [SD] AHI, 41.3 [22.2] events/h), 49 were randomized to the control group and 40 were randomized to the intervention group. The intervention group had a greater decrease in AHI (51% reduction; change, -21.2 events/h; 95% CI, -25.4 to -16.9 events/h) than the control group (change, 2.5 events/h; 95% CI, -2.0 to 6.9 events/h) at the intervention end point, with a mean between-group difference of -23.6 events/h (95% CI, -28.7 to -18.5 events/h). At 6 months after intervention, the reduction in AHI was 57% in the intervention group, with a mean between-group difference of -23.8 events/h (95% CI, -28.3 to -19.3 events/h). In the intervention group, 18 of 40 participants (45.0%) no longer required CPAP therapy at the intervention end point, and 6 of 40 participants (15.0%) attained complete OSA remission. At 6 months after intervention, 21 of 34 participants (61.8%) no longer required CPAP therapy, and complete remission of OSA was attained by 10 of 34 participants (29.4%). In the intervention vs control group, greater improvements in body weight (change, -7.1 kg [95% CI, -8.6 to -5.5 kg] vs -0.3 kg [95% CI, -1.9 to 1.4 kg]) and composition (eg, change in fat mass, -2.9 kg [95% CI, -4.5 to -1.3 kg] vs 1.4 kg [95% CI, -0.3 to 3.1 kg]), cardiometabolic risk (eg, change in blood pressure, -6.5 mm Hg [95% CI, -10.3 to -2.6 mm Hg] vs 2.2 mm Hg [95% CI, -2.1 to 6.6 mm Hg]), and health-related quality of life (eg, change in Sleep Apnea Quality of Life Index, 0.8 points [95% CI, 0.5-1.1 points] vs 0.1 points [95% CI, -0.3 to 0.4 points]) were also found at the intervention end point.

CONCLUSIONS AND RELEVANCE

In this study, an interdisciplinary weight loss and lifestyle intervention involving Spanish men with moderate to severe OSA and had overweight or obesity and were receiving CPAP therapy resulted in clinically meaningful and sustainable improvements in OSA severity and comorbidities as well as health-related quality of life. This approach may therefore be considered as a central strategy to address the substantial impact of this increasingly common sleep-disordered breathing condition.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03851653.

Leptin: A Potential Link Between Obstructive Sleep Apnea and Obesity

Chronic intermittent hypoxia (CIH), a pathophysiological manifestation of obstructive sleep apnea (OSA), is strongly correlated with obesity, as patients with the disease experience weight gain while exhibiting elevated plasma levels of leptin. This study was done to determine whether a relationship may exist between CIH and obesity, and body energy balance and leptin signaling during CIH. Sprague-Dawley rats were exposed to 96 days of CIH or normoxic control conditions, and were assessed for measures of body weight, food and water intake, and food conversion efficiency. At the completion of the study leptin sensitivity, locomotor activity, fat pad mass and plasma leptin levels were determined within each group. Additionally, the hypothalamic arcuate nucleus (ARC) was isolated and assessed for changes in the expression of proteins associated with leptin receptor signaling. CIH animals were found to have reduced locomotor activity and food conversion efficiency. Additionally, the CIH group had increased food and water intake over the study period and had a higher body weight compared to normoxic controls at the end of the study. Basal plasma concentrations of leptin were significantly elevated in CIH exposed animals. To test whether a resistance to leptin may have occurred in the CIH animals due to the elevated plasma levels of leptin, an acute exogenous (ip) leptin (0.04 mg/kg carrier-free recombinant rat leptin) injection was administered to the normoxic and CIH exposed animals. Leptin injections into the normoxic controls reduced their food intake, whereas CIH animals did not alter their food intake compared to vehicle injected CIH animals. Within ARC, CIH animals had reduced protein expression of the short form of the obese (leptin) receptor (isoform OBR₁₀₀) and showed a trend toward an elevated protein expression of the long form of obese (leptin) receptor (OBRb). In addition, pro-opiomelanocortin (POMC) protein expression was reduced, but increased expression of the phosphorylated extracellular-signal-regulated kinase 1/2 (pERK1/2) and of the suppressor of cytokine signaling 3 (SOCS3) proteins was observed in the CIH group, with little change in phosphorylated signal transducer and activator of transcription 3 (pSTAT3). Taken together, these data suggest that long-term exposure to CIH, as seen in obstructive sleep apnea, may contribute to a state of leptin resistance promoting an increase in body weight.

Serum Transferrin Level Is Associated with the Severity of Obstructive Sleep Apnea Independently of Obesity: A Propensity Score-Match Observational Study

INTRODUCTION

Dysregulation of iron metabolism is closely associated with the development of obesity and obstructive sleep apnea (OSA), but little is known about the relationship between serum transferrin (TF) level and OSA severity. We aimed to verify this relationship and fit into account for obesity-related confounders among bariatric candidates.

METHODS

We compared data retrospectively collected in 270 bariatric candidates. A propensity score-matched (PSM) analysis was used to determine the impact of iron metabolism on OSA severity independently of obesity. Univariate analysis was used to evaluate the relationship between serum TF level and the severity of OSA reflected by hypoxia and night awakenings parameters. Serum TF level to predict the severity of OSA was assessed by using univariate and multiple logistic regression model.

RESULTS

The preliminary analysis showed that serum ferritin (113 ng/mL [50-203] vs. 79 ng/mL [40-130], p = 0.009) and TF (2.72 g/L [2.46-3.09] vs. 2.65 g/L [2.34-2.93], p = 0.039) level was significantly higher in the moderate/severe OSA group than the no/mild OSA group. After PSM analysis, there were 75 patients in each group and only serum TF level remained significant (p = 0.014). The proportion of patients with combined T2D and hyperlipidemia also remained higher in moderate/severe OSA groups. Univariate analysis showed that the group with higher degree of hypoxia had higher serum TF levels no matter the severity of OSA was grouped by oxygen desaturation index (ODI; 2.79 g/L [2.56-3.06] vs. 2.55 g/L [2.22-2.84], p < 0.001) or minimum oxygen saturation (SpO2nadir; 2.75 g/L [2.50-3.03] vs. 2.56 g/L [2.24-2.92], p = 0.009). Univariate and multiple logistic regression analysis further showed that serum TF level emerged as a significant and independent factor associated with OSA severity especially grouped by ODI (odds ratio: 2.91, 95% CI: 1.36-6.23, p = 0.006).

CONCLUSION

The existence of OSA exacerbates obesity comorbidities, particularly type 2 diabetes and hyperlipidemia. Serum TF level is associated with the severity of OSA independently of obesity and might be a potential identification and therapeutic targets.

Assessing the needs and perspectives of patients with obesity and obstructive sleep apnea syndrome following continuous positive airway pressure therapy to inform health care practice: A focus group study

Objective

This study aims to investigate the lived experience in patients with obstructive sleep apnea syndrome (OSAS) and comorbid obesity following after continuous positive airway pressure (CPAP) therapy made with the disease the device, and to identify barriers and facilitators to the use of CPAP to improve rehabilitation provision and aid in disease self-management.

Methods

Qualitative research was conducted using three focus groups with a representative sample of 32 inpatients (37% female) undergoing a 1-month pulmonary rehabilitation program at the IRCSS Istituto Auxologico Italiano San Giuseppe Hospital, Verbania, Italy. The focus groups were recorded on tape, and contemporaneous notes were made. The tapes were transcribed verbatim, and Interpretative Phenomenological Analysis was used to develop themes.

Results

Six main themes were extracted: (1) Living the diagnosis as a shock; (2) You should not sleep on it: the importance of prevention; (3) The adjustment to CPAP; (4) Barriers and facilitators to the use of CPAP; (5) Three in a bed; and (6) The relationship with the healthcare system.

Conclusion

Results of this study suggest potential avenues for interventions to increase adherence to CPAP, including the provision of information and continued support. Individual counseling providing strategies aimed at helping the person to cope with the emotional problem and relational difficulties associated with the use of CPAP, and at strengthening self-efficacy and self-management skills are also encouraged for optimal care during the rehabilitation program.

Long-Term Weight Change and Glycemic Control in Patients With Type 2 Diabetes Mellitus and Treated vs. Untreated Sleep-Disordered Breathing-Analysis From the DIAbetes COhoRtE

Hypothesis: Positive airway pressure (PAP) is the standard treatment for sleep-disordered breathing (SDB), a prevalent condition in patients with type 2 diabetes mellitus (DM2). Recent studies showed that short-term PAP treatment may cause weight gain. However, long-term data for patients with DM2 are scarce. Therefore, the aim of the present analysis was to assess changes in weight and glycemic control in patients with DM2 and treated vs. untreated SDB.

Methods: The DIAbetes COhoRtE (DIACORE) study is a prospective population-based cohort study in patients with DM2. At baseline, patients of the DIACORE-SDB sub-study were tested for SDB [defined as apnea-hypopnea-index (AHI) ≥ 15/h] using a two-channel ambulatory SDB-monitoring device. In this observational study, PAP treatment was initiated in a subgroup of patients with SDB (SDB PAP) within clinical routine between the baseline and first follow-up visit [median observation period of 2.3 (2.2; 2.4) years], whereas the other patients with SDB did not receive PAP (SDB untreated). At baseline and first follow-up visit, weight and HbA1c were assessed.

Results: Of the 346 patients with SDB [mean age 68 years, 71% male, body-mass index (BMI) 31.9 kg/m²], 17% were in the SDB PAP and 83% in the SDB untreated group. Weight change within the observation period was similar in both groups (−0.2 and −0.9 kg; p = 0.322). The percentage of patients with severe weight gain (≥ 5 kg) within the observation period was significantly higher in the SDB PAP group compared to the SDB untreated group (15.0 vs. 5.6%; p = 0.011). Multivariable regression analysis, accounting for baseline HbA1c, insulin substitution, BMI, waist-to-hip ratio (WHR), physical activity, and AHI, showed that PAP treatment was significantly associated with a weight gain ≥ 5 kg [odds ratio (OR) = 3.497; 95% CI (1.343; 9.106); p = 0.010] and an increase in HbA1c [B = 2.410; 95% CI (0.118; 4.702); p = 0.039].

Conclusion: Median weight change was similar in patients with SDB with and without PAP treatment. However, patients with DM2 and PAP treatment have an increased risk of severe long-term weight gain and an increase in HbA1c.

Clinical Trial registration: DRKS00010498

Obstructive sleep apnoea/hypopnoea syndrome: relationship with obesity and management in obese patients

Obstructive sleep apnoea/hypopnoea syndrome (OSAHS) is a disease characterised by upper airway obstruction during sleep, quite frequent in the general population, even if underestimated. Snoring, sleep apnoea and diurnal hypersomnia are common in these patients. Central obesity plays a key role: it reduces the size and changes the conformation of the upper airways, besides preventing lung expansion, with consequent reduction of lung volumes. Furthermore, obese people are also resistant to leptin, which physiologically stimulates ventilation; as a result, this causes scarce awakening during apnoea. OSAHS diagnosis is based on the combination of clinical parameters, such as apnoea/hypopnoea index (AHI), medical history, physical examination and Mallampati score. The first objective reference method to identify OSAHS is polysomnography followed by sleep endoscopy. Therapy provides in the first instance reduction of body weight, followed by continuous positive airway pressure (CPAP), which still remains the treatment of choice in most patients, mandibular advancement devices (MAD) and finally otolaryngology or maxillofacial surgery. Among surgical techniques, central is barbed reposition pharyngoplasty (BRP), used in the field of multilevel surgery.

Bi-directional relationships between co-morbid insomnia and sleep apnea (COMISA)

Insomnia and obstructive sleep apnea (OSA) commonly co-occur. Approximately 30-50% of patients with OSA report clinically significant insomnia symptoms, and 30-40% of patients with chronic insomnia fulfil diagnostic criteria for OSA. Compared to either insomnia or OSA alone, co-morbid insomnia and sleep apnea (COMISA) is associated with greater morbidity for patients, complex diagnostic decisions for clinicians, and reduced response to otherwise effective treatment approaches. Potential bi-directional causal relationships between the mechanisms and manifestations of insomnia and OSA could play an integral role in the development and management of COMISA. A greater understanding of these relationships is required to guide personalized diagnostic and treatment approaches for COMISA. This review summarizes the available evidence of bi-directional relationships between COMISA, including epidemiological research, case studies, single-arm treatment studies, randomized controlled treatment trials, and objective sleep study data. This evidence is integrated into a conceptual model of COMISA to help refine the understanding of potential bi-directional causal relationships between the two disorders. This theoretical framework is essential to help guide future research, improve diagnostic tools, determine novel therapeutic targets, and guide tailored sequenced and multi-faceted treatment approaches for this common, complex, and debilitating condition.

Chronobiology and the case for sleep health interventions in the community

Our sleep-wake cycle is determined by the interaction between our homeostatic sleep drive and circadian rhythm. Each of us has a personalised biological rhythm or chronotype that determines the optimal time to fall asleep and wake up. Chronic sleep deprivation has been linked to the development of several physical and mental health disorders, as well as accidents and occupational errors. Around the world, growing recognition of the importance of sleep has led to the adoption of practices that promote sleep health. Given that Singaporeans were consistently found to be one of the most sleep-deprived populations in the world, we believe that there is an urgent need to pursue the introduction of community-based sleep health interventions here. This includes sleep education and promotion of sleep hygiene, adopting practices to reduce social jetlag and improve sleep health, and enhancing screening and treatment of sleep disorders.

Self-reported snoring is associated with chronic kidney disease in obese but not in normal-weight Chinese adults

Background

The relationship between sleeping disorders and chronic kidney disease (CKD) has already been reported. Snoring, a common clinical manifestation of obstructive sleep apnea–hypopnea syndrome, is of clinical value in assessing sleeping disorder severity. However, investigations of the connection between snoring and CKD are limited, especially in normal-weight populations. This study assessed the relationship between snoring frequency and CKD in obese and normal-weight people in China.

Methods

A community-based retrospective cross-sectional study of 3250 participants was performed. Study participants were divided into three groups – the regularly snoring group, occasionally snoring group, and never snoring group – based on their self-reported snoring frequency. CKD was defined as an estimated glomerular filtration rate of less than 60 mL/min/1.73 m². Multiple logistic regression analysis was used to explore the relevance between snoring frequency and CKD prevalence.

Results

The CKD prevalence in obese participants was higher than that in normal-weight participants. Frequent snorers had a higher prevalence of CKD than those who were not frequent snorers in the obese group. Snoring frequency was correlated with CKD prevalence in obese participants independent of age, sex, smoking and drinking status, systolic blood pressure, triglyceride level, high-density lipoprotein, and homeostasis model assessment of insulin resistance (odds ratio: 2.66; 95% CI: 1.36–5.19; p=.004), while the same relationships did not exist in normal-weight participants (odds ratio: 0.79; 95% CI: 0.32–1.98; p=.614).

Conclusions

Snoring appears to be independently associated with CKD in obese but not in normal-weight Chinese adults.

Employer-mandated obstructive sleep apnea treatment and healthcare cost savings among truckers

OBJECTIVE

To evaluate the effect of an employer-mandated obstructive sleep apnea (OSA) diagnosis and treatment program on non-OSA-program trucker medical insurance claim costs.

METHODS

Retrospective cohort analysis; cohorts constructed by matching (randomly, with replacement) Screen-positive Controls (drivers with insurance screened as likely to have OSA, but not yet diagnosed) with Diagnosed drivers (n = 1,516; cases = 1,224, OSA Negatives = 292), on two factors affecting exposure to medical claims: experience level at hire and weeks of job tenure at the Diagnosed driver's polysomnogram (PSG) date (the "matching date"). All cases received auto-adjusting positive airway pressure (APAP) treatment and were grouped by objective treatment adherence data: any "Positive Adherence" (n = 932) versus "No Adherence" (n = 292). Bootstrap resampling produced a difference-in-differences estimate of aggregate non-OSA-program medical insurance claim cost savings for 100 Diagnosed drivers as compared to 100 Screen-positive Controls before and after the PSG/matching date, over an 18-month period. A two-part multivariate statistical model was used to set exposures and demographics/anthropometrics equal across sub-groups, and to generate a difference-in-differences comparison across periods that identified the effect of OSA treatment on per-member per-month (PMPM) costs of an individual driver, separately from cost differences associated with adherence choice.

RESULTS

Eighteen-month non-OSA-program medical claim costs savings from diagnosing (and treating as required) 100 Screen-positive Controls: $153,042 (95% CI: -$5,352, $330,525). Model-estimated effect of treatment on those adhering to APAP: -$441 PMPM (95% CI: -$861, -$21).

CONCLUSIONS

Results suggest a carrier-based mandatory OSA program generates substantial savings in non-OSA-program medical insurance claim costs.

The Microbiome in Obstructive Sleep Apnea

Recent evidence has highlighted important associations between obstructive sleep apnea and the microbiome. Although the intricacies of the pathophysiologic mechanisms are not well understood, available evidence suggests a bidirectional relationship between OSA and microbiota composition. Sleep fragmentation, intermittent hypoxia, and intermittent hypercapnia all play significant roles in altering the microbiome, and initial evidence has shown that alterations of the microbiota affect sleep patterns. Animal model evidence strongly supports the idea that the microbiome mediates disease states associated with OSA including hypertension, atherosclerosis, and obesity. The majority of evidence focuses on changes in the gut microbiome, which may result from OSA as well as contribute to sleep pattern changes, OSA-related CVD, and obesity. Meanwhile, a developing body of work suggests changes in the upper airway microbiome may be associated with OSA and periodontitis-related oral cavity microbiome changes may have significance in OSA-related CVD. Lastly, while evidence is limited, several studies suggest there may be a role for treatment of OSA and OSA-related comorbidities through alteration of the microbiome with probiotics, prebiotics, and microbiota transplantation. These early animal and human studies begin to characterize the interrelationships of the microbiome and OSA and may lead to new avenues for treatment.

One-month of a low-energy diet, with no additional effect of high-protein, reduces Obstructive Sleep Apnea severity and improve metabolic parameters in obese males

PURPOSE

Obstructive Sleep Apnea (OSA) is closely associated with obesity. Weight loss ameliorates OSA and its associated metabolic disorders. A high protein intake may improve weight loss through increased energy expenditure, and fat-free mass maintenance during weight loss.

OBJECTIVES

To evaluate the effects of a low-energy, high-protein diet on OSA severity and metabolic parameters in obese men.

METHODS

Forty-five OSA obese (BMI ≥ 30 kg/m²) males were included in this randomized study and submitted to nocturnal polysomnography, body composition measured by plethysmography, biochemical analyses of blood glucose, insulin and lipids, and food intake evaluations before and after one month of a low-energy diet. Diets were designed to create a 30% deficit in total energy expenditure with 1.6 g of protein/kg/day (High Protein group - HP) or 0.8 g of protein/kg/day (Low Protein group - LP).

RESULTS

Only a time effect of the intervention was observed in body mass (-3.7 ± 2.0% for the LP group and -4.0 ± 1.5% for the HP group; p < 0.001), Body Mass Index (p < 0.001), fat mass in kg (p < 0.01) and fat-free mass in kg (p < 0.01). Significant improvements in Apnea Hypopnea Index were observed in both groups (54.0 ± 25.0 to 33.7 ± 31.7 in LP group; 39.7 ± 24.3 to 21.4 ± 25.9 in HP group; p = 0.06). Improvements of 38% and 46% in the Apnea-Hypopnea Index were observed in the LP and HP groups, respectively. Both interventions provided equivalent metabolic benefits as reductions in glucose (p < 0.001), insulin (p < 0.001), HOMA-IR (p = 0.005), triglycerides (p = 0.002), and in total cholesterol (p = 0.004).

CONCLUSION

One month of a low-energy diet resulted in significant improvements in OSA severity in obese men. Increased protein intake during a short period of low-energy diet had no further beneficial effects on OSA severity or biochemical parameters than a standard protein diet. Registered under ClinicalTrials.gov Identifier no. NCT01985035.

Body Fat Indices as Effective Predictors of Insulin Resistance in Obstructive Sleep Apnea: Evidence from a Cross-Sectional and Longitudinal Study : BFI as Predictors of IR in OSA

PURPOSE

Body fat indices serve as predictive markers of insulin resistance (IR) in metabolic diseases. IR is common in obstructive sleep apnea (OSA). However, whether body fat indices have utility as predictors of IR in OSA remain unknown.

MATERIALS AND METHODS

A longitudinal study was conducted in 46 patients undergoing bariatric surgery to explore the relationship between IR and body fat indices. Then, a cross-sectional study was performed to evaluate the relationships between body fat indices and IR, and receiver operating characteristic (ROC) curves were generated. Body indices, homeostasis model assessment index of insulin resistance (HOMA-IR), biological indicators, and polysomnographic variables were collected.

RESULTS

In the longitudinal study, significant relationships were found between remission of IR and changes in visceral adiposity index (VAI) (r = 0.452, P < 0.05) and triglyceride-glucose index (TyG) (r = 0.650, P < 0.01). In the cross-sectional study, lipid accumulation product (LAP) (best cutoff value: 30.16, area under the curve (AUC) = 0.728, P < 0.001) and TyG (best cutoff value: 8.54, AUC = 0.740, P < 0.001) were indicators of IR in normal weight group. In overweight/obese group, body mass index (BMI) (best cutoff value: 27.69 AUC = 0.707, P < 0.001) and waist circumference (WC) (best cutoff value: 97.25, AUC = 0.708, P < 0.001) were markers of IR. TyG showed better ability to predict IR in normal weight females (best cutoff value: 8.39 AUC = 0.813, P < 0.001).

CONCLUSIONS

Body fat indices are predictive markers of IR in patients with OSA.

Role of physical activity and fitness on sleep in sedentary middle-aged adults: the FIT-AGEING study

The association of physical activity and fitness with sleep still remains unclear since there is a lack of studies in this field of research using objective measurements of these variables. This study aimed to investigate the association of objectively-measured sedentariness, physical activity levels, and physical fitness with sleep quantity and quality in sedentary middle-aged adults. A total of 74 volunteers (52.7% women; aged 53.7 ± 5.1) were recruited for the present study. Cardiorespiratory fitness was measured through a maximal treadmill test, and muscular strength by extension and flexion peak torque, and by the hand grip test. Physical activity and objective sleep parameters were determined through accelerometry, and subjective sleep by the Pittsburgh Sleep Quality Index (PSQI). Reduced levels of sedentariness, greater VO_2max, and greater muscular strength were positively related to improved objective sleep quantity and quality (all P ≤ 0.05). Furthermore, higher levels of overall physical activity, VO_2max, and muscular strength were related to better subjective sleep quantity and quality (all P ≤ 0.05). Reduced sedentariness and increased physical activity and fitness may be a potential prevention and/or treatment pathway to reduce sleep disturbances and, in general, to improve patients physical and psychological health for a successful aging process.

Sleep-Disordered Breathing, Quality of Sleep and Chronotype in a Cohort of Adult Patients with Bardet-Biedl Syndrome

OBJECTIVE/BACKGROUND

Bardet-Biedl syndrome (BBS) is a rare but well-recognized ciliopathy with high genetic and phenotypic heterogeneity. Cardinal features include obesity, diabetes and high blood pressure (HBP), which are often associated with sleep-disordered breathing. Also, the high prevalence of blindness due to retinal dystrophy could affect circadian sleep-wake rhythms. We characterized in this cohort of adult BBS patients sleep-disordered breathing, sleep quality, daytime sleepiness and chronotype.

PATIENTS AND METHODS

Thirty-two patients with genetically confirmed BBS were included in this observational single center study. Overnight respiratory polygraphy was performed for sleep apnea syndrome (SAS) in 30 patients. Quality of sleep, daytime sleepiness, fatigue and chronotype were assessed in 25 patients using Pittsburgh sleep quality index (PSQI), 14-day sleep diary (SD), Epworth sleepiness scale (ESS), Pichot fatigue scale (PFS) and Horne and Ostberg morningness-eveningness questionnaire (MEQ).

RESULTS

Patients' mean age was 32±11 years and mean BMI 32.6±7.7 kg/m². Eleven (35%) patients had HBP and 7 (22%) diabetes. Moderate to severe sleep apnea syndrome (SAS) was present in 5 (17%) and was not associated with altered sleep, daytime sleepiness or fatigue. Most of the patients (63%) evaluated their sleep as of good quality (PSQI ≤ 5). Median scores of sleep quality, daytime sleepiness and fatigue were normal (PSQI of 3.0 [2.0-6.0], ESS of 9.0 [6.0-13.0] and PFS of 8.0 [3.0-13.0], respectively). Predominant chronotypes according to MEQ were either "intermediate" (57%) or "moderate morning" (29%). None had a free running sleep-wake cycle. 14-day SD revealed overall few awakenings at night and low daytime napping.

CONCLUSIONS

Given the cardiovascular risk factors, systematic screening for SAS should be considered in BBS patients, regardless of sleep and daytime vigilance complaints. None of these highly visually impaired patients had a circadian sleep-wake rhythm disorder. Further objective assessments are needed to better characterize sleep and circadian rhythms in BBS patients.

Surgical management of obstructive sleep apnoea: A position statement of the Australasian Sleep Association. Respirology 2020;25:1292-1308. [PMID: 33190389 PMCID: PMC7839593 DOI: 10.1111/resp.13967]

Surgery for adult obstructive sleep apnoea (OSA) plays a key role in contemporary management paradigms, most frequently as either a second‐line treatment or in a facilitatory capacity. This committee, comprising two sleep surgeons and three sleep physicians, was established to give clarity to that role and expand upon its appropriate use in Australasia. This position statement has been reviewed and approved by the Australasian Sleep Association (ASA) Clinical Committee.

Metabolic bariatric surgery as a treatment for obstructive sleep apnea hypopnea syndrome: review of the literature and potential mechanisms

Obstructive sleep apnea hypopnea syndrome (OSAHS) is closely related to obesity and can cause multiple organs and systems damage. Metabolic bariatric surgery (MBS) is presently the only long-term effective treatment and an important strategy for severely obese population, which also provides a novel therapeutic for obese patients with OSAHS, especially in patients with poor continuous positive air pressure (CPAP) adherence. To date, the resolution mechanism of OSAHS in obese patients after MBS has not been fully clarified. In addition, there is no specific metabolic bariatric surgical treatment of OSAHS guidelines. Therefore, this review provides an update on the relationship between OSAHS and MBS for highlighting the importance of weight loss strategies for obese patients with OSAHS.

Is Sleep Associated with the S-Klotho Anti-Aging Protein in Sedentary Middle-Aged Adults? The FIT-AGEING Study

Sleep and Klotho have both been closely related to the ageing process, both playing a substantial role in the endocrine and immune systems and, thereby, in oxidative stress and chronic inflammation. However, there are no studies elucidating the relationship between sleep and Klotho. Therefore, this study investigated the association of sleep quantity and quality with the shed form of the α-Klotho gene (S-Klotho plasma levels) in sedentary middle-aged adults. A total of 74 volunteers (52.7% women; aged 53.7 ± 5.1) were recruited for the present study. Objective sleep quality parameters (total sleep time (TST), wake after sleep onset (WASO), and sleep efficiency (SE)) were determined using a wrist-worn accelerometer over seven consecutive days, and the subjective sleep quality was assessed by the Pittsburgh Sleep Quality Index (PSQI; higher scores indicate worse sleep quality). The S-Klotho plasma levels were measured in the ethylenediaminetetraacetic acid plasma using a solid-phase sandwich enzyme-linked immunosorbent assay. Objective sleep parameters were associated with the S-Klotho plasma levels only after including the age, fat mass percentage, and lean mass index as covariates. A direct relationship was observed between the subjective sleep quality (inverse of PSQI scores) and the S-Klotho plasma levels in sedentary middle-aged adults. Improving sleep quantity and quality could be considered an anti-aging therapeutic approach for the prevention, slowing, and even reversal of the physiological decline and degenerative pathologies that are certainly related to the aging process.

Transferrin saturation is independently associated with the severity of obstructive sleep apnea syndrome and hypoxia among obese subjects

INTRODUCTION & AIMS

Obstructive sleep apnea syndrome (OSAS) is a frequent complication of obesity. Intermittent chronic hypoxia which frequently results from OSAS could modulate the systemic control of iron metabolism and alter serum iron parameters, especially among obese patients.

AIMS

to evaluate whether serum parameters of iron bioavailability and storage (primary), as well as age, waist circumference, arterial hypertension and tobacco use (secondary) are associated with OSAS severity and/or hypoxia.

METHODS

design: a single-center retrospective study with prospective data collection; inclusion criteria: consecutive patients referred for initial assessment for obesity underwent nocturnal respiratory polygraphy and iron status serum assessment within a 3-month period. The adjusted analyzes were performed using ANOVA and reported as adjusted means and 95% confidence interval (95% CI).

RESULTS

13 men and 56 women were included. OSAS prevalence: 72% (n = 50). Ferritin (mean ± SD, 260 ± 276 vs. 111 ± 89 μg/l, p = 0.01) and transferrin saturation (31 ± 10 vs. 24 ± 9%, p = 0.002) were significantly higher in case of moderate/severe OSAS than in absent/mild OSAS, independently from gender and tobacco use. Serum iron (19.4 μg/l [CI95%, 16.5-22.3] vs. 16.2 μg/l ([14.1-18.2], p = 0.056) and transferrin saturation (31.5% [26.3-36.7]) vs. 25.3% [21.6-29.1], p = 0.043) were higher when time under oxygen saturation <90% was >15%. Age (mean ± SD, 51 ± 11 vs. 41 ± 12 yr, p = 0.001), waist circumference (136 ± 18 vs. 123 ± 12 cm, p = 0.003), arterial hypertension (59% (n = 13/22) vs. 23% (n = 11/47), p = 0.004) and tobacco use (64% (n = 14/22) vs. 32% (n = 15/47), p = 0.01) were significantly greater in moderate/severe OSAS than in absent/mild OSAS.

CONCLUSIONS

Transferrin saturation was associated with OSAS severity and time under hypoxia. This suggests a relationship between OSAS-induced hypoxia and iron metabolism among obese patients.

Obstructive sleep apnea and risk of type 2 diabetes mellitus: A systematic review and dose-response meta-analysis of cohort studies

BACKGROUND

This meta-analysis was performed to quantitatively evaluate the dose-response association between obstructive sleep apnea (OSA) and risk of type 2 diabetes mellitus (T2DM).

METHODS

PubMed, Embase, and Web of Science were searched up to 12 December 2018 for articles that assessed the OSA-T2DM association. Random effects models were used to analyze the quantitative association between OSA and risk of T2DM. Restricted cubic splines were used to model the dose-response association between apnea-hypopnea index (AHI), used to assess the severity of OSA according to events/h, and risk of T2DM.

RESULTS

We included 16 cohort studies in our meta-analysis. During a median follow-up of 10.5 years (range: 3.0-22.0), 19 355 T2DM cases were reported among 338 912 study participants. The pooled relative risk of T2DM was 1.40 (95% CI, 1.32-1.48) for OSA in the binary meta-analysis and 1.08 (1.01-1.14) for each 5-event/h increase in AHI value. We found a positive linear association between OSA and T2DM risk.

CONCLUSIONS

Our dose-response meta-analysis revealed a linear association between OSA and T2DM.

Body Composition Impact on Sleep in Young Adults: The Mediating Role of Sedentariness, Physical Activity, and Diet

Obesity and sleep disturbances are both related to endocrine and metabolic alterations, cardiovascular disease, and impaired daytime functioning and mood. However, the bidirectional relationship between these conditions and the underlying mechanisms still remain unclear. This study aimed to investigate the potential association of anthropometric and body composition parameters with sleep in young adults, considering the mediating role of sedentariness, physical activity, and diet. A total of 187 adults aged 18–25 (35.29% men) participated in the study. Body mass index (BMI), waist–hip ratio, and waist–height ratio were calculated, and a dual-energy X-ray absorptiometry scanner was used to assess body composition. Sedentary time and physical activity, as well as sleep duration and quality, were objectively and subjectively measured using accelerometry and the Pittsburgh Sleep Quality Index. An inverse association was found between BMI and total sleep time (β = −0.165, p = 0.029). Waist–hip ratio and lean mass index were also negatively associated with total sleep time (β = −0.222, p = 0.007, and β = −0.219, p = 0.004) and sleep efficiency (β = −0.174, p = 0.037, and β = −0.188, p = 0.013). Sedentary time moderated by sex explained the association of BMI with total sleep time such that a high BMI was related to higher sedentariness in men which, in turn, was significantly associated with shorter sleep duration. Sedentary time is, therefore, a link/risk factor mediating the association of high BMI with short sleep duration in healthy young men.

Effectiveness of an intensive weight-loss program for severe OSA in patients undergoing CPAP treatment: a randomized controlled trial

STUDY OBJECTIVES

To determine whether an intensive weight-loss program (IWLP) is effective for reducing weight, the severity of obstructive sleep apnea (OSA), and metabolic variables in patients with obesity and severe OSA undergoing continuous positive airway pressure treatment.

METHODS

Forty-two patients were randomized to the control (CG, n = 20) or the intervention group (IG, n = 22), who followed a 12-month IWLP. The primary outcome was a reduction in the apnea-hypopnea index (AHI) as measured at 3 and 12 months by full polysomnography. Metabolic variables, blood pressure, body fat composition by bioimpedance, carotid intima media thickness, and visceral fat by computed tomography were also assessed.

RESULTS

Mean age was 49 (6.7) years, body mass index 35 (2.7) kg/m², and AHI 69 (20) events/h. Weight reduction was higher for the IG than the CG at 3 and 12 months, -10.5 versus -2.3 kg (P < .001), and -8.2 versus -0.1 kg (P < .001), respectively, as was loss of visceral fat at 12 months. AHI decreased more in the IG at 3 months (-23.72 versus -9 events/h) but the difference was not significant at 12 months, though 28% of patients from the IG had an AHI < 30 events/h compared to none in the CG (P = .046). At 12 months, the IG showed a reduction in C-reactive protein (P = .013), glycated hemoglobin (P = .031) and an increase in high density lipoprotein cholesterol (P = .027).

CONCLUSIONS

An IWLP in patients with obesity and severe OSA is effective for reducing weight and OSA severity. It also results in an improvement in lipid profiles, glycemic control, and inflammatory markers.

CLINICAL TRIAL REGISTRATION

Registry: ClinicalTrials.gov; Title: Effectiveness of an Intensive Weight Loss Program for Obstructive Sleep Apnea Syndrome (OSAS) Treatment; Identifier: NCT02832414; URL: https://clinicaltrials.gov/ct2/show/record/NCT02832414.

Effects of an individualized exercise training program on severity markers of obstructive sleep apnea syndrome: a randomised controlled trial

OBJECTIVE

Obstructive sleep apnea (OSA) is a high prevalent disorder with severe consequences including sleepiness, metabolic, and cardiovascular disorders. The aim of this study was to assess the effect of an individualized exercise-training (IET) program with educational sessions vs educational sessions alone on severity markers of OSA over an eight-week duration.

METHODS

This was a randomised, controlled, parallel-design study. In sum, 64 patients with moderate-to-severe OSA (apnea-hypopnea index AHI 15-45/hour), low physical activity level (Voorrips<9), body-mass index (BMI) <40 kg/m² were included in intervention group (IG) or control group (CG), and 54 patients finished the study. All underwent polysomnography (PSG), multiple sleep latency test (MSLT), constant workload exercise test, blood samples and fulfilled questionnaires twice. The primary endpoint was the change in apnea-hypopnea (AHI) at eight weeks from baseline. Main secondary endpoints were daytime sleepiness assessed by questionnaire and objective tests.

RESULTS

No significant between-group differences were found for changes in AHI. A reduction in AHI was found in IG only (p = 0.005). Compared to CG, exercise training leads to a greater decrease in AHI during REM sleep (p = 0.0004), with a significant increase in mean daytime sleep latency (p = 0.02). Between-group differences were significant for weight reduction, severity of fatigue, insomnia and depressive symptoms with trend for sleepiness symptoms.

CONCLUSIONS

In adult patients with moderate-to-severe OSA, IET did not decrease AHI compared to the control group but improved markers of severity of OSA, in particular AHI in rapid eye movement (REM) sleep and objective daytime sleepiness. Adding personalized exercise training to the management of patients with OSA should be considered. CLINICALTRIALS.

GOV IDENTIFIER

NCT01256307.

The relationship between obstructive sleep apnea syndrome and obesity: A new perspective on the pathogenesis in terms of organ crosstalk

INTRODUCTION

Obstructive sleep apnea syndrome (OSAS) is a common disorder that has a major impact on public health. The connection between OSAS and obesity is very complex and likely represents an interaction between biological and lifestyle factors. Oxidative stress, inflammation and metabolic dysregulation are both actors involved in the pathogenesis of OSAS and obesity. Also, the current evidence suggests that gut microbiota plays a significant role in the emergence and progression of some metabolic disorders. When the relationship between OSAS and obesity is evaluated extensively, it is understood that they show mutual causality with each other, and that metabolic challenges such as impaired microbiota affect this bidirectional organ interaction, and by ensuing organ injury.

OBJECTIVES

The aim of this study is to investigate the association between OSAS and obesity, and the effect of "organ crosstalk" on the pathogenesis of the relationship and to contribute to the diagnosis and treatment options in the light of current data.

DATA SOURCE

We performed an electronic database search including PubMed, EMBASE and Web of Science. We used the following search terms: OSAS, obesity, inflammation, metabolic dysregulation and gut microbiota.

CONCLUSION

Obesity and OSAS adversely affect many organs and systems. Besides the factors affecting the diagnosis of the OSAS-obesity relationship, mutual organ interactions among the respiratory system, adipose tissue and intestines should not be ignored for prevention and treatment of OSAS and obesity. Comprehensive clinical trials addressing the efficacy and efficiency of current or potential treatments on therapeutic applications in the OSAS-obesity relationship are needed.

Impact of Obesity and Obstructive Sleep Apnea in Lateral Skull Base Cerebrospinal Fluid Leak Repair

OBJECTIVE

To investigate the prevalence and impact of obstructive sleep apnea (OSA) and obesity in lateral skull base cerebrospinal fluid leak repair (LSBR) of various etiologies.

METHODS

Retrospective case review at a tertiary skull base center was conducted of consecutive adults undergoing LSBR via transmastoid, middle cranial fossa, or combined approach between 2013-2018. The following data were collected: demographics, comorbidities, radiology and intraoperative findings, and surgical outcomes including complications and need for revision surgery or shunt placement. Patients with incomplete data or leaks following skull base surgery, trauma or chronic ear disease were excluded.

RESULTS

Ninety-four patients (67.4% female, mean age 53.5 ± 12.9 years) underwent repair for spontaneous (sCSFL, 44%) and other etiology (nsCSFL) leaks. nsCSFL served as a comparison group consisting of leaks status-post lateral skull base surgery, temporal bone fractures, and chronic ear disease. Class III obesity (P = .02), OSA (P = .03), and imaging findings of empty sella (OR = 3.32, P = .02), and skull base thinning including contralateral tegmen thinning (31%, OR = 4.3, P = .02), arachnoid granulations (26%, OR = 4.35, P = .02), and superior canal dehiscence (15.8%, OR = 8.57, P = .04) were more common in sCSFL. Four patients (4.2%) required surgical revision for recurrence, and another four (4.2%) resolved with shunting. Evidence of elevated intracranial hypertension was present in nine patients with sCSF leaks and was predictive of need for revision or shunt procedures (P < .01).

CONCLUSION

Obesity, OSA, and imaging consistent with elevated intracranial pressures were more common among patients with sCSFL. Elevated intracranial pressure predicted outcomes following multilayer repair of spontaneous CSF leaks LEVEL OF EVIDENCE: 4 Laryngoscope, 130:2234-2240, 2020.

Interdisciplinary Weight Loss and Lifestyle Intervention for Obstructive Sleep Apnoea in Adults: Rationale, Design and Methodology of the INTERAPNEA Study

Obesity is a major risk factor for obstructive sleep apnoea (OSA), the most common sleep-disordered breathing related to neurocognitive and metabolic syndromes, type II diabetes, and cardiovascular diseases. Although strongly recommended for this condition, there are no studies on the effectiveness of an interdisciplinary weight loss and lifestyle intervention including nutrition, exercise, sleep hygiene, and smoking and alcohol cessation. INTERAPNEA is a randomised controlled trial with a two-arm parallel design aimed at determining the effects of an interdisciplinary tailored weight loss and lifestyle intervention on OSA outcomes. The study will include 84 males aged 18–65 with a body mass index of ≥25 kg/m² and severe to moderate OSA randomly assigned to usual care (i.e., continuous positive airway pressure), or interdisciplinary weight loss and lifestyle intervention combined with usual care. Outcomes will be measured at baseline, intervention end-point, and six-month post-intervention, including apnoea-hypopnoea index (primary outcome), other neurophysical and cardiorespiratory polysomnographic outcomes, sleep quality, daily functioning and mood, body weight and composition, physical fitness, blood biomarkers, health-related quality of life, and cost-effectiveness. INTERAPNEA may serve to establish a cost-effective treatment not only for the improvement of OSA and its vast and severe comorbidities, but also for a potential remission of this condition.

Assessing the impact of diet, exercise and the combination of the two as a treatment for OSA: A systematic review and meta-analysis

This study aimed to provide an updated systematic review and meta-analysis of randomized controlled trials (RCT) investigating the effectiveness of lifestyle interventions on weight loss and the impact on the severity of obstructive sleep apnoea (OSA). A systematic search of five databases between 1980 and May 2018 was used to identify all RCT which employed a lifestyle intervention (i.e. diet-only, exercise-only or combination of the two) aiming to reduce the severity of OSA (assessed using the apnoea-hypopnoea index (AHI)). Random-effects meta-analyses followed by meta-regression were conducted. Ten RCT involving 702 participants (Intervention group: n = 354; Control group: n = 348) were assessed in two meta-analyses. The weighted mean difference in AHI (-8.09 events/h, 95% CI: -11.94 to -4.25) and body mass index (BMI, -2.41 kg/m² , 95% CI: -4.09 to -0.73) both significantly favoured lifestyle interventions over control arms. Subgroup analyses demonstrated that all interventions were associated with reductions in the AHI, but only the diet-only interventions were associated with a significant reduction in BMI. No association was found between the reduction in AHI or BMI and the length of the intervention, or with baseline AHI and BMI levels. All lifestyle interventions investigated appear effective for improving OSA severity and should be an essential component of treatment for OSA. Future research should be directed towards identifying subgroups likely to reap greater treatment benefits as well as other therapeutic benefits provided by these interventions.