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

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.

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.

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).

Approach the Patient With Obstructive Sleep Apnea and Obesity

Obstructive sleep apnea (OSA) and obesity are highly prevalent and bidirectionally associated. OSA is underrecognized, however, particularly in women. By mechanisms that overlap with those of obesity, OSA increases the risk of developing, or having poor outcomes from, comorbid chronic disorders and impairs quality of life. Using 2 illustrative cases, we discuss the relationships between OSA and obesity with type 2 diabetes, dyslipidemia, cardiovascular disease, cognitive disturbance, mood disorders, lower urinary tract symptoms, sexual function, and reproductive disorders. The differences in OSA between men and women, the phenotypic variability of OSA, and comorbid sleep disorders are highlighted. When the probability of OSA is high due to consistent symptoms, comorbidities, or both, a diagnostic sleep study is advisable. Continuous positive airway pressure or mandibular advancement splints improve symptoms. Benefits for comorbidities are variable depending on nightly duration of use. By contrast, weight loss and optimization of lifestyle behaviors are consistently beneficial.

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.

Effect of yoga-based lifestyle and dietary modification in overweight individuals with sleep apnea: A randomized controlled trial (ELISA)

BACKGROUND

Obesity is recognised as an important risk factor for obstructive sleep apnea (OSA), with obese individuals at a four times higher risk of being diagnosed with the syndrome. Treating obesity with lifestyle modification is associated with a reduction in the severity of obstructive sleep apnea. Yoga comprises lifestyle modification that includes asana (postures), pranayama (breathing techniques), dhyana (meditation) and guideline principles for healthy living (Yama and Niyama). There is a scarcity of data to evaluate the effect of yoga on OSA. This study was conducted to evaluate the efficacy of Yoga based lifestyle modification on OSA.

METHODS

Consenting obese patients (BMI >23) diagnosed with obstructive sleep apnea (OSA) (AHI>5) on Polysomnography (PSG) were enrolled. Eligible patients were randomized into two groups. The control group received counselling for dietary modification (staple Indian) with regular exercise and the active intervention group received Yoga intervention as treatment (OSA module) in addition to similar dietary modification and regular exercise counselling. Polysomnography (PSG) was conducted at baseline and one year follow-up. All patients were evaluated at baseline, six months, and one year for compliance and anthropometric parameters. Additional assessment with Hamilton scales for depression and anxiety, SF-36, and the Pittsburgh sleep quality index was also conducted.

RESULTS

A total of 37 eligible patients (19 in the control group and 18 in the yoga group) were recruited for the study. The age [45.73 ± 10.71 vs. 46.22 ± 9.39 years, p = 0.88] and gender [15(78.95%) vs. 12(66.67%), p = 0.48 (males)] distribution was similar in both groups. After adjusting for age and gender, the percentage reduction in weight between the two groups did not reach statistical significance at one year. There was no significant difference in mean AHI between the two groups at one year. However, the number of patients with more than 40% AHI reduction [2/19 (10.52%) vs 8/18 (44.44%), p = 0.02] was significantly higher in the yoga group. Additionally, within the groups, the mean AHI at one year was significantly reduced in the yoga group [51.2 ± 28.0 to 36.8 ± 21.0/hour, p = 0.003], while no significant change was found in the control group [47.2 ± 23 to 38.8 ± 19.9/hour, p = 0.08].

CONCLUSIONS

Lifestyle alteration using Yoga intervention and modification of staple Indian diet may be effective in reducing OSA severity among obese patients.

CTRI NUMBER

CTRI/2017/05/008462.

An individualized mobile health intervention to promote physical activity in adults with obstructive sleep apnea: An intervention mapping approach

Objective

Combining continuous positive airway pressure with physical activity (PA) might be a promising strategy to treat obstructive sleep apnea (OSA). This article describes how intervention mapping (IM) can guide the development, content, and mechanisms of action of a mobile application to promote PA in adults with OSA.

Methods

To develop the program, the IM approach was followed. This article presents the first three steps of IM to develop a mixed intervention (with interventionists and a digital application) aiming to: (1) assess patients' health problems and needs in a literature review to determine their expectations and perceived facilitators and barriers to PA behavior change and thus select the determinants of behavior; (2) formulate the expected intervention outcomes and objectives to be met to achieve the overall program goals; and (3) select and implement the behavior change techniques (BCTs) to achieve the change objectives.

Results

The literature review identified the relevant determinants (e.g., self-efficacy, coping, planning, and habit) of PA behavior using the health action process approach and multiprocess action control. These results were used to specify the program outcomes for PA adapted to physical, psychological, and social parameters. Overall, 11 performance objectives and 30 change objectives were defined. Lastly, BCTs and practical applications were identified.

Conclusions

The study provides a theoretical and methodological basis for researchers and practitioners given the current paucity of evidence-based PA interventions for adults with OSA. It addresses the lack of BCTs (framing and prompts/cue techniques) and meaningful behavioral determinants (identity and habit) in most interventions.

Examining the relationship between obstructive sleep apnoea and eating behaviours and attitudes: A systematic review

BACKGROUND

Between 60 and 90% of adults with OSA are reported as overweight. The co-existence of obesity and OSA can greatly increase an individual's risk of type 2 diabetes, metabolic syndrome and cardiovascular disease. To better understand this relationship between OSA and weight, this review aimed to investigate if there is evidence of certain eating behaviours or eating attitudes that might be found in adults living with OSA.

METHODS

We searched four databases (MEDLINE, Embase, PsycInfo and Web of Science) on January 17th, 2022, to identify studies assessing the association between eating patterns and OSA in adults. Twenty-one studies met the inclusion criteria. A narrative synthesis was conducted on the included studies, following the vote-counting method.

RESULTS

There is preliminary evidence that the time of day when calories are consumed is associated with lower OSA severity. No other clear patterns of eating behaviours or attitudes were identified however this may be due to disparity within research studies and their reported results.

CONCLUSION

Further research is needed to examine the relationship between eating times and OSA severity. We recommend standardising the approach to examining the eating patterns of those living with OSA and the relationship that this might have on OSA symptoms as well as looking at attitudes towards food in this population. This may prove helpful in providing a better understanding of the relationship between OSA and persons with overweight and help in future intervention development.

Homecare interventions as a Service model for Obstructive sleep Apnea: Delivering personalised phone call using patient profiling and adherence predictions

BACKGROUND AND OBJECTIVE

Obstructive Sleep Apnea (OSA) is a sleep disorder that leads to different pathologies like depression and cardiovascular problems. The first-line medical treatment for OSA is Continuous Positive Airway Pressure (CPAP) therapy. However, this therapy has the lowest adherence level when compared to other homecare therapies. Consequently, the main objective of this paper is to increase this adherence level with methods that can be replicated in a large number of patients.

METHODS

The Homecare Intervention as a Service model can build, verify, and deliver per-sonalised home care interventions. With the Homecare Intervention as a Service model, we build and provide on-demand personalised interventions according to the patient's needs. The 2 core components of this model are patient clustering and CPAP adherence predictions. To define the patient profiles and predict the adherence level, we apply the K-means and the Logistic Regression algorithm respectively. To support these algorithms, we use the CPAP monitoring data and qualitative data on the patients.

RESULTS

We demonstrate that there are 3 patient profiles (non-adherent, attempter, and adherent). We draw a comparison with multiple machine learning algorithms to predict CPAP adherence at 30, 60 and 90 days. In this case, the Logistic Regression gives the best results with a f1-score of 0.84 for30 days, 0.79 for 60 days and 0.76 for 90 days. These newly build profiles were to be used to deliver personalised phone call interventions. The phone call intervention shows an increase in adherence by 1.02 h/night for non-adherent patients and 0.69 h/night for attempter patients.

CONCLUSIONS

This is the first study in CPAP therapy that formalises the process of transforming raw data into effective home care interventions that can be delivered directly to the patients. In fact,it is the first time that both patient characterisation and predictions based on data are used to provide personalised patient management for CPAP therapy. Our model is flexible to be extended to new types of interventions and other homecare therapies.

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.

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.

Trending Weight Loss Between Usual Care and Bariatric Surgery Among Higher Weight Persons With Obstructive Sleep Apnea

Background This study aimed to investigate the actual weight change documented as a goal of treatment after patients were newly diagnosed with obstructive sleep apnea (OSA). We hypothesized that patients with OSA and classified as overweight and obese based on BMI would fail to achieve significant weight loss over a two- to five-year period. Methodology This retrospective review included adults aged 18 years or older who were newly diagnosed with OSA in 2015, as indicated by a full nocturnal polysomnogram and using the 4% rule for the definition of hypopnea. Data collected were between January 01, 2015, and December 31, 2020. Patients received either usual care for weight reduction or bariatric surgery to assess the overall weight loss and identify barriers. Statistical analysis included independent t-tests, Mann-Whitney U tests and related samples McNemar change statistics, Cox proportional hazards regression, and Kaplan-Meier curves to analyze age, gender, ethnicity, and weight differences between usual care and bariatric surgery groups. Results The number of participants included for usual care and bariatric surgery was 100 and 24, respectively. Over five years, 87% of the usual care patients remained in the same BMI classification, 7% lowered their classification, and 6% raised theirs. For usual care patients, the average net weight per individual of 2.19 kg gained represented a 1.96% weight change. Bariatric patients lost an average net weight of 30.40 kg (22.39%). Cox proportional hazards regression showed that the overall model fit was statistically significant (χ² = 55.40, degrees of freedom [df] = 9, and P-value < 0.001). The significant variables were time-dependent weight change and ethnicity. The Kaplan-Meier curve revealed that weight loss reduced over time in treatment. Conclusions This study confirmed that despite the direction to lose weight, only 7% of OSA patients lowered their BMI classification. Patient instruction and provider-driven weight loss strategies seem equally ineffective to achieve sustained weight reduction among high-risk groups. More research is needed to investigate optimal strategies that include interprofessional collaborative practices for sustained weight loss.

Current and Novel Treatment Options for OSA

Obstructive sleep apnoea is a challenging medical problem due to its prevalence, its impact on quality of life and performance in school and professionally, the implications for risk of accidents, and comorbidities and mortality. Current research has carved out a broad spectrum of clinical phenotypes and defined major pathophysiological components. These findings point to the concept of personalised therapy, oriented on both the distinct clinical presentation and the most relevant pathophysiology in the individual patient. This leads to questions of whether sufficient therapeutic options other than positive airway pressure (PAP) alone are available, for which patients they may be useful, if there are specific indications for single or combined treatment, and whether there is solid scientific evidence for recommendations. This review describes our knowledge on PAP and non-PAP therapies to address upper airway collapsibility, muscle responsiveness, arousability and respiratory drive. The spectrum is broad and heterogeneous, including technical and pharmaceutical options already in clinical use or at an advanced experimental stage. Although there is an obvious need for more research on single or combined therapies, the available data demonstrate the variety of effective options, which should replace the unidirectional focus on PAP therapy.

The analysis of individual pathophysiological composition opens new directions towards personalised treatment of OSA, focusing not only on pharyngeal dilation, but also on technical or pharmaceutical interventions on muscle function or breathing regulationhttps://bit.ly/3sayhkd

Effect of exercise as adjuvant to energy-restricted diets on quality of life and depression outcomes: a meta-analysis of randomized controlled trials

BACKGROUND AND AIM

Obesity and related co-morbidities lead to a decrease in health-related quality of life (HRQOL) and mood. Lifestyle strategies may improve these outcomes. However, the efficacy of exercise in conjunction with a weight-loss diet on HRQOL and mood is unclear. The aim of this systematic review and meta-analysis of randomized controlled trials (RCTs) was to examine whether the addition of exercise to energy-restricted dietary programs improves HRQOL and mood status when compared with energy-restricted diets alone in overweight and obese adults.

METHODS

Eligible RCTs were identified by searching PubMed/MEDLINE, EMBASE, ISI (Web of sciences), Scopus, and Google Scholar up to April 2021. Summary effects were derived using a random-effects model. The quality of evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology.

RESULTS

The meta-analysis revealed that an energy-restricted diet plus exercise compared with an energy-restricted diet alone had no significant effects on depression (n = 6, hedges'g = - 0.04, 95% CI: - 0.28,0.20), MOS 36-Item Short-Form Health Survey (SF-36)-physical component summary scores (n = 8, weighted mean difference (WMD) = 1.51, 95% CI: - 0.16, 3.18), SF36-mental component summary scores (n = 7, WMD = 0.64, 95% CI: - 1.00, 2.28), and HRQOL disease-specific questionnaire scores (n = 5, hedges'g = 0.16, 95% CI: - 0.09, 0.40). The GRADE revealed that the quality of evidence was low for disease-specific HRQOL scores, and depression status; and high for physical and mental health assessed by SF-36.

CONCLUSION

In our sample of overweight and obese adults, no beneficial effect of adding exercise to an energy-restricted diet was found in terms of HRQOL and Depression.

High quality and anti-inflammatory diets and a healthy lifestyle are associated with lower sleep apnea risk

STUDY OBJECTIVES

Most studies on diet and sleep apnea focus on calorie restriction. Here we investigate potential associations between dietary quality [healthy eating index (HEI), dietary inflammatory index (DII)] and overall healthy lifestyle with sleep apnea risk.

METHODS

National Health and Nutrition Examination Survey data (waves 2005-2008, and 2015-2018; N=14,210) were used to determine HEI, DII and their quintiles, with the fifth quintile indicating highest adherence to each dietary construct. A healthy lifestyle score was determined using diet, smoking, alcohol intake and physical activity level. STOP-BANG questionnaire was used to define sleep apnea risk. Generalized linear regression models with binomial family and logit link were used to investigate potential associations. The models were adjusted for socioeconomic status, lifestyle factors and chronic conditions.

RESULTS

Prevalence of high sleep apnea risk was 25.1%. Higher DII was positively associated with sleep apnea (odds ratio (OR)_{Q5 vs. Q1}=1.55; 95% CI: 1.24-1.94; p for trend <0.001) whereas higher HEI was associated with reduced sleep apnea risk (OR_{Q5 VS. Q1}=0.72: 0.59-0.88; p for trend=0.007). Higher healthy lifestyle score was also associated with decreased odds of sleep apnea (p for trend <0.001). There was a significant interaction between healthy lifestyle and sex with sleep apnea risk (p for interaction=0.049) whereby females with higher healthy lifestyle scores had lower risk of sleep apnea versus males.

CONCLUSIONS

Higher quality and anti-inflammatory diets and a healthier overall lifestyle are associated with lower sleep apnea risk. These findings underline the importance of strategies to improve overall diet quality and promote healthy behavior, not just calorie restriction, to reduce sleep apnea risk.

Obesity definition, diagnosis, bias, standard operating procedures (SOPs), and telehealth: An Obesity Medicine Association (OMA) Clinical Practice Statement (CPS) 2022

Background

The Obesity Medicine Association (OMA) Clinical Practice Statement (CPS) regarding definition, diagnosis, bias, standard operating procedures (SOPs) and telehealth is intended to provide clinicians an overview of obesity medicine and provide basic organizational tools towards establishing, directing, managing, and maintaining an obesity medical practice.

Methods

This CPS is based upon published scientific citations, clinical perspectives of OMA authors, and peer review by Obesity Medicine Association leadership.

Results

OMA has defined obesity as: "A chronic, progressive, relapsing, and treatable multi-factorial, neurobehavioral disease, wherein an increase in body fat promotes adipose tissue dysfunction and abnormal fat mass physical forces, resulting in adverse metabolic, biomechanical, and psychosocial health consequences." While body mass index may be sufficiently diagnostic for populations and many patients, accurate diagnosis of adiposity in an individual may require anthropometric assessments beyond body weight alone (e.g., waist circumference, percent body fat, and android/visceral fat). Obesity complications can be categorized as "sick fat disease" (adiposopathy) and/or "fat mass disease." Obesity complications predominantly of fat mass origins include sleep apnea and orthopedic conditions. Obesity complications due to adiposopathic endocrinopathies and/or immunopathies include cardiovascular disease, cancer, elevated blood sugar, elevated blood pressure, dyslipidemia, fatty liver, and alterations in sex hormones in both males (i.e., hypogonadism) and females (i.e., polycystic ovary syndrome). Obesity treatment begins with proactive steps to avoid weight bias, including patient-appropriate language, office equipment, and supplies. To help manage obesity and its complications, this CPS provides a practical template for an obesity medicine practice, creation of standard operating procedures, and incorporation of the OMA "ADAPT" method in telehealth (Assessment, Diagnosis, Advice, Prognosis, and Treatment).

Conclusions

The OMA CPS regarding "Obesity Definition, Diagnosis, Bias, Standard Operating Procedures (SOPs), and Telehealth" is one in a series of OMA CPSs designed to assist clinicians care for patients with the disease of obesity.

Higher HEI-2015 Scores Are Associated with Lower Risk of Sleep Disorder: Results from a Nationally Representative Survey of United States Adults

Whether there is an association between dietary quality and sleep disorder in American adults is unclear. We conducted this study to analyze whether dietary quality, using the Healthy Eating Index-2015 (HEI-2015) scores as the measure, was associated with self-reported sleep disorders. Data came from the National Health and Nutrition Examination Survey (2005–2014). Step-weighted logistic regression models were performed to explore the relationships between the HEI-2015 scores and sleep disorder. Weighted quantile sum regression model was used to identify the HEI-2015 components most strongly associated with sleep disorders. According to quartiles, HEI scores were categorized into inadequate (<25%), average (25–75%), and optimal (>75%). Compared to inadequate HEI status, average HEI status (OR: 0.961, 95%CI: 0.959–0.962) and optimal HEI status (OR: 0.913, 95% CI: 0.912–0.915) were associated with reduced risk of sleep disorder after multivariable adjustments. Greens and beans, added sugars, saturated fats, total vegetables and total protein foods were the top five important components for sleep disorders. Our results suggest that there is a statistically significant association between better dietary quality and reduced risk of sleep disorder among United States adults.

Obesity and Obstructive Sleep Apnea

Obstructive sleep apnea (OSA) is characterized by upper airway collapse during sleep. Chronic intermittent hypoxia, sleep fragmentation, and inflammatory activation are the main pathophysiological mechanisms of OSA. OSA is highly prevalent in obese patients and may contribute to cardiometabolic risk by exerting detrimental effects on adipose tissue metabolism and potentiating the adipose tissue dysfunction typically found in obesity. This chapter will provide an update on: (a) the epidemiological studies linking obesity and OSA; (b) the studies exploring the effects of intermittent hypoxia and sleep fragmentation on the adipose tissue; (c) the effects of OSA treatment with continuous positive airway pressure (CPAP) on metabolic derangements; and (d) current research on new anti-diabetic drugs that could be useful in the treatment of obese OSA patients.

Novel avenues to approach non-CPAP therapy and implement comprehensive OSA care

Recent advances in obstructive sleep apnoea (OSA) pathophysiology and translational research have opened new lines of investigation for OSA treatment and management. Key goals of such investigations are to provide efficacious, alternative treatment and management pathways that are better tailored to individual risk profiles to move beyond the traditional, continuous positive airway pressure (CPAP)-focused, "one size fits all", trial and error approach which is too frequently inadequate for many patients. Identification of different clinical manifestations of OSA (clinical phenotypes) and underlying pathophysiological phenotypes (endotypes), that contribute to OSA have provided novel insights into underlying mechanisms and have underpinned these efforts. Indeed, this new knowledge has provided the framework for precision medicine for OSA to improve treatment success rates with existing non-CPAP therapies such as mandibular advancement devices and upper airway surgery, and newly developed therapies such as hypoglossal nerve stimulation and emerging therapies such as pharmacotherapies and combination therapy. These concepts have also provided insight into potential physiological barriers to CPAP adherence for certain patients. This review summarises the recent advances in OSA pathogenesis, non-CPAP treatment, clinical management approaches and highlights knowledge gaps for future research. OSA endotyping and clinical phenotyping, risk stratification and personalised treatment allocation approaches are rapidly evolving and will further benefit from the support of recent advances in e-health and artificial intelligence.

Positionspapier „Schlafmedizin in der Kardiologie“, Update 2021

Es hat sich viel getan in der Welt der Schlafmedizin in der Kardiologie, weshalb eine vollwertige Überarbeitung des Positionspapiers „Schlafmedizin in der Kardiologie“ erforderlich wurde. In der aktuellen neuartigen Version finden sich nicht nur alle verfügbaren Studien, Literaturstellen und Updates zu Pathophysiologie, Diagnostik- und Therapieempfehlungen, sondern auch Ausblicke auf neue Entwicklungen und zukünftige Forschungserkenntnisse. Dieses überarbeitete Positionspapier gibt Empfehlungen für Diagnostik und Therapie von Patienten mit kardiovaskulären Erkrankungen mit schlafassoziierten Atmungsstörungen und erteilt darüber hinaus einen fundierten Überblick über verfügbare Therapien und Evidenzen, gibt aber ebenso Ratschläge wie mit Komorbiditäten umzugehen ist. Insbesondere enthält dieses überarbeitete Positionspapier aktualisierte Stellungnahmen zu schlafassoziierten Atmungsstörungen bei Patienten mit koronarer Herzerkrankung, Herzinsuffizienz, arterieller Hypertonie, aber auch für Patienten mit Vorhofflimmern. Darüber hinaus finden sich erstmals Empfehlungen zur Telemedizin als eigenes, neues Kapitel. Dieses Positionspapier bietet Kardiologen sowie Ärzten in der Behandlung von kardiovaskulären Patienten die Möglichkeit einer evidenzbasierten Behandlung der wachsend bedeutsamen und mit zunehmender Aufmerksamkeit behafteten Komorbidität schlafassoziierter Atmungsstörungen. Und nicht zuletzt besteht mit diesem neuen Positionspapier eine enge Verknüpfung mit dem neuen Curriculum Schlafmedizin der Deutschen Gesellschaft für Kardiologie, weshalb dieses Positionspapier eine Orientierung für die erworbenen Fähigkeiten des Curriculums im Umgang von kardiovaskulären Patienten mit schlafassoziierten Atmungsstörungen darstellt.

Physical activity and sleep: An updated umbrella review of the 2018 Physical Activity Guidelines Advisory Committee report

Physical activity (PA) is widely considered to improve sleep, but a comprehensive review of the research on this topic has not been performed. In this umbrella review, conducted initially for the 2018 Physical Activity Guidelines for Americans Advisory Committee and updated to reflect more recent research, we examined whether PA enhances sleep outcomes across the lifespan as well as among individuals with sleep disorders. Systematic reviews and meta-analyses were utilized to assess the evidence. We also examined dose-response considerations and whether the association between PA and sleep was moderated by various factors (e.g., timing, sociodemographic characteristics). We found strong evidence that both acute bouts of PA and regular PA improved sleep outcomes. Moderate evidence indicated that longer bouts of PA (both acute and regular) improved sleep, and that the effects of PA on sleep outcomes were generally preserved across adult age groups and sex. Finally, moderate evidence demonstrated that PA improved sleep in adults with insomnia symptoms or obstructive sleep apnea. Several important areas in need of future research were also identified. Overall, the review supported the claim that PA improves sleep, but highlighted gaps that need to be addressed to facilitate more widespread utilization of PA for improving sleep.

Exercise capacity and comorbidities in patients with obstructive sleep apnea

STUDY OBJECTIVES

There are few studies evaluating (1) exercise capacity as assessed by the 6-minute walking distance (6MWD) test in large populations with obstructive sleep apnea (OSA); and (2) correlations with patients' comorbidities.

METHODS

This study presents a cluster analysis performed on the data of 1,228 patients. Severity of exercise limitation was defined on the basis of 6MWD.

RESULTS

Sixty-one percent showed exercise limitation (29.2% and 31.9% mild and severe exercise limitation, respectively). About 60% and 40% of patients were included in cluster 1 (CL1) and 2 (CL2), respectively. CL1 included younger patients with high prevalence of apneas, desaturations, and hypertension with better exercise tolerance. CL2 included older patients, all with chronic obstructive pulmonary disease (COPD), high prevalence of chronic respiratory failure (CRF), fewer apneas but severe mean desaturation, daytime hypoxemia, more severe exercise limitation, and exercise-induced desaturations. Only CRF and COPD significantly (P < .001) correlated with 6MWD < 85% of predicted value. 6MWD correlated positively with apnea-hypopnea index, oxygen desaturation index, nocturnal pulse oxygen saturation (SpO₂), resting arterial oxygen tension, mean SpO₂ on exercise, and negatively with age, body mass index, time spent during night with SpO₂ < 90%, mean nocturnal desaturation, arterial carbon dioxide tension, and number of comorbidities. Patients without severe comorbidities had higher exercise capacity than those with severe comorbidities, (P < .001). Exercise limitation was significantly worse in OSA severity class I when compared to other classes (P < .001).

CONCLUSIONS

A large number of patients with OSA experience exercise limitation. Older age, comorbidities such as COPD and CRF, OSA severity class I, severe mean nocturnal desaturation, and daytime hypoxemia are associated with worse exercise tolerance.

Headache attributed to idiopathic intracranial hypertension and persistent post-idiopathic intracranial hypertension headache: A narrative review

OBJECTIVE

Headache is a near-universal sequela of idiopathic intracranial hypertension (IIH). The aim of this paper is to report current knowledge of headache in IIH and to identify therapeutic options.

BACKGROUND

Disability in IIH is predominantly driven by headache; thus, headache management is an urgent and unmet clinical need. At present, there is currently no scientific evidence for the directed use of abortive or preventative headache therapy.

METHODS

A detailed search of the scientific literature and narrative review was performed.

RESULTS

Headache in IIH is driven by raised intracranial pressure (ICP) and reduction of ICP has been reported in some studies to reduce headache. Despite resolution of papilledema and normalization of raised ICP, a majority suffer persistent post-IIH headache. The lack of evidence-based management approaches leaves many untreated. Where clinicians attempt to manage IIH headache, they use off-label therapies to target the prevailing headache phenotype. A recent prospective open-label study demonstrated the effective use of a calcitonin gene-related peptide monoclonal antibody therapy in IIH for persistent post-IIH headache.

CONCLUSIONS

There is overwhelming evidence of the headache burden in IIH. Studies are required to investigate the biological foundations of headache related to ICP and to develop treatments specifically directed to manage headache in IIH.

Participation in physical activity is associated with reduced nocturnal hypoxaemia in males

Moderate to vigorous physical activity (MVPA) interventions reduce the severity of obstructive sleep apnoea (OSA); however, little epidemiological research exists to confirm these findings.

789 participants from the population-based Men Androgen Inflammation Lifestyle Environment and Stress (MAILES) Study underwent polysomnography. MVPA was assessed using the Active Australia questionnaire, which was completed when participants were first recruited to the MAILES study (2002–2006), and again in 2010. Multinomial logistic regressions established odds ratio between OSA severity categories with MVPA, whilst adjusted linear models determined associations between OSA metrics with MVPA.

Cross-sectionally, each hour of MVPA was associated with reduced severity of mean oxygen desaturation (unstandardised β (B)=−0.002, p=0.043) and reduced time below 90% oxygen saturation (B=−0.03, p=0.034).

Longitudinally, each hour increase in MVPA was associated with a 4% reduction in the odds of severe OSA and less severe mean oxygen desaturation (B=−0.003, p=0.014), time below 90% oxygen saturation (B=−0.02, p=0.02), and mean duration of apnoeas (B=−0.004, p=0.016).

MVPA is associated with reduced hypoxaemia in a cohort of community dwelling males, approximately half of whom had untreated OSA. As nocturnal intermittent hypoxaemia is associated with cardiometabolic disorders, MVPA may offer protection for patients with OSA.

This study provides epidemiological evidence that moderate to vigorous physical activity is associated with less severe OSA-induced hypoxaemia. This result suggests that MVPA should be actively implemented in treatment regimens for people with OSA.https://bit.ly/3a9asiZ

Clinical and Research Solutions to Manage Obstructive Sleep Apnea: A Review

Obstructive sleep apnea (OSA), a common sleep disorder disease, affects millions of people. Without appropriate treatment, this disease can provoke several health-related risks including stroke and sudden death. A variety of treatments have been introduced to relieve OSA. The main present clinical treatments and undertaken research activities to improve the success rate of OSA were covered in this paper. Additionally, guidelines on choosing a suitable treatment based on scientific evidence and objective comparison were provided. This review paper specifically elaborated the clinically offered managements as well as the research activities to better treat OSA. We analyzed the methodology of each diagnostic and treatment method, the success rate, and the economic burden on the world. This review paper provided an evidence-based comparison of each treatment to guide patients and physicians, but there are some limitations that would affect the comparison result. Future research should consider the consistent follow-up period and a sufficient number of samples. With the development of implantable medical devices, hypoglossal nerve stimulation systems will be designed to be smart and miniature and one of the potential upcoming research topics. The transcutaneous electrical stimulation as a non-invasive potential treatment would be further investigated in a clinical setting. Meanwhile, no treatment can cure OSA due to the complicated etiology. To maximize the treatment success of OSA, a multidisciplinary and integrated management would be considered in the future.

Impact of the COVID-19 pandemic on obstructive sleep apnea: recommendations for symptom management

STUDY OBJECTIVES

In the context of the current COVID-19 pandemic situation, we address the following important questions: (1) How can patients be identified for possible OSA while sleep clinic testing is temporarily unavailable or limited? and (2) What measures can be suggested to improve sleep health until proper diagnosis and treatment become safe and available again?

METHODS

As a proxy for home or in-laboratory testing, validation of a symptom-based measure of OSA risk is presented, based on an ongoing larger prospective study of 156 family medicine patients with OSA (88 women, 68 men; mean age, 57 years) and 60 control participants (36 women, 24 men; mean age, 54 years) recruited from the community. Participants completed the Sleep Symptom Checklist (SSC) and a range of other self-report measures; primary care patients also underwent a polysomnographic sleep study.

RESULTS

Results showed that (1) individuals with OSA reported more symptoms on the SSC related to insomnia, daytime symptoms, sleep disorders, and psychological maladjustment than did the control group (all P < .001), and (2) their sleep-related symptoms were significantly more severe than those of the control patients. In addition, several polysomnographic indices in recently diagnosed untreated individuals with OSA were significantly correlated with SSC measured sleep disorder symptoms, and SSC scores significantly distinguished participants with OSA from control participants.

CONCLUSIONS

Our findings suggest that family practitioners can effectively prescreen patients for possible OSA by inquiring about 5 items that form the SSC sleep disorders subscale. If OSA is suspected, then we can recommend a range of behavioral techniques to improve symptoms. The current pandemic causes us to reflect that the provisional targeting of symptoms and guidance regarding mitigation strategies while waiting for specialist care could serve patients well at any time.

Cultivating Lifestyle Transformations in Obstructive Sleep Apnea

Today, our well-being and awareness have become markedly determined by our way of living through our everyday activities. Needless to say, daily practices specifically have a significant impact on the quality of sleep. Obstructive sleep apnea (OSA) is an exhausting sleep disorder regulating an individual's routine life. Although several therapeutic modalities are available for curing OSA, behavioral therapies are also utilized for a positive outcome. Besides, several studies are performed to prove the efficacy of lifestyle strategies to resolute OSA in adults. Reducing weight, quitting alcohol and smoking, eating a nutritional diet, and exercising are the modifications to benefit people. This review aims to expand our knowledge of the association between alterations to comportment and better treatment outcomes for sleep apnea.

Interstitial lung disease and obstructive sleep apnea

Obstructive sleep apnea (OSA) is one of the most common comorbidities in patients with interstitial lung disease (ILD). Growing evidence highlights the significance of sleep disturbance on health outcomes in this population. The relationships between ILD and OSA are complex and possibly bidirectional, with multiple mechanisms postulated for the pathogenic and physiologic links. This review synthesizes current evidence and hypotheses regarding different aspects of the relationships between ILD and OSA, emphasizing the interactions between epidemiology, pathogenesis, and pathophysiology.

Association Between Eating Habits and Risk of Obstructive Sleep Apnea: A Population-Based Study

OBJECTIVE

The effect of dietary factors on OSA remains unclear. This study was to investigate the association of obstructive sleep apnea (OSA) with individual and overall effects of eating habits among adult Chinese.

METHODS

A total of 9733 participants were selected from the baseline survey of the Guangzhou Heart Study. OSA was ascertained by Berlin Questionnaire. Food consumption was collected using a food frequency questionnaire, and eating patterns were extracted by principal component analysis. Odds ratios (ORs) with 95% confidence intervals (95% CIs) were calculated by the logistic regression model.

RESULTS

After adjustment for confounders, fried food intake with ≥1/week was associated with an increased risk of OSA (OR: 1.77, 95% CI: 1.37-2.27), while fruit consumption of ≥1/day was associated with a 26% reduced risk of OSA (OR: 0.74, 95% CI: 0.62-0.88). Three eating patterns were defined and labeled as pattern I, II, and III. Eating pattern III which had higher factor loadings of animal innards, fried food, salted food, carbonate, and non-carbonated beverages was associated with an increased risk of OSA (OR: 1.30, 95% CI: 1.09-1.55) when comparing the highest with the lowest tertile of pattern score, after adjusting for confounders; every 1-unit increment of pattern III score was associated with an increased risk of OSA (OR: 1.09, 95% CI: 1.04-1.14). Neither pattern I nor pattern II was observed to be associated with OSA risk.

CONCLUSION

A higher frequency intake of fruits was associated with a reduced OSA risk and a diet with higher levels of consumption of animal innards, fried food, salted food, carbonated beverages, and non-carbonated beverages may increase the risk of OSA.

Effects on obstructive sleep apnea severity following a tailored behavioral sleep medicine intervention aimed at increased physical activity and sound eating: an 18-month follow-up of a randomized controlled trial

STUDY OBJECTIVES

Positive effects have been reported following a behavioral sleep medicine (BSM) intervention targeting physical activity and eating behavior in addition to continuous positive airway pressure (CPAP) treatment in patients with obstructive sleep apnea (OSA). Long-term follow-up remains to be explored. The aim was to examine the long-term effects of a tailored BSM intervention addressing physical activity and eating behavior in addition to CPAP treatment in patients with moderate to severe OSA combined with overweight and physical inactivity. Further, the aim was to identify variables at baseline, associated with treatment success regarding OSA severity.

METHODS

Sixty participants (body mass index: 34.5 ± 5.0 kg/m²; apnea-hypopnea index [AHI]: 43.7 ± 21.2 events/h) completed the randomized controlled trial with a follow-up at 18 months. The participants were randomized to either a control group treated with CPAP or an experimental group treated with CPAP and a BSM intervention targeting physical activity and eating behavior changes. OSA was categorized as mild (AHI: 5 to <14.9 events/h), moderate (AHI: 15 to <29.9 events/h), or severe (AHI ≥30 events/h).

RESULTS

Being in the experimental group was associated with a larger improvement (B = -9.353, P = .029) in AHI at the 18-month follow-up compared with being in the control group when adjusting for baseline AHI and body mass index. Improvement in OSA category occurred more frequently in the experimental group participants (n = 11; 36.7%) compared with the control group (n = 2; 6.7%). Deterioration in OSA category was found in 1 (3.3%) participant in the experimental group and 3 (10%) in the control group.

CONCLUSIONS

The importance of a BSM intervention as an adjunct treatment in patients with OSA is emphasized due to its long-term benefits.

CLINICAL TRIAL REGISTRATION

Registry: ClinicalTrials.gov; Name: Lifestyle changes in obstructive sleep apnea; Identifier: NCT01102920.

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.

Effect of exercise training on subjective parameters in patients with obstructive sleep apnea: a systematic review and meta-analysis

Obstructive sleep apnea (OSA) has many effects on subjective parameters of the disease, such as reduction in quality of life (QoL), sleep quality (SQ), and increases in daytime sleepiness. Studies have reported the beneficial effect of exercise training on OSA severity; however, whether it improves subjective parameters remains unclear. The purpose of the present review was to investigate the effect of exercise training on QoL, daytime sleepiness, and SQ in adults with OSA by summarizing the results of clinical trials. The study adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and was registered in PROSPERO. A systematic review of the PubMed, Scopus, and Cochrane (CENTRAL) databases was conducted. Risk of bias analysis was performed using the Cochrane tool, and Review Manager version 5.2 (R Foundation for Statistical Computing, Vienna, Austria) was used to perform the meta-analysis. Of the 1573 studies initially retrieved, 8 relevant studies with 228 participants were included in the analysis. The studies presented moderate risk of bias. Exercise training significantly improved QoL (mean difference, 12.9 [95% confidence interval (CI) 6.4 to 19.5]) and SQ (mean difference, -2.0 [95% CI -3.6 to -0.5]), and reduced daytime sleepiness (mean difference, -3.7 [95% CI -6.1 to -1.2]), and OSA severity (mean difference, -11.4 [95% CI -13.4 to -9.4 events/h]). Thus, physical exercise training was effective in improving subjective parameters and reducing the severity of OSA. Additional randomized clinical trials, however, should be performed to confirm these findings.