The impact of diet and lifestyle management strategies for obstructive sleep apnoea in adults: a systematic review and meta-analysis of randomised controlled trials

Effects of aerobic exercise and resistance training on obstructive sleep apnea: a systematic review and meta-analysis

STUDY OBJECTIVES

We investigated the therapeutic effects of exercise in patients with obstructive sleep apnea, aiming to identify the subgroups that benefit the most and determine the optimal exercise protocol.

METHODS

Major databases were searched for randomized controlled trials involving patients with obstructive sleep apnea performing aerobic exercise and/or resistance training. The investigated outcomes included apnea-hypopnea index (AHI), Epworth Sleepiness Scale, body mass index, and peak oxygen consumption during exercise (VO2peak). The pre- and postintervention unstandardized mean difference (USMD) of these parameters was compared between the exercise and control groups.

RESULTS

Twelve studies involving 526 patients were included. Exercise training significantly reduced AHI (USMD = -7.08 events/h, 95% confidence interval: -9.98 to -4.17, P < .00001), Epworth Sleepiness Scale (USMD = -2.37, 95% confidence interval: -3.21 to -1.54, P < .00001), and body mass index (USMD = -0.72 kg/m2, 95% confidence interval: -1.22 to -0.22, P = .005) and enhanced VO2peak (USMD = 3.46 ml·kg-1·min-1, 95% confidence interval: 1.20 to 5.71, P = .003). Subgroup analyses revealed that in continuous positive airway pressure-adherent patients, exercise significantly improved VO2peak but did not reduce AHI and Epworth Sleepiness Scale. A trend was observed that combining resistance training with aerobic exercise resulted in greater AHI reduction and VO2peak enhancement. Notably, exercise improved AHI, Epworth Sleepiness Scale, body mass index, and VO2peak regardless of the baseline AHI or body mass index.

CONCLUSIONS

Exercise, including resistance and aerobic training, should be part of treatment for patients with obstructive sleep apnea of all severities, regardless of obesity status, and even for those who are already under continuous positive airway pressure.

CITATION

Lin C-F, Ho N-H, Hsu W-L, Lin C-H, Wang Y-H, Wang Y-P. Effects of aerobic exercise and resistance training on obstructive sleep apnea: a systematic review and meta-analysis. J Clin Sleep Med. 2024;20(11):1839-1849.

The effects of exercise programs on sleep architecture in obstructive sleep apnea: a meta-analysis of randomized controlled trials

OBJECTIVES

Exercise is an effective intervention for obstructive sleep apnea (OSA). However, the effects of exercise on objective sleep architecture in patients with OSA remain unknown. This meta-analysis aimed to collect data from randomized controlled trials of exercise interventions in patients with OSA, with a specific focus on objective sleep parameters derived from polysomnography.

METHODS

Randomized control trials that targeted patients with OSA aged >18 years, measured sleep using polysomnography after exercise programs, and reported the proportion of sleep stages were included for meta-analysis. Bias was assessed using the revised Cochrane risk-of-bias tool and funnel plots. The random effects model was applied.

RESULTS

Six studies with a total of 236 patients were included in the meta-analysis. There were no significant differences in the total sleep time (TST), sleep efficiency, sleep onset latency, stage N1 sleep, or rapid eye movement sleep between the exercise and control groups. Participation in an exercise program lasting >12 weeks significantly decreased stage N2 and increased stage N3 sleep as observed in the subgroup analysis. Although this tendency did not reach statistical significance in the total-group analysis, it was significant after excluding the possible confounding effects of heart disease.

CONCLUSIONS

The exercise program decreased N2 and increased N3 proportions over the TST among patients with OSA, which may correspond to subjective sleep quality. The beneficial effects were significant when the program lasted >12 weeks and after excluding the confounding effects of heart disease. Exercise program duration should be considered when providing clinical advice.

Effects of respiratory exercises in sleep bruxism and associated obstructive sleep apnea: a double-blind, placebo-controlled randomized clinical trial

PURPOSE

The aim of this study is to assess the effects of respiratory exercises (inspiratory and expiratory) in individuals with sleep bruxism (SB) and associated obstructive sleep apnea (OSA).

METHODS

This is a double-blind, placebo-controlled randomized clinical trial including individuals with SB and associated respiratory events in OSA. Respiratory physical therapy was performed using inspiratory (Threshold® IMT), expiratory (Threshold® PEP) muscle training, and compared with a placebo group. A total of 30 daily respiratory cycles (inspiration and expiration) were performed five times a week for 12 weeks. Individuals were reassessed at two times, at baseline (T1) and after 12 weeks of training (T2) by means of the Pittsburgh Sleep Quality Index and Polysomnography.

RESULTS

Awakening was significantly different (p ≤ 0.05) between the inspiratory group and placebo 12 weeks after respiratory physical therapy. The number of contractions of the masseter muscle differed between the inspiratory, expiratory, and placebo groups (p ≤ 0.05).

CONCLUSION

Respiratory physical therapy for OSA improved awaking levels in 80 and 67% of the number of masseter muscle contractions, when compared to placebo.

TRIAL REGISTRATION

Brazilian Registry of Clinical Trials (No. RBR-9F6JKM).

Obstructive Sleep Apnea and a Comprehensive Remotely Supervised Rehabilitation Program: Protocol for a Randomized Controlled Trial

BACKGROUND

Obstructive sleep apnea (OSA) is characterized by recurrent, intermittent partial or complete obstruction of the upper respiratory tract during sleep, which negatively affects the patient's daily quality of life (QoL). Middle-aged and older men who smoke and have obesity are most at risk. Even though the use of continuous positive airway pressure (CPAP) during sleep remains the gold standard treatment, various rehabilitation methods, such as exercise, respiratory therapy, myofunctional therapy, and nutritional lifestyle interventions, also appear to be effective. Moreover, it is increasingly recommended to use alternative or additional therapy options in combination with CPAP therapy.

OBJECTIVE

This study aims to evaluate if a comprehensive home-based, remotely supervised rehabilitation program (tele-RHB), in combination with standard therapy, can improve OSA severity by decreasing the apnea-hypopnea index (AHI); improve objective parameters of polysomnographic, spirometric, anthropometric, and body composition examinations; improve lipid profile, maximal mouth pressure, and functional capacity tests; and enhance the subjective perception of QoL, as well as daytime sleepiness in male participants with moderate to severe OSA. Our hypothesis is that a combination of the tele-RHB program and CPAP therapy will be more effective by improving OSA severity and the abovementioned parameters.

METHODS

This randomized controlled trial aims to recruit 50 male participants between the ages of 30 and 60 years with newly diagnosed moderate to severe OSA. Participants will be randomized 1:1, either to a 12-week tele-RHB program along with CPAP therapy or to CPAP therapy alone. After the completion of the intervention, the participants will be invited to complete a 1-year follow-up. The primary outcomes will be the polysomnographic value of AHI, Epworth Sleepiness Scale score, 36-Item Short Form Health Survey (SF-36) score, percentage of body fat, 6-minute walk test distance covered, as well as maximal inspiratory and expiratory mouth pressure values. Secondary outcomes will include polysomnographic values of oxygen desaturation index, supine AHI, total sleep time, average heart rate, mean oxygen saturation, and the percentage of time with oxygen saturation below 90%; anthropometric measurements of neck, waist, and hip circumference; BMI values; forced vital capacity; forced expiratory volume in 1 second; World Health Organization's tool to measure QoL (WHOQOL-BREF) score; and lipid profile values.

RESULTS

Study recruitment began on October 25, 2021, and the estimated study completion date is December 2024. Analyses will be performed to examine whether the combination of the tele-RHB program and CPAP therapy will be more effective in the reduction of OSA severity and improvement of QoL, body composition and circumferences, exercise tolerance, lipid profile, as well as respiratory muscle and lung function, compared to CPAP therapy alone.

CONCLUSIONS

The study will evaluate the effect of a comprehensive tele-RHB program on selected parameters mentioned above in male participants. The results of this intervention could help the further development of novel additional therapeutic home-based options for OSA.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04759456; https://clinicaltrials.gov/ct2/show/NCT04759456.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/47460.

Evaluation and Treatment of Obesity and Its Comorbidities: 2022 Update of Clinical Practice Guidelines for Obesity by the Korean Society for the Study of Obesity

The goal of the 8th edition of the Clinical Practice Guidelines for Obesity is to help primary care physician provide safe, effective care to patients with obesity by offering evidence-based recommendations to improve the quality of treatment. The Committee for Clinical Practice Guidelines comprised individuals with multidisciplinary expertise in obesity management. A steering board of seven experts oversaw the entire project. Recommendations were developed as the answers to key questions formulated in patient/problem, intervention, comparison, outcomes (PICO) format. Guidelines underwent multi-level review and cross-checking and received endorsement from relevant scientific societies. This edition of the guidelines includes criteria for diagnosing obesity, abdominal obesity, and metabolic syndrome; evaluation of obesity and its complications; weight loss goals; and treatment options such as diet, exercise, behavioral therapy, pharmacotherapy, and bariatric and metabolic surgery for Korean people with obesity. Compared to the previous edition of the guidelines, the current edition includes five new topics to keep up with the constantly evolving field of obesity: diagnosis of obesity, obesity in women, obesity in patients with mental illness, weight maintenance after weight loss, and the use of information and communication technology-based interventions for obesity treatment. This edition of the guidelines features has improved organization, more clearly linking key questions in PICO format to recommendations and key references. We are confident that these new Clinical Practice Guidelines for Obesity will be a valuable resource for all healthcare professionals as they describe the most current and evidence-based treatment options for obesity in a well-organized format.

Alternate-Day Fasting Combined with Exercise: Effect on Sleep in Adults with Obesity and NAFLD

Objective: This study investigated how alternate-day fasting (ADF) combined with aerobic exercise impacts body weight and sleep in adults with non-alcoholic fatty liver disease (NAFLD). Methods: Adults with obesity and NAFLD (n = 80) were randomized into one of four groups for 3 months: combination of ADF (600 kcal “fast day,” alternated with an ad libitum intake “feast day”) and moderate-intensity aerobic exercise (five sessions per week, 60 min/session); ADF alone; exercise alone; or a no-intervention control group. Results: By month 3, body weight and intrahepatic triglyceride content decreased (p < 0.001, group × time interaction) in the combination group versus the exercise group and control group, but not versus the ADF group. Sleep quality, measured by the Pittsburgh Sleep Quality Inventory (PSQI), did not change in the combination group (baseline: 6.0 ± 0.7; month 3: 5.6 ± 0.7), ADF group (baseline: 8.9 ± 1.0; month 3: 7.5 ± 0.8), or exercise group (baseline: 6.4 ± 0.6; month 3: 6.7 ± 0.6), versus controls (baseline: 5.5 ± 0.7; month 3: 4.6 ± 0.5). Wake time, bedtime, sleep duration, and insomnia severity did not change (no group x time interaction) over the course of the study in any group. Risk for obstructive sleep apnea was present in 30% of combination subjects, 75% of ADF subjects, 40% of exercise subjects, and 75% of controls, and did not change in the intervention groups, versus controls, by month 3. No associations were observed between changes in body weight, intrahepatic triglyceride content, and any sleep outcome. Conclusions: The weight loss induced by ADF combined with exercise does not improve sleep quality, duration, insomnia severity, or risk of obstructive sleep apnea in individuals with NAFLD.

Comparing the influence of foot reflexology and fasting mimicking diet on quality of life and sleep quality in obesity hypoventilation syndrome

OBJECTIVES

Obesity hypoventilation syndrome is one of the most serious outcomes of obesity-related respiratory difficulties, resulting in higher healthcare costs as well as increased cardio-respiratory morbidity and mortality.

METHODS

Sixty-two males who had a high risk of obstructive sleep apnea according to the STOP-BANG Sleep Apnea Questionnaire were enrolled in the study. Their age is 50-60 years old, and they have a BMI of 35-40 kg/m², daytime hypercapnia, and sleep breathing problems. The patients were divided into two equal groups at random reflexology fasting-mimicking diet groups. Weight, height, waist, and neck circumference were assessed at the beginning of the study and after two months of the intervention. Sleep quality was measured using the Pittsburgh Sleep Quality Index (PSQI), which is used to evaluate sleep quality. The Maugeri Obstructive Sleep Apnea Syndrome (MOSAS) questionnaire was used to assess a patient's quality of life.

RESULTS

There was a significant change in the MOSAS and PSQI questionnaires for both groups post-intervention, as the p-value was less than 0.05. The percentage change in the MOSAS questionnaire score and PSQI questionnaire was higher in the mimic diet group than in the reflexology group. Also, the mimic diet group's weight and neck circumference were considerably reduced after the intervention, with no change in the reflexology group.

CONCLUSIONS

Reflexology and a fasting-mimicking diet were found to have a substantial impact on enhancing the quality of life and sleep in people with obesity hypoventilation syndrome.

Effect of the Implementation of a Structured Diet Management Plan on the Severity of Obstructive Sleep Apnea: A Systematic Review

PURPOSE OF REVIEW

The prevalence of obstructive sleep apnea (OSA) is increasing worldwide, in line with the increase in obesity prevalence. Taken into consideration the low compliance rates to continuous positive airway pressure (CPAP) treatment, and since obesity is a risk factor for OSA, these patients should receive additional counseling for weight loss through a diet plan. The aim of this review is to examine the role of a structured diet management plan on OSA severity, nocturnal oxygen indices, and subjective sleep parameters.

RECENT FINDINGS

Τhis systematic review of the literature resulted in four studies and demonstrated that severity of OSA, assessed by the apnea-hypopnea index, is reduced by a dietary management plan when delivered through an educational program. Moreover, nocturnal oxygenation is improved, as well as subjective sleep parameters, when initiating a diet on top of CPAP use. In summary, the present systematic review reports on the beneficial effects of a structured diet management plan in patients with OSA. Although CPAP remains the gold standard of OSA treatment, a specific dietary plan should be sought when managing patients with OSA. Nevertheless, still the evidence is low, and further research on this field is needed to reduce the burden of OSA.

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.

The correlation between the body shape and otolithic function in patients with obstructive sleep apnea

OBJECTIVE

To identify the typical pattern of changes of vestibular-evoked myogenic potentials (VEMPs) and explore the relationship between VEMPs and the anthropometry factors in patients with obstructive sleep apnea (OSA).

METHODS

Patients diagnosed as OSA after overnight polysomnography (PSG) tests were enrolled as the study group. Healthy volunteers were recruited as the control group. Anthropometry data of the body shape and VEMPs results were collected completely. The correlation analysis was conducted among those parameters.

RESULTS

Forty-nine patients with OSA who were diagnosed in the Therapy Center of Sleep-disordered Breathing in our hospital and sex- and age-matched healthy controls as well. Significant changes in ocular and cervical VEMPs (oVEMP and cVEMP) in the study group were observed, which were reduced response rates, elevated thresholds, decreased amplitudes, and prolonged first wave latencies. In oVEMP, the first wave (n1) latency was significantly correlated with weight, body mass index (BMI), neck circumference, waist circumference, hip circumference, and apnea hypopnea index (AHI). In a tentative application, combined use of BMI and oVEMP n1 latency increased the detection rate during OSA screening prior to PSG.

CONCLUSION

OSA can negatively affect function of otolithic organs and their pathways. The first wave latency of the VEMPs waveform may be another important parameter to define peripheral nervous system lesions caused by systemic diseases as OSA.

Self-management behavior, associated factors and its relationship with social support and health literacy in patients with obstructive sleep apnea–hypopnea syndrome

Background

The proportion of patients with obstructive sleep apnea–hypopnea syndrome (OSAHS) is increasing year by year in China, which has become a major public health problem. Self-management of OSAHS and multiple support from caregivers are key to low hospital admissions and high quality of life for patients with OSAHS. Social support and health literacy are the main promoters of self-management behavior. However, their contributions have not been adequately studied. The purpose of this study is to investigate the level of self-management among patients with OSAHS and its relationship with general demographics, social support, and health literacy.

Methods

A total of 280 patients with OSAHS treated in two Classiii Grade A hospitals in Jinzhou City, Liaoning Province from October 2020 to July 2021 were selected as the study subjects. Patients were investigated by General Characteristics Questionnaire, Social Support Rating Scale (SSRS), Health Literacy Scale for Chronic Patients (HLSCP), and OSAHS Self-management Behavior Questionnaire, and the influencing factors of self-management of patients with OSAHS were analyzed.

Results

The average score of OSAHS self-management was 74.49(SD = 8.06), SSRS and HLSCP scores were positively correlated with total scores of self-management behavior. Furthermore, we found that disease duration, SSRS, and HLSCP scores were the main predictors of self-management behavior (R² = 0.390, P < 0.001).

Conclusion

This study found that OSAHS patients with a longer duration of disease and higher SSRS or HLSCP scores also had higher levels of self-management. The factors discussed in this study may be helpful in developing individualized interventions in self-management for patients with OSAHS.

Dose-response relationship between weight loss and improvements in obstructive sleep apnea severity after a diet/lifestyle interventions: secondary analyses of the "MIMOSA" randomized clinical trial

STUDY OBJECTIVES

Lifestyle-induced weight loss is a complementary therapeutic approach for obstructive sleep apnea (OSA). We aimed at identifying the dose-response relationship between weight loss and OSA severity improvement.

METHODS

This is a secondary analysis of a 6-month clinical trial in 180 adult, overweight/obese moderate-to-severe OSA patients. Participants were randomized to a standard care, a Mediterranean diet, or a Mediterranean lifestyle arm. All patients were prescribed with continuous positive airway pressure (CPAP), while intervention arms additionally participated in a weight-loss dietary/lifestyle intervention. Based on percent change in weight at 6 months, participants were categorized into a weight-stable/gain (WS/GG) group or 3 weight-loss groups (WLG): < 5%WLG, 5%-10%WLG, and ≥ 10%WLG. Polysomnographic data and OSA symptoms were evaluated preintervention and postintervention.

RESULTS

Respiratory events and oximetry indices improved only in patients who lost weight and improvements were proportional to the degree of weight loss. Median percent change in apnea-hypopnea index (AHI) was -11.7%, - 37.9%, and - 49.3% in the < 5%WLG, 5%-10%WLG, and ≥ 10%WLG, respectively (P < .001). Compared to the WS/GG, the age-, sex-, baseline-, and CPAP use-adjusted relative risk (95% confidence interval) of severe OSA (AHI ≥ 30 events/h) was 0.45 (0.23-0.87) in the 5%-10%WLG and 0.32 (0.17-0.64) in the ≥ 10%WLG; the risk was also lower in the ≥ 10%WLG vs the < 5%WLG (0.42 [0.22-0.82]). Insomnia and daytime sleepiness also improved more in participants exhibiting ≥ 5% weight loss.

CONCLUSIONS

Even a < 5% weight loss can reduce respiratory events, but a ≥ 5% and ideally ≥ 10% weight loss is necessary for reducing the prevalence of severe OSA.

CLINICAL TRIAL REGISTRATION

Registry: ClinicalTrials.gov; Name: Mediterranean Diet/Lifestyle Intervention in Obstructive Sleep Apnea; URL: https://clinicaltrials.gov/ct2/show/NCT02515357; Identifier: NCT02515357.

CITATION

Georgoulis M, Yiannakouris N, Kechribari I, et al. Dose-response relationship between weight loss and improvements in obstructive sleep apnea severity after a diet/lifestyle intervention: secondary analyses of the "MIMOSA" randomized clinical trial. J Clin Sleep Med. 2022;18(5):1251-1261.

Sleep Apnea Syndrome (SAS) Clinical Practice Guidelines 2020

The prevalence of sleep disordered breathing (SDB) is reportedly very high. Among SDBs, the incidence of obstructive sleep apnea (OSA) is higher than previously believed, with patients having moderate-to-severe OSA accounting for approximately 20% of adult males and 10% of postmenopausal women not only in Western countries but also in Eastern countries, including Japan. Since 1998, when health insurance coverage became available, the number of patients using continuous positive airway pressure (CPAP) therapy for sleep apnea has increased sharply, with the number of patients about to exceed 500,000 in Japan. Although the "Guidelines for Diagnosis and Treatment of Sleep Apnea Syndrome (SAS) in Adults" was published in 2005, a new guideline was prepared in order to indicate the standard medical care based on the latest trends, as supervised by and in cooperation with the Japanese Respiratory Society and the "Survey and Research on Refractory Respiratory Diseases and Pulmonary Hypertension" Group, of Ministry of Health, Labor and Welfare and other related academic societies, including the Japanese Society of Sleep Research, in addition to referring to the previous guidelines. Because sleep apnea is an interdisciplinary field covering many areas, this guideline was prepared including 36 clinical questions (CQs). In the English version, therapies and managements for SAS, which were written from CQ16 to 36, were shown. The Japanese version was published in July 2020 and permitted as well as published as one of the Medical Information Network Distribution Service (Minds) clinical practice guidelines in Japan in July 2021.

Sleep Apnea Syndrome (SAS) Clinical Practice Guidelines 2020

The prevalence of sleep-disordered breathing (SDB) is reportedly very high. Among SDBs, the incidence of obstructive sleep apnea (OSA) is higher than previously believed, with patients having moderate-to-severe OSA accounting for approximately 20% of adult males and 10% of postmenopausal women not only in Western countries but also in Eastern countries, including Japan. Since 1998, when health insurance coverage became available, the number of patients using continuous positive airway pressure (CPAP) therapy for sleep apnea has increased sharply, with the number of patients about to exceed 500,000 in Japan. Although the "Guidelines for Diagnosis and Treatment of Sleep Apnea Syndrome (SAS) in Adults" was published in 2005, a new guideline was prepared to indicate the standard medical care based on the latest trends, as supervised by and in cooperation with the Japanese Respiratory Society and the "Survey and Research on Refractory Respiratory Diseases and Pulmonary Hypertension" Group, of Ministry of Health, Labor and Welfare and other related academic societies, including the Japanese Society of Sleep Research, in addition to referring to the previous guidelines. Since sleep apnea is an interdisciplinary field covering many areas, this guideline was prepared including 36 clinical questions (CQs). In the English version, therapies and managements for SAS, which were written from CQ16 to 36, were shown. The Japanese version was published in July 2020 and permitted as well as published as one of the Medical Information Network Distribution Service (Minds) clinical practice guidelines in Japan in July 2021.

Endorsement of: "treatment of adult obstructive sleep apnea with positive airway pressure: an American academy of Sleep Medicine Clinical Practice Guideline" by World Sleep Society

Guidelines for the evaluation and management of sleep disorders from national societies provide recommendations that may be regionally appropriate but may not always be practical or relevant in other parts of the world. A task force of experts from the World Sleep Society's (WSS) International Sleep Medicine Guidelines Committee and Sleep and Breathing Disorders Taskforce reviewed the American Academy of Sleep Medicine's Clinical Practice Guideline on the Treatment of Adult Obstructive Sleep Apnea (OSA) with Positive Airway Pressure with respect to its relevance and applicability to the practice of sleep medicine by sleep specialists in various regions of the world. To improve the evaluation of the guideline, surveys were sent by the senior author and the WSS to approximately 800 sleep doctors around the world to query the availability of OSA treatments in their respective region. The task force and the WSS guidelines committee endorsed the AASM's CPAP guidelines with respect to the indications for PAP therapy, utilization of different PAP modalities, and concurrent strategies to improve outcomes, noting appropriate caveats for universal applicability.

The role of circadian rhythms in Obstructive Sleep Apnea symptoms and novel targets for treatment

Obstructive Sleep Apnea (OSA) is a common disorder that is associated with disability, premature mortality and lost quality of life. Excessive daytime sleepiness and depressive symptoms confer a great portion of the disability and lost quality of life associated with the disorder. While showing robust rates of response and symptoms resolutions, current treatments aimed at correcting the respiratory disturbances are not universally successful and a non-negligible proportion of patients who are correctly using available therapies do not experience symptomatic relief, suggesting that mechanisms beyond the respiratory disturbances may be involved in the pathogenesis of symptoms. A growing body of literature concerning animal and human models suggests that the sleep and respiratory disturbances commonly seen in OSA, namely sleep fragmentation, partial sleep deprivation, intermittent hypoxia, can promote shifts in circadian rhythms ultimately leading to misalignment between sleep-wake rhythms and the internal clock, as well as desynchrony amongst peripheral clocks and peripheral and central clock. This manuscript reviews the current evidence in support of a circadian disturbance underlying OSA symptomatology and proposes new applications for existing chronotherapeutic interventions with the potential for improving symptoms and quality of life for those patients that do not find symptomatic relief with currently available treatments.

The public health burden of obstructive sleep apnea

Obstructive sleep apnea (OSA) is the most common respiratory disorder of sleep. The vast majority (>80%) of adults with moderate to severe OSA remain undiagnosed. The economic costs associated with OSA are substantial for both the individual and society as a whole; expenses are likely to be underestimated given that the disease remains undiagnosed in such a large percentage of individuals. The economic burden of motor vehicle collisions related to OSA alone is significant; it is estimated that 810,000 collisions and 1400 fatalities from car crashes in the United States were attributable to sleep apnea in 2000. The many health consequences of OSA include daytime sleepiness, reduced quality of life, decreased learning skills, and importantly, neurocognitive impairments that include impaired episodic memory, executive function, attention and visuospatial cognitive functions. Untreated OSA leads to numerous medical problems such as cardiovascular diseases that can potentially increase healthcare utilization. Untreated patients with sleep apnea consume a disproportionate amount of healthcare resources, expenditures that decrease after treatment. The gold-standard management of OSA remains treatment with CPAP (Continuous Positive Airway Pressure), which is effective in eliminating sleep fragmentation and preserving nocturnal oxygenation, thereby improving daytime sleepiness and quality of life. However, its impacts in reversing neurocognitive function are still uncertain. A significant impediment to CPAP effectiveness is low adherence rates (ranges from 50% to 75%). It is commonly accepted that CPAP improves excessive drowsiness; hence meliorates attention, and accumulating data suggest that CPAP improves a variety of other outcomes such as the risk of motor vehicle crashes.

A weight-loss Mediterranean diet/lifestyle intervention ameliorates inflammation and oxidative stress in patients with obstructive sleep apnea: results of the "MIMOSA" randomized clinical trial

PURPOSE

Inflammation and oxidative stress are implicated in obstructive sleep apnea (OSA) pathophysiology. We aimed at exploring whether the combination of a weight-loss Mediterranean diet/lifestyle intervention with OSA standard care, i.e., continuous positive airway pressure (CPAP) prescription, can lead to greater improvements in inflammation and oxidative stress, compared to standard care alone.

METHODS

This was a randomized controlled clinical trial in 187 adult, overweight patients with moderate-to-severe OSA. Participants were randomized to a standard care (SCG, n = 65), a Mediterranean diet (MDG, n = 62) or a Mediterranean lifestyle group (MLG, n = 60). All groups received OSA standard care. Intervention arms participated in a 6-month behavioral weight-loss intervention based on the Mediterranean diet, while the MLG also received counselling on physical activity and sleep habits.

RESULTS

Seven patients were excluded and 53/180 were lost to follow-up. In intention to treat analysis (n = 180), the SCG did not exhibit changes in any of the markers assessed. Post-intervention age-, sex-, baseline- and CPAP use-adjusted plasma high sensitivity C-reactive protein levels (mg/L) were lower in the MDG and the MLG compared to the SCG (mean difference - 1.33, P = 0.039 and - 1.68, P = 0.007, respectively). The MLG also exhibited lower urinary 8-iso prostaglandin F2a levels (ng/mg creatinine) compared to the SCG and the MDG (mean difference - 1.10, P < 0.0001 and - 0.80, P = 0.001, respectively). Adiponectin and oxidized guanine levels were not altered in any of the study groups. Results were similar in per protocol analysis (n = 127).

CONCLUSION

A weight-loss Mediterranean diet/lifestyle intervention on top of CPAP has anti-inflammatory and antioxidant benefits in OSA.

REGISTRATION

The trial was prospectively registered at ClinicalTrials.gov (NCT02515357) on August 4, 2015.

Body Mass Index Reduction and Selected Cardiometabolic Risk Factors in Obstructive Sleep Apnea: Meta-Analysis

Although clinical studies have been carried out on the effects of weight reduction in sleep apnea patients, no direct link has been shown between weight reduction and changes in cardio-metabolic risk factors. We aimed to analyze changes in the apnea–hypopnea index and selected cardio-metabolic parameters (total cholesterol, triglycerides, glucose, insulin, blood pressure) in relation to the reduction in body mass index in obstructive sleep apnea patients. Medline, Web of Science and Cochrane databases were searched to combine results from individual studies in a single meta-analysis. We identified 333 relevant articles, from which 30 papers were assigned for full-text review, and finally 10 (seven randomized controlled trials and three nonrandomized studies) were included for data analysis. One unit of body mass index reduction was found to significantly influence changes in the apnea–hypopnea index (−2.83/h; 95% CI: −4.24, −1.41), total cholesterol (−0.12 mmol/L; 95% CI: −0.22, −0.01), triglycerides (−0.24 mmol/L; 95% CI: −0.46, −0.02), fasting insulin (−7.3 pmol/L; 95% CI: −11.5, −3.1), systolic (−1.86 mmHg; 95% CI: −3.57, −0.15) and diastolic blood pressure (−2.07 mmHg; 95% CI: −3.79, −0.35). Practical application of lifestyle modification resulting in the reduction of one unit of body mass index gives meaningful changes in selected cardio-metabolic risk factors in obstructive sleep apnea patients.

Smart polymer implants as an emerging technology for treating airway collapse in obstructive sleep apnea: a pilot (proof of concept) study

STUDY OBJECTIVES

To assess the use of a novel magnetic polymer implant in reversing airway collapse and identify potential anatomical targets for airway implant surgery in an in vivo porcine model.

METHODS

Target sites of airway collapse were genioglossus muscle, hyoid bone, and middle constrictor muscle. Magnetic polymer implants were sutured to these sites, and external magnetic forces, through magnets with pull forces rated at 102 kg and 294 kg, were applied at the skin. The resultant airway movement was assessed via nasendoscopy. Pharyngeal plexus branches to the middle constrictor muscle were stimulated at 0.5 mA, 1.0 mA, and 2.0 mA and airway movement assessed via nasendoscopy.

RESULTS

At the genioglossus muscles, large magnetic forces were required to produce airway movement. At the hyoid bone, anterior movement of the airway was noted when using a 294 kg rated magnet. At the middle constrictor muscle, an anterolateral (or rotatory) pattern of airway movement was noted when using the same magnet. Stimulation of pharyngeal plexus branches to the middle constrictor revealed contraction and increasing rigidity of the lateral walls of the airway as stimulation amplitude increased. The resultant effect was prevention of collapse as opposed to typical airway dilation, a previously unidentified pattern of airway movement.

CONCLUSIONS

Surgically implanted smart polymers are an emerging technology showing promise in the treatment of airway collapse in obstructive sleep apnea. Future research should investigate their biomechanical role as an adjunct to treatment of airway collapse through nerve stimulation.

The effectiveness of a weight-loss Mediterranean diet/lifestyle intervention in the management of obstructive sleep apnea: Results of the "MIMOSA" randomized clinical trial

BACKGROUND & AIMS

Although continuous positive airway pressure (CPAP) is the first-line treatment for obstructive sleep apnea (OSA), lifestyle interventions have also emerged as complementary therapeutic choices. We aimed to explore whether the addition of a weight-loss Mediterranean diet/lifestyle intervention to OSA standard care, i.e. CPAP prescription and brief written healthy lifestyle advice, has an incremental effect on improving OSA severity, over the effect of standard care alone.

METHODS

We designed a parallel, randomized, controlled, superiority clinical trial. Eligible participants were adult, overweight men and women, diagnosed with moderate-to-severe OSA [apnea-hypopnea index (AHI)≥ 15 events/h] through an attended overnight polysomnography. Participants were blindly randomized to a standard care group (SCG, n = 65), a Mediterranean diet group (MDG, n = 62) or a Mediterranean lifestyle group (MLG, n = 60). All three study groups were prescribed with CPAP. The SCG additionally received written healthy lifestyle advice, while intervention arms were subjected to a 6-month behavioral intervention aiming at weight loss and increasing adherence to the Mediterranean diet. The MLG also received counselling on physical activity and sleep habits. Polysomnographic data and OSA symptoms were evaluated pre- and post-intervention.

RESULTS

A total of 187 OSA patients were recruited. Seven patients were excluded post-randomization and 53/180 (29%) were lost to follow-up. No harms from the interventions applied were reported. According to intention-to-treat analysis (n = 180), mean (95% confidence interval) AHI change was -4.2 (-7.4, -1.0) for the SCG, -24.7 (-30.4, -19.1) for the MDG and -27.3 (-33.9, -20.6) for the MLG. Post-intervention age-, sex-, baseline- and CPAP use-adjusted AHI was significantly lower in the MDG and the MLG compared to the SCG (mean difference: -18.0, and -21.2, respectively, both P < 0.001), and the differences remained significant after further adjustment for body-weight change (P = 0.004 and 0.008, respectively). Other respiratory event indices, daytime sleepiness and insomnia were also significantly lower in both intervention arms compared to the SCG (all P < 0.05). The MLG only presented higher percent rapid-eye-movement sleep and lower daytime sleepiness compared to the MDG (both P < 0.05). Results were similar in the per-protocol analysis (n = 127).

CONCLUSIONS

A dietary/lifestyle intervention on top of standard care leads to greater improvements in OSA severity and symptomatology compared to standard care alone. Benefits are evident regardless of CPAP use and weight loss.

TRIAL REGISTRATION

Clinicaltrials.gov NCT02515357, https://clinicaltrials.gov/ct2/show/NCT02515357.

The implementation of a physical activity intervention in adults with Obstructive Sleep Apnoea over the age of 50 years: a feasibility uncontrolled clinical trial

Background

Obstructive Sleep Apnoea (OSA) is a risk factor for cardiovascular disease (CVD) and Type 2 diabetes (T2D). Observational studies suggested that OSA treatment might reduce CVD and T2D but RCTs failed to support these observations in part due to poor adherence to continuous positive airway pressure (CPAP). Physical activity (PA) has been shown to have favourable impact on CVD and the risk of T2D independent of its impact on weight and therefore might provide additional health gains to patients with OSA, whether or not adherent to CPAP.

Methods

The main aim of this study was to explore the feasibility of providing a 12-week PA intervention to adults aged over 50 with OSA. The secondary aim was to assess the impact of the PA intervention on OSA severity. Patients with moderate-severe OSA (apnoea hypopnea index (AHI) ≥ 15 events/hour (based on overnight ApneaLink™) were recruited in response to posters displayed in workplaces. A 12-week daily PA intervention was delivered in participant’s home setting and PA was monitored via text and validated by objective PA measures (GT3X accelerometers).

Results

The intervention was feasible as all 10 patients (8 males, mean (SD) age 57.3 (6.01)) completed the intervention and PA increased across the 12-weeks. The duration of PA increased from baseline (113.1 min (64.69) per week to study-end following the intervention (248.4 min (148.31) (p = 0.02). Perceived Exertion (RPE) (physical effort) increased significantly between baseline (M = 10.7 (1.94)) to end of intervention (M = 13.8, (1.56) (p < 0.001). The intervention had no significant impact on weight or composition. Following the intervention, there was a statistically non-significant a reduction in AHI from baseline to study end (22.3 (7.35) vs. 15.8 (7.48); p = 0.09).

Conclusion

It is feasible to deliver a PA intervention to adults aged over 50 with OSA. The intervention resulted in improved PA and AHI levels somewhat and seemingly independent of weight changes. Future trials need to examine whether PA can reduce the burden of OSA associated comorbidities.

Trial registration

CTN: ISRCTN11016312 Retrospectively Registered 21/07/20.

To Study the Effect of Calorie Deficit Diet and Strength Training in Patients with Mild to Moderate Obstructive Sleep Apnoea

OSA is a disease of modernisation. Though many modalities are available for its treatment from invasive to non-invasive; the role of lifestyle modification can never be underrated. Lifestyle modification normally includes walk; diet with less fat; abstinence from alcohol and smoking along with regularising of sleep schedule. However the role of calorie deficit diet along with strength training in OSA has not been extensively researched till date. The present study aimed to evaluate the effect of the calorie deficit diet and strength training in patients with mild to moderate obstructive sleep apnea. It is a prospective randomised control trial of 40 patients. The patients were divided into 2 groups. Group A was given lifestyle modification while Group B was given Lifestyle Modification with calorie deficit diet and strength training. The outcomes were measured by comparing pre-intervention and post-intervention polysomnography and Epworth sleepiness score after 3 months. The most common symptom found in our group was excessive daytime sleepiness and Loud snoring; both present in 39/40 patients. Other common symptoms were Awakening with a dry mouth or sore throat; morning headache; difficulty concentrating during the day; experiencing mood changes, such as depression or irritability and high blood pressure. The post intervention BMI in Group A was - 1.75 ± 0.698 than pre-intervention BMI while in Group B the difference between pre-intervention and post intervention was - 3.05 ± 1.32. The difference in AHI events pre-intervention versus post-intervention in Group A and Group B was - 3.5 ± 1.11 and - 5.55 ± 1.90 respectively. The ESS decreased by - 2.2 ± 0.871 and - 3.31 ± 0.05 respectively in Group A and Group B post-intervention. Calorie deficit diet along with strength training markedly improves the AHI index; BMI and ESS score in Mild to moderate OSA patients and is highly recommended in motivated patients in addition to lifestyle modification.

Effect of Rehabilitation on Sleep Quality After Ablation for Atrial Fibrillation: Data From a Randomized Trial

BACKGROUND

Low sleep quality is common in patients with atrial fibrillation (AF). Positive effects of cardiac rehabilitation on patients treated for AF with ablation have been found, but whether cardiac rehabilitation affects sleep quality is unknown. The objectives of this study were to investigate (1) differences in sleep quality between cardiac rehabilitation and usual care groups and (2) whether other factors could affect sleep quality.

METHODS

From the randomized CopenHeartRFA trial, 210 patients treated for AF with ablation were included. A rehabilitation program consisting of physical exercise and psychoeducational consultations was tested. Sleep quality was measured with the Pittsburg Sleep Quality Index (PSQI) questionnaire before intervention and at the end of intervention. Anxiety, depression, and European Heart Rhythm Association scores were assessed.

RESULTS

No difference between groups in sleep quality was found (PSQI global mean [SD] score, 6.60 [3.61] points for the cardiac rehabilitation group [n = 83] and 6.08 [3.60] points for the usual care group [n = 90]; P = .34), although improvements in sleep quality were noted in both groups. Sleep latency, duration, and efficiency were significant by type of AF at 1 month. Anxiety, depression, and higher European Heart Rhythm Association scores at 4 months were associated with a higher PSQI global mean score at the end of intervention.

CONCLUSION

The rehabilitation program showed no effect on sleep quality. A large proportion of patients reported poor sleep quality, and patients reporting anxiety, depression, or AF symptoms described worse sleep quality compared with patients who did not experience anxiety, depression, or AF symptoms. More research in the field is warranted.

Weight loss and lifestyle interventions for obstructive sleep apnoea in adults: Systematic review and meta-analysis

Lifestyle interventions addressing diet, exercise-training, sleep hygiene, and/or tobacco/alcohol cessation are recommended in the management of obstructive sleep apnoea (OSA). Yet their effectiveness on this condition still requires further research. This systematic review and meta-analysis was aimed at establishing (a) the effectiveness of lifestyle interventions on apnoea-hypopnoea index (AHI), oxygen desaturation index (ODI), excessive daytime sleepiness (EDS), and secondary OSA measures among adults, and (b) which intervention characteristics may drive the greatest improvements. A systematic search of studies was conducted using CINAHL, ProQuest, Psicodoc, Scopus, and Web of Science, from inception to April 2018. Standardized mean differences were calculated using the inverse variance method and random-effects models. The meta-analyses of 13 randomized controlled trials and 22 uncontrolled before-and-after studies (1420 participants) revealed significant reductions on AHI (d = -0.61 and -0.46, respectively), ODI (d = -0.61 and -0.46) and EDS (d = -0.41 and -0.49). Secondary OSA outcomes were also improved after interventions. However, effectiveness of interventions differed depending on their components, OSA severity, and gender. Thus, until future research further supports the differential effectiveness among lifestyle interventions on OSA, those addressing weight loss through diet and exercise-training may be the most effective treatments for male patients with moderate-severe OSA.

Effects of a Combined Community Exercise Program in Obstructive Sleep Apnea Syndrome: A Randomized Clinical Trial

Physical activity is associated with a decreased prevalence of obstructive sleep apnea and improved sleep efficiency. Studies on the effects of a comprehensive exercise program in a community setting remain limited. Our objective was to investigate the effects of a combined physical and oropharyngeal exercise program on the apnea-hypopnea index in patients with moderate to severe obstructive sleep apnea. This was a randomized clinical trial where the intervention group followed an eight-week urban-walking program, oropharyngeal exercises, and diet and sleep recommendations. The control group followed diet and sleep recommendations. A total of 33 patients were enrolled and randomized and, finally, 27 patients were included in the study (IG, 14; CG, 13) Obstructive sleep apnea patients were analyzed with a median age of 67 (52–74) and median apnea-hypopnea index of 32 events/h (25–41). The apnea-hypopnea index did not differ between groups pre- and post-intervention. However, in intervention patients younger than 60 (n = 6) a reduction of the apnea-hypopnea index from 29.5 (21.8–48.3) to 15.5 (11–34) events/h (p = 0.028) was observed. While a comprehensive multimodal program does not modify the apnea-hypopnea index, it could reduce body weight and increase the walking distance of patients with moderate to severe obstructive sleep apnea. Patients younger than 60 may also present a decreased apnea-hypopnea index after intervention.

Relationship of evening meal with sleep quality in obese individuals with obstructive sleep apnea

PURPOSE

To determine the relationship between habitual food intake, resting energy expenditure and sleep pattern in obstructive sleep apnea (OSA) patients.

METHODS

Forty-five OSA obese males were included in the study. All participants were submitted to nocturnal polysomnography, body composition measurements by plethysmography, resting energy expenditure (REE) analysis by indirect calorimetry and they filled in a 3-day food record.

RESULTS

No differences in body composition, REE and food intake were found between the moderate and severe OSA groups. A trend towards higher energy intake in the severe OSA group was observed, compared to the moderate group (p = 0.08). Significant associations between apnea-hypopnea index (AHI) with body weight, body mass index (BMI) and resting energy expenditure (REE) were found. Higher food intake in the evening period was positively correlated with sleep stage NREM1, arousal index, and AHI and negatively correlated with sleep stage NREM3 and sleep efficiency. A multivariate linear regression showed energy intake at breakfast to be a significant negative predictor of AHI; protein intake (g/kg) showed a positive association, while energy intake at breakfast and at dinner were negative predictors of sleep efficiency; and energy intake at dinner was a negative predictor of stage NREM1 sleep.

CONCLUSIONS

We conclude that higher amounts of food intake during the evening period may diminish sleep quality in moderate and severe sleep apnea patients. In addition, despite observing no differences between OSA severity groups, a moderate correlation between REE and sleep quality and OSA exists.

Effects of Exercise Domain and Intensity on Sleep in Women and Men with Overweight and Obesity

Inadequate sleep is associated with cardiometabolic risk and adiposity. Exercise has been suggested as an efficient strategy to improve sleep; however, the effects of different types of exercise on sleep in individuals with overweight and obesity are not well understood. We examined effects of active commuting and leisure-time exercise on sleep in individuals with overweight or obesity. 130 physically inactive adults (20-45 years) with overweight or class 1 obesity (body mass index: 25-35 kg/m²) were randomized to 6 months of habitual lifestyle (CON, n = 18), active commuting by bike (BIKE, n = 35), or leisure-time exercise of moderate intensity (MOD, 50% VO₂peak-reserve, n = 39) or vigorous intensity (VIG, 70% VO₂peak-reserve, n = 38), 5 days/week. Sleep was assessed from 7-day/night accelerometry and questionnaires at baseline, 3 months, and 6 months. 92 participants were included in a per protocol analysis. At 3 months, sleep duration was longer in VIG (29 min/night [3; 55] (mean [95% CI]), p=0.03) but not in BIKE and MOD (p ≥ 0.11) compared with CON and was not different between groups at 6 months (p ≥ 0.36 vs. CON). At 6 months, sleep duration variability was lower in MOD (-31% [-50; -3], p=0.03) and numerically lower in VIG (-28% [-49; 1], p=0.06) relative to CON but was unchanged in BIKE (p=0.17 vs. CON). The effects were, however, primarily attributable to shorter and more irregular sleep in CON over time. Our findings suggest that effects of exercise on sleep in individuals with overweight and obesity may be restricted to leisure-time exercise with a short-term effect on sleep duration after vigorous intensity exercise (3 months) but a more regular sleep pattern after 6 months of moderate and vigorous intensity exercise compared with physically inactive controls. This trial was registered at clinicaltrials.gov with ID NCT01962259.

Prevalence of Sleep Disorders in Adults With Down Syndrome: A Comparative Study of Self-Reported, Actigraphic, and Polysomnographic Findings

STUDY OBJECTIVES

Sleep problems are often undetected in adults with Down syndrome (DS). Our objective was to determine the prevalence of sleep disorders in adults with DS through self-reported and objective sleep measures.

METHODS

We performed a community-based cross-sectional study of 54 adults with DS not referred for sleep disorders. Two polysomnography (PSG) sleep studies were performed. Sleep quality was evaluated using the Pittsburgh Sleep Quality Index (PSQI); daytime sleepiness was evaluated using the Epworth Sleepiness Scale (ESS) and the risk for the sleep apnea syndrome (OSA) was identified using the Berlin Questionnaire (BQ). Participants' sleep/wake pattern was assessed from sleep diaries and by wrist actigraphy. PSQI, ESS, and PSG measures were compared with 35 sex-, age-, and body mass index-matched patients in the control groups.

RESULTS

In PSG measures, adults with DS showed lower sleep efficiency (69 ± 17.7 versus 81.6 ± 11; P < .001), less rapid eye movement sleep (9.4 ± 5.8 versus 19.4 ± 5.1; P < .001), a higher prevalence of OSA (78% versus 14%; P < .001), and a higher apnea-hypopnea index (23.5 ± 24.5 versus 3.8 ± 10.5; P < .001) than patients in the control group. In the DS group, the questionnaires (mean PSQI 3.7 ± 2.9; mean ESS 6.3 ± 4.5 and mean BQ 1 ± 0) did not reflect the sleep disturbances detected on the PSG. Actigraphy data recorded daytime sleep that was not self-reported (118.2 ± 104.2 minutes).

CONCLUSIONS

Adults with DS show severe sleep disruption and a high prevalence of OSA, undetected by self-reported sleep measures. Actigraphy, PSG, and validated simplified devices for screening OSA should be routinely recommended for this population because treatment of sleep disorders can contribute to healthy aging.

Correlation between body mass index and obstructive sleep apnea severity indexes - A retrospective study

PURPOSE

To evaluate if Body Mass Index (BMI) is correlated to Apnea-Hypopnea Index (AHI), mean arterial oxygen saturation (SaO₂) and Nadir SaO₂, which are all indexes defining the severity of the respiratory stress associated with Obstructive Sleep Apnea (OSA).

MATERIALS AND METHODS

Seventy-five adult patients (mean age 51.4) referred for polysomnography were retrospectively recruited. BMI was calculated for each patient, as well as AHI, SaO₂, and Nadir SaO₂ recorded during polysomnography. Spearman's Rho test was used to evaluate if OSA severity was correlated to BMI values. First type error was set as p < 0.025.

RESULTS

No correlation was observed between BMI and AHI, and between BMI and SaO₂. A statistically significant negative correlation (r² = 0.424; p < 0.001) was found between the BMI index and the Nadir SaO₂.

CONCLUSIONS

Higher BMI values were correlated with lower Nadir SaO₂ during overnight polysomnography. Since hypoxia stress is a risk factor for cardiovascular diseases and alters the lipid metabolism, dietary consulting should be recommended in association with other treatment modalities for OSA.

Circadian Impairment of Distal Skin Temperature Rhythm in Patients With Sleep-Disordered Breathing: The Effect of CPAP

Study objectives

Our aim was to evaluate the circadian rhythm of distal skin temperature (DST) in sleep-disordered breathing (SDB), its relation to excessive daytime sleepiness and the effect of continuous positive airway pressure (CPAP) on DST.

Methods

Eighty SDB patients (53.1 ± 1.2 years old, 27.6% women) and 67 healthy participants (52.3 ± 1.6 years old, 26.9% women) wore a temperature data logger for 1 week. On the last day of that week, SDB patients underwent a polysomnography followed by a Maintenance of Wakefulness Test (MWT), Multiple Sleep Latency Test, and Sustained Attention to Response Task protocol to objectively quantify daytime sleepiness. A subset of 21 moderate to severe SDB patients were treated with CPAP during at least 3 months and revaluated with the same procedure. A nonparametric analysis was performed to characterize DST to assess differences between groups and associations among DST, polysomnography, and daytime sleepiness measures.

Results

SDB patients showed an unstable, fragmented, flattened, phase-advanced, and less robust DST rhythm as compared to healthy participants. The more severe the SDB, the worse the DST pattern was, as indicated by the correlation coefficient. Sleepiness, according to MWT sleep latencies, was also associated with the higher fragmentation, lower amplitude, and less robustness of the DST rhythm. Treatment with CPAP improved DST pattern regularity and robustness.

Conclusion

DST is altered in SDB, exhibiting a direct relationship to the severity of this condition, and improves with CPAP treatment. DST independently correlates with sleepiness, thus, its measurement may contribute to the understanding of the pathophysiology of sleepiness in these patients.

Effect of Lifestyle Modification Using a Smartphone Application on Obesity With Obstructive Sleep Apnea: A Short-term, Randomized Controlled Study

Objectives

To investigate the short-term effects of a lifestyle modification intervention based on a mobile application (app) linked to a hospital electronic medical record (EMR) system on weight reduction and obstructive sleep apnea (OSA).

Methods

We prospectively enrolled adults (aged >20 years) with witnessed snoring or sleep apnea from a sleep clinic. The patients were randomized into the app user (n=24) and control (n=23) groups. The mobile app was designed to collect daily lifestyle data by wearing a wrist activity tracker and reporting dietary intake. A summary of the lifestyle data was displayed on the hospital EMR and was reviewed. In the control group, the lifestyle modification was performed as per usual practice. All participants underwent peripheral arterial tonometry (WatchPAT) and body mass index (BMI) measurements at baseline and after 4 weeks of follow-up.

Results

Age and BMI did not differ significantly between the two groups. While we observed a significant decrease in the BMI of both groups, the decrease was greater in the app user group (P <0.001). Apnea-hypopnea index, respiratory distress index, and oxygenation distress index did not change significantly in both groups. However, the proportion of sleep spent snoring at >45 dB was significantly improved in the app user group alone (P =0.014). In either group, among the participants with successful weight reduction, the apnea-hypopnea index was significantly reduced after 4 weeks (P =0.015). Multiple regression analyses showed that a reduction in the apnea-hypopnea index was significantly associated with BMI.

Conclusion

Although a short-term lifestyle modification approach using a mobile app was more effective in achieving weight reduction, improvement in OSA was not so significant. Long-term efficacy of this mobile app should be evaluated in the future studies.

Which place of pharmacological approaches beyond continuous positive airway pressure to treat vascular disease related to obstructive sleep apnea?

Obstructive sleep apnea (OSA) is characterized by recurrent episodes of partial or complete upper airway obstruction, occurring during sleep, leading to chronic intermittent hypoxia (IH), which harms the cardiovascular system. OSA is associated with both functional and structural vascular alterations that contribute to an increased prevalence of fatal and non-fatal cardiovascular events. OSA is a heterogeneous disease with respect to the severity of hypoxia, the presence of daytime symptoms, obesity, and cardiovascular comorbidities. Various clusters of OSA phenotypes have been described leading to more highly personalized treatment. The aim of this review is to describe the various therapeutic strategies including continuous positive airway pressure (CPAP), oral appliances, surgery, weight loss, and especially pharmacological interventions that have been evaluated to reduce vascular alterations in both OSA patients and preclinical animal models. Conventional therapies, predominantly CPAP, have a limited impact on vascular alterations in the presence of co-morbidities. A better knowledge of pharmacological therapies targeting IH-induced vascular alterations will facilitate the use of combined therapies and is crucial for designing clinical trials in well-defined OSA phenotypes.

Improvement in obstructive sleep apnea after a tailored behavioural sleep medicine intervention targeting healthy eating and physical activity: a randomised controlled trial

Purpose

The aim of the present single-centre randomised controlled trial was to assess the effect of a behavioural sleep medicine (BSM) intervention on obstructive sleep apnea (OSA) severity in patients who have been referred for new treatment with continuous positive airway pressure (CPAP).

Methods

After baseline assessment including ventilatory and anthropometric parameters, and physical activity monitoring, 86 patients who were overweight (BMI ≥ 25) and had moderate-severe OSA with apnea-hypopnea index (AHI) ≥ 15 were randomised into a control group (CG; CPAP and advice about weight loss) or an experimental group (ExpG; CPAP and BSM intervention targeting physical activity and eating behaviour). The BSM intervention comprised 10 individual sessions with a dietician and a physiotherapist and included behaviour change techniques such as goal setting and self-monitoring. After 6 months, a new recording of ventilatory parameters was performed without CPAP.

Results

In ExpG, 40% (n = 14) had improved from severe to moderate or mild OSA or from moderate to mild OSA compared to 16.7% in CG (n = 6, p = 0.02). Further, a lower AHI and amount body fat at baseline were correlated with improvement in severity class. Being in ExpG implied a mean improvement in AHI by 9.7 and an odds ratio of 4.5 for improving in severity classification.

Conclusions

The results highlight the clinical importance of lifestyle modifications in conjunction with CPAP treatment in patients with OSA.

Current child, but not maternal, snoring is bi-directionally related to adiposity and cardiometabolic risk markers: A cross-sectional and a prospective cohort analysis

PURPOSE

Obstructive sleep apnea (OSA), typically manifested as snoring, is closely associated with obesity. However, the directionality of associations of OSA with cardiometabolic risk markers is unclear, as obesity increases risk for OSA, and OSA results in excess weight gain and its metabolic consequences. Less is known about how obesity and OSA may relate in children and adolescents and whether maternal OSA may influence the development of obesity and cardiometabolic dysfunction in offspring.

BASIC PROCEDURES

Among 1078 children from the Project Viva cohort, we examined cross-sectionally and prospectively associations of parent-reported child or maternal snoring with cardiometabolic outcomes, including adiposity, adipokines, and insulin resistance.

MAIN FINDINGS

Cross-sectionally, child snoring was related to adiposity and metabolic risk, particularly body mass index (BMI; β 0.61kg/m2, 95% CI 0.33, 0.89; p<0.001), trunk fat mass index (β 0.23kg/m2, CI 0.12, 0.34; p<0.001), high-density lipoprotein cholesterol (β -1.47mg/dL, CI -2.69, -0.25; p=0.02), and metabolic risk z-score (β 0.08, CI 0.02, 0.14; p=0.01) after correction for covariates. Prospectively, adiposity (BMI, trunk fat, fat mass, and waist circumference) and cardiometabolic (leptin, HOMA-IR, CRP, and global metabolic risk) measures at mid-childhood (~7y) were associated with child snoring at the early teen visit (~12y) after correction for covariates. Child snoring at ~9y was related to changes in adiposity between mid-childhood and early teen visits.

CONCLUSIONS

Child but not maternal snoring, was related to child adiposity and cardiometabolic outcomes. Adiposity and child snoring are associated with each other cross-sectionally and are each predictive of the other among children/adolescents prospectively. These results suggest similar mechanisms in pediatric/adolescent populations as in adults for the development of sleep-disordered breathing and sleep apnea that will need to be confirmed in randomized clinical trials. Importantly, this research points to the need to target both sleep and obesity in order to break this vicious cycle.

Nutrition and Exercise Rehabilitation in Obesity hypoventilation syndrome (NERO): a pilot randomised controlled trial

Background

Respiratory management of obesity hypoventilation syndrome (OHS) focusses on the control of sleep-disordered breathing rather than the treatment of obesity. Currently, there are no data from randomised trials of weight loss targeted rehabilitation programmes for patients with OHS.

Intervention

A 3-month multimodal hybrid inpatient–outpatient motivation, exercise and nutrition rehabilitation programme, in addition to non invasive ventilation (NIV), would result in greater per cent weight loss compared with standard care.

Methods

A single-centre pilot randomised controlled trial allocated patients to either standard care or standard care plus rehabilitation. Primary outcome was per cent weight loss at 12 months with secondary exploratory outcomes of weight loss, exercise capacity and health-related quality of life (HRQOL) at the end of the rehabilitation programme to assess the intervention effect.

Results

Thirty-seven patients (11 male, 59.8±12.7 years) with a body mass index of 51.1±7.7 kg/m2 were randomised. At 12 months, there was no between-group difference in per cent weight loss (mean difference −5.9% (95% CI −14.4% to 2.7%; p=0.17)). At 3 months, there was a greater per cent weight loss (mean difference −5% (95% CI −8.3% to −1.4%; p=0.007)), increased exercise capacity (6 min walk test 60 m (95% CI 29.5 to 214.5) vs 20 m (95% CI 11.5 to 81.3); p=0.036) and HRQL (mean difference SF-36 general health score (10 (95% CI 5 to 21.3) vs 0 (95% CI −5 to 10); p=0.02)) in the rehabilitation group.

Conclusion

In patients with OHS, a 3-month comprehensive rehabilitation programme, in addition to NIV, resulted in improved weight loss, exercise capacity and QOL at the end of the rehabilitation period, but these effects were not demonstrated at 12 months, in part, due to the limited retention of patients at 12 months.

Trial registration number

Pre-results; NCT01483716.

Depressive symptom trajectories in the first 10 years of diabetes diagnosis: antecedent factors and link with future disability in Taiwan

PURPOSE

This study identified depressive symptom trajectories in the years after diabetes diagnosis, examined factors that predict the probability for people following a specific trajectory, and investigated how the trajectories are associated with subsequent disability.

METHODS

We drew data from a nationally representative survey in Taiwan to identify adults aged 50 and older diagnosed with diabetes; 487 patients newly diagnosed with diabetes during 1996-2007 were included. Time axis was set to zero when diabetes was first reported in any given wave in the survey, and data related to depressive symptoms after that were recorded. We used group-based semi-parametric mixture models to identify trajectories of depressive symptoms and multinomial logistic regressions to examine factors associated with the trajectories.

RESULTS

Older adults with newly diagnosis of diabetes in Taiwan follow different trajectories of depressive symptoms over time. Being female, lower educated, not married/partnered, with lower self-rated health, hospitalizations, more limitations in physical function, less regular exercise before diagnosis, and not regularly using anti-diabetic medication at the beginning of their diagnosis were factors associated with increasing or high stable depressive symptom trajectories. Those who experienced high depressive symptoms were more likely than individuals with stable depressive symptoms to have physical limitations in the last follow-up interview.

CONCLUSIONS

Depressive symptom trajectories after diabetes diagnosis were associated with select sociodemographic, health, and lifestyle factors before diagnosis, and also predicted subsequent disability. Risk groups identified in the present study may be used for personalized diabetes care that prevents diabetes-related distress and future disability.

Behavioral interventions to promote adequate sleep among women: protocol for a systematic review and meta-analysis

BACKGROUND

Short and poor sleep have been associated with adverse health outcomes in adults, such as overweight/obesity and type 2 diabetes, especially among women. Women therefore represent an important target for interventions aimed at improving sleep and such interventions have been advocated to enhance maternal, fetal, and infant health. This systematic review will assess the efficacy or effectiveness of behavioral interventions aimed at promoting adequate sleep among women. The primary outcomes will be changes in sleep duration and/or sleep quality from baseline to post-intervention and to the last available follow-up measured either through self-reports or objectively. Secondary outcomes will be assessing the behavior change techniques that are responsible for the changes in sleep duration and quality among women.

METHODS

Behavioral interventions that are non-pharmacological and target either sleep directly or sleep hygiene behaviors will be included. Randomized controlled trials, quasi-experimental, and one-group pre-post studies will be included, but treated separately in the analyses, given that a limited number of studies on the topic of sleep is expected. MEDLINE/PubMed, PsycINFO, CINAHL, EMBASE, and Proquest Dissertations and Theses will be investigated. There will be no restriction on the year of publication of the articles, but we will include only the ones written in English or French. Two authors will independently assess articles for eligibility and will extract data using a standardized data extraction form that will have been previously pilot-tested. The quality of the studies will be assessed using the Effective Public Health Practice Project tool for quantitative study designs. The intervention procedures will be classified according to the latest validated taxonomy of behavior change techniques. If there is a sufficient number of studies (k > 5), a meta-analysis of the results will be performed with a random-effect model. If the heterogeneity is high (I 2 ≥ 75%), it will be investigated through sensitivity analyses and meta-regression.

DISCUSSION

This review will provide valuable information to those interested in promoting adequate sleep among women and, hopefully, encourage additional research in this important field to promote maternal, fetal, and infant health.

SYSTEMATIC REVIEW REGISTRATION

The study protocol was registered in PROSPERO in October 2016 (CRD42016049538).

Does personality play a role in continuous positive airway pressure compliance?

Key points

Obstructive sleep apnoea (OSA) is a condition characterised by repetitive, intermittent partial or complete collapse/obstruction of the upper airway during sleep. Continuous positive airway pressure (CPAP) is highly efficacious in treating OSA but its effectiveness is limited due to suboptimal acceptance and adherence rates, with as many as 50% of OSA patients discontinuing CPAP treatment within the first year. Until recently, research has focused on examining mechanistic and demographic factors that could explain nonadherence (e.g. age, sex, race and education level) with limited applicability in a prospective or clinical manner.

More recent research has focused on personality factors or types of patients with OSA who comply and do not comply with CPAP adherence in an attempt to enhance the accuracy of predicting treatment compliance. Type D personality has been found to be prevalent in one third of patients with OSA. The presence of Type D personality increases noncompliance and poor treatment outcomes due to negative affectivity, social inhibition, unhealthy lifestyle, and a reluctance to consult and/or follow medical advice. Conversely, individuals who are more likely to adhere to CPAP treatment tend to have a high internal locus of control and high self-efficacy, self-refer for treatment, and have active coping skills. By assessing personality and coping skills, the clinician may gain insight into the likelihood of a patient’s adherence to treatment. If the patient displays potential risk factors for CPAP noncompliance, the clinician can offer the patient education, refer them to a support group, engage in behavioural/motivational therapy and undertake regular follow-up visits or phone calls incorporating troubleshooting to increase CPAP adherence, especially in individuals with Type D personality.

OSA patients should be assessed for Type D personality to determine likely CPAP compliancehttp://ow.ly/DIbb309cMPH

Surgical Management of Obstructive Sleep Apnea

Surgical management of snoring and obstructive sleep apnea is indicated when a surgically correctable abnormality is believed to be the source of the problem. Many patients opt for surgical treatment after noninvasive forms of treatment have been proven ineffective or difficult to tolerate. With increasing frequency, functional rhinoplasty, septoplasty, turbinoplasty, palatal surgery, and orthognathic surgery are being used in the management of snoring and obstructive sleep apnea. Plastic surgeons' experience with aesthetic nasal surgery, nasal reconstruction, palatal surgery, and craniofacial surgery puts them at the forefront of performing surgery for snoring and sleep apnea. The role of functional septorhinoplasty, turbinoplasty, palatal surgery, genioglossal advancement, and orthognathic surgery is indispensable in the surgical management of obstructive sleep apnea. Multidisciplinary management of these patients is critical, and plastic surgeons are encouraged to work collaboratively with sleep medicine clinicians and centers.

High Adherence to CPAP Treatment Does Not Prevent the Continuation of Weight Gain among Severely Obese OSAS Patients

STUDY OBJECTIVES

Obstructive sleep apnea syndrome (OSAS) patients benefit from continuous positive airway pressure (CPAP) treatment in a dose-response manner. We determined adherence and weight control, as well as their predictors, among long-term CPAP users.

METHODS

Cohort of 1,023 OSAS patients had used CPAP on average of 6.6 ± 1.2 years. BMI was determined at baseline and at follow-up visits. There were 7.4 ± 1.7 BMI and 6.5 ± 1.8 CPAP usage measurements per patient on average. Using the Bayesian hierarchical model, we determined the patients' individual trends of BMI and adherence development. Patients with significantly increasing or decreasing trends were identified at the posterior probability level of > 90%.

RESULTS

The mean age in the cohort was 55.6 ± 9.8 years, BMI 33.5 ± 6.4 kg/m(2), apnea-hypopnea index 33.7 ± 23.1, and CPAP usage 6.0 ± 1.8 h/day. The majority of patients had no significant change in BMI (mean annual weight gain 0.04 ± 0.29 kg/m(2)) or CPAP adherence (mean annual increase 11.4 ± 7.0 min/day). However, at the individual level, 10% of the patients showed significant annual weight gain (0.63 ± 0.35 kg/m(2)) during the 5-year follow-up period. At baseline these patients were already more severely obese (mean BMI 40.0 ± 5.9 kg/m(2)) despite being younger (mean 50.9 ± 9.5 years) than the rest of the cohort.

CONCLUSIONS

In the majority of CPAP-treated OSAS patients, weight did not significantly change but gained slightly slower than in age-matched population in general. However, in 10% of patients, high adherence to CPAP treatment did not prevent the continuation of weight gain. These patients present a high-risk group for OSAS-related multimorbidity later in life.

COST-EFFECTIVENESS OF TREATMENTS FOR MILD-TO-MODERATE OBSTRUCTIVE SLEEP APNEA IN FRANCE

OBJECTIVES

Untreated obstructive sleep apnea-hypopnea syndrome (OSAHS) is associated with excessive daytime sleepiness, increased risk of cardiovascular (CV) disease, and road traffic accidents (RTAs), which impact survival and health-related quality of life. This study, funded by the French National Authority for Health (HAS), aimed to assess the cost-effectiveness of different treatments (i.e., continuous positive airway pressure [CPAP], dental devices, lifestyle advice, and no treatment) in patients with mild-to-moderate OSAHS in France.

METHODS

A Markov model was developed to simulate the progression of two cohorts, stratified by CV risk, over a lifetime horizon. Daytime sleepiness and RTAs were taken into account for all patients while CV events were only considered for patients with high CV risk.

RESULTS

For patients with low CV risk, incremental cost-effectiveness ratio (ICER) of dental devices versus no treatment varied between 32,976 EUR (moderate OSAHS) and 45,579 EUR (mild OSAHS) per quality-adjusted life-year (QALY), and CPAP versus dental devices, above 256,000 EUR/QALY. For patients with high CV risk, CPAP was associated with a gain of 0.62 QALY compared with no treatment, resulting in an ICER of 10,128 EUR/QALY.

CONCLUSION

The analysis suggests that it is efficient to treat all OSAHS patients with high CV risk with CPAP and that dental devices are more efficient than CPAP for mild-to-moderate OSAHS with low CV risk. However, out-of-pocket costs are currently much higher for dental devices than for CPAP (i.e., 3,326 EUR versus 2,430 EUR) as orthodontic treatment is mainly non-refundable in France.

Systematic review of impact of lifestyle-modification programs on metabolic risks and patient-reported outcomes in adults with metabolic syndrome

BACKGROUND

Metabolic syndrome (MetS) is primarily attributed to an unhealthy lifestyle, which is a modifiable risk factor. Researchers have been exploring various strategies, including lifestyle-modification programs (LMPs), to prevent the progression of MetS. However, the effectiveness of LMPs on metabolic risks and patient-reported outcomes (PROs) among adults with MetS remains inconclusive.

AIM

To evaluate the effectiveness of LMPs on the metabolic risks and PROs among adults with MetS.

METHODS

A systematic review of randomized controlled trials published from January 1985 to June 2014 was conducted. The review extracted LMP interventions that included outcomes on the metabolic risks and PROs (quality of life and any other psychological health indicators). The quality of the included studies was assessed using the Cochrane Collaboration criteria.

RESULTS

Among the five trials included, the most commonly applied intervention components were diet plans, supervised exercise, health education, individual counseling, behavioral modification, and motivational interviewing. Three fifths of the studies were nurse-led, and only one of the selected trials was theory-guided. LMPs can effectively reduce triglyceride levels, waist circumference, and systolic blood pressure. However, few trials consistently confirmed the benefits of metabolic risks, and none revealed a significant effect on high-density lipoprotein, fasting blood glucose, or any PRO, except quality of life. The duration of LMPs in the included trials ranged from 4 to 24 weeks, and durations of at least 12 weeks significantly improved quality of life.

LINKING EVIDENCE TO ACTION

LMPs had positive effects on some metabolic risks and on quality of life, whereas longer-duration LMPs may have highly beneficial effects on quality of life. The essential elements of LMPs need to be evaluated more thoroughly to determine their effectiveness. Larger and more rigorous randomized controlled trials are required to assess the effectiveness of LMPs on metabolic risks and PROs among adults with MetS.

Obstructive sleep apnoea syndrome

Obstructive sleep apnoea syndrome (OSAS) is a common clinical condition in which the throat narrows or collapses repeatedly during sleep, causing obstructive sleep apnoea events. The syndrome is particularly prevalent in middle-aged and older adults. The mechanism by which the upper airway collapses is not fully understood but is multifactorial and includes obesity, craniofacial changes, alteration in upper airway muscle function, pharyngeal neuropathy and fluid shift towards the neck. The direct consequences of the collapse are intermittent hypoxia and hypercapnia, recurrent arousals and increase in respiratory efforts, leading to secondary sympathetic activation, oxidative stress and systemic inflammation. Excessive daytime sleepiness is a burden for the majority of patients. OSAS is also associated with cardiovascular co-morbidities, including hypertension, arrhythmias, stroke, coronary heart disease, atherosclerosis and overall increased cardiovascular mortality, as well as metabolic dysfunction. Whether treating sleep apnoea can fully reverse its chronic consequences remains to be established in adequately designed studies. Continuous positive airway pressure (CPAP) is the primary treatment modality in patients with severe OSAS, whereas oral appliances are also widely used in mild to moderate forms. Finally, combining different treatment modalities such as CPAP and weight control is beneficial, but need to be evaluated in randomized controlled trials. For an illustrated summary of this Primer, visit: http://go.nature.com/Lwc6te.