Chest
Volume 137, Issue 3, March 2010, Pages 711-719
Journal home page for Chest

Postgraduate Education Corner
Contemporary Reviews in Sleep Medicine
Interactions Between Obesity and Obstructive Sleep Apnea: Implications for Treatment

https://doi.org/10.1378/chest.09-0360Get rights and content

Obstructive sleep apnea (OSA) adversely affects multiple organs and systems, with particular relevance to cardiovascular disease. Several conditions associated with OSA, such as high BP, insulin resistance, systemic inflammation, visceral fat deposition, and dyslipidemia, are also present in other conditions closely related to OSA, such as obesity and reduced sleep duration. Weight loss has been accompanied by improvement in characteristics related not only to obesity but to OSA as well, suggesting that weight loss might be a cornerstone of the treatment of both conditions. This review seeks to explore recent developments in understanding the interactions between body weight and OSA. Weight loss helps reduce OSA severity and attenuates the cardiometabolic abnormalities common to both diseases. Nevertheless, weight loss has been hard to achieve and maintain using conservative strategies. Since bariatric surgery has emerged as an alternative treatment of severe or complicated obesity, impressive results have often been seen with respect to sleep apnea severity and cardiometabolic disturbances. However, OSA is a complex condition, and treatment cannot be limited to any single symptom or feature of the disease. Rather, a multidisciplinary and integrated strategy is required to achieve effective and long-lasting therapeutic success.

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.,

References (0)

Cited by (511)

  • Obstructive sleep apnea and cardiovascular risk

    2024, Clinica e Investigacion en Arteriosclerosis
  • Urinary metabolite signatures reflect the altered host metabolism in severe obstructive sleep apnea

    2023, Journal of Chromatography B: Analytical Technologies in the Biomedical and Life Sciences
View all citing articles on Scopus

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.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestpubs.org/site/misc/reprints.xhtml).

View full text