Chest
Postgraduate Education CornerContemporary Reviews in Sleep MedicineInteractions Between Obesity and Obstructive Sleep Apnea: Implications for Treatment
Section snippets
Epidemiology of OSA
The best prevalence estimates of OSA in the general population are derived from six large studies conducted worldwide. These studies suggest that approximately 25% of adults with a BMI between 25 kg/m2 and 28 kg/m2 have at least mild OSA (apnea-hypopnea index [AHI] ≥ 5).5, 6, 7, 8, 9, 10 However, the prevalence of OSA varies according to gender (∼30% in men and ∼15% in women), age, and body weight. Men's risk for OSA is twofold-higher than that of women.6 Postmenopausal women are at higher risk
Obesity and OSA
Obesity is considered a major risk factor for the development and progression of OSA.8, 19, 20, 27, 28 The prevalence of OSA in obese or severely obese patients is nearly twice that of normal-weight adults. Furthermore, patients with mild OSA who gain 10% of their baseline weight are at a sixfold-increased risk of progression of OSA, and an equivalent weight loss can result in a more than 20% improvement in OSA severity.28 Moreover, the higher prevalence of OSA in obese subjects is not limited
OSA, Sleep Deprivation, and Metabolic Dysregulation
Several cardiometabolic alterations have been associated with OSA, independent of obesity and other potential confounders. Among the most important are glucose intolerance and insulin resistance, which are risk factors for the development of diabetes and cardiovascular disease.42, 43 Moreover, OSA has been associated with a heightened systemic inflammatory state, as shown by increases in cytokines,38, 44 serum amyloid A,45 and, in some but not all studies, C-reactive protein.46, 47 Subjects
Weight Loss as a Treatment of OSA
Most studies assessing the effects of weight loss on OSA have had methodologic limitations, including lack of either randomization and/or a control group for comparisons, inadequate adjustment for potential confounders, and limited follow-up. Many of the more recent studies assessing weight loss on OSA severity and outcomes were in the context of bariatric surgery.
In the last few years, three randomized trials have addressed whether weight loss can improve OSA through nonsurgical treatments.66,
CPAP Treatment of OSA
CPAP is considered the mainstay of treatment of OSA and has shown benefits in dozens of randomized controlled trials. These benefits include reducing daytime sleepiness, improving quality of life, and lowering blood pressure.105 In addition, short-term data suggest that CPAP may possibly attenuate some of the cardiometabolic alterations that are present not only in OSA but common also to obesity and sleep deprivation. CPAP therapy has also been associated with reductions in visceral fat and
Conclusions
Weight loss appears to confer benefits not only on OSA severity but also in terms of mitigating cardiometabolic consequences related to both OSA and obesity. Unfortunately, weight loss through diet, exercise, and/or medications has been hard to achieve and maintain. Bariatric surgery may be an alternative treatment of severe or complicated obesity, and important and sometimes impressive changes have been noted in cardiovascular risk factors, metabolic markers, and OSA severity. In addition,
Acknowledgments
Financial/nonfinancial disclosures: The authors have reported to CHEST the following conflicts of interest: Dr Romero-Corral is an advisor for Select Research. Dr Caples has received research funding from the ResMed Foundation, Restore Medical, and Ventus. Dr Somers has served as a consultant for ResMed, Respironics, GlaxoSmithKline, Sepracor, and Cardiac Concepts; he has received research grants from the ResMed Foundation, the Respironics Sleep and Respiratory Research Foundation, Sorin, Inc.,
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Funding/Support: At the time of the writing of this manuscript, Dr Romero-Corral was supported by a Postdoctoral Fellowship from the American Heart Association. Dr Caples is supported by NIH grant HL99534. Dr Lopez-Jimenez is a recipient of a Clinical Scientist Development Award from the American Heart Association. Dr Somers is supported by NIH grants HL-65176, HL-73211, and 1 UL1 RR024150, and by the Mayo Clinic College of Medicine.
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