Abdominal fat and sleep apnea: the chicken or the egg?

Classification and identification of risk factors for type 2 diabetes

The risk factors for type 2 diabetes mellitus (T2DM) have been increasingly researched, but the lack of systematic identification and categorization makes it difficult for clinicians to quickly and accurately access and understand all the risk factors, which are categorized in this paper into five categories: Social determinants, lifestyle, checkable/testable risk factors, history of illness and medication, and other factors, which are discussed in a narrative review. Meanwhile, this paper points out the problems of the current research, helps to improve the systematic categorisation and practicality of T2DM risk factors, and provides a professional research basis for clinical practice and industry decision-making.

Exploring the Association Between Triglyceride-Glucose Indices and Their Derivatives With Obstructive Sleep Apnea: Insights From the National Health and Nutrition Examination Survey

Background

Simple and affordable methods for evaluating Insulin Resistance (IR) have been suggested, such as the Triglyceride-Glucose (TyG) index and its variants, including the TyG-Body Mass Index (TyG-BMI), TyG-Waist Circumference (TyG-WC), and TyG-Waist-to-Height Ratio (TyG-WHtR). The aim of this study is to investigate the relationship between these TyG-related indices, which measure IR, and Obstructive Sleep Apnea (OSA).

Methods

This study analyzed NHANES data from 2007-2008, 2015-2016, and 2017-2020. TyG and its derivatives were evaluated as continuous and categorical variables in relation to OSA using multivariable logistic regression models. Subgroup analyses, dose-response relationships, and threshold effects were explored, and the diagnostic performance of TyG-related indices was assessed using AUC curves.

Results

The study included 8,374 participants. The fully adjusted Model 3 analysis (Note: Body Mass Index was not adjusted for TyG-BMI) of continuous variables showed a positive correlation between OSA and all four indices. All four TyG-related indicators showed statistically significant relationships with OSA when grouped into quartiles (TyG: AOR = 1.448, 95% CI: 1.260-1.663; TyG-BMI: AOR = 3.785, 95% CI: 3.319-4.317; TyG-WC: AOR = 2.089, 95% CI: 1.629-2.677; TyG-WHtR: AOR = 1.913, 95% CI: 1.548-2.363). Subgroup analysis revealed a stronger association of TyG-WHtR with OSA in the 41-59 age group (AOR = 1.459, 95% CI: 1.254-1.698) and the low-income group (AOR = 1.451, 95% CI: 1.241-1.698). TyG showed a linear relationship with OSA, while TyG-BMI, TyG-WC, and TyG-WHtR exhibited nonlinear relationships. The diagnostic capability was highest for TyG-WC, with an AUC of 0.647.

Conclusion

The study confirms strong associations between OSA and the TyG indices, particularly TyG-WC, which demonstrates significant predictive power for OSA risk. Future longitudinal studies are recommended to further investigate these associations and enhance OSA management in resource-constrained environments.

Association between weight-adjusted waist index and obstructive sleep apnea among adults in the United States: data from NHANES (2005-2008 and 2015-2018)

OBJECTIVE

We aimed to examine the relationship between the weight-adjusted waist index (WWI) and obstructive sleep apnea (OSA), a condition often caused by obesity, which remains unclear.

METHODS

In this cross-sectional study, we analyzed data from the National Health and Nutrition Examination Survey among adults in the United States (US) aged 20 to 65 years, covering the periods 2005 to 2008 and 2015 to 2018. The study included 8278 participants; we used multivariate logistic regression, restricted cubic splines, and subgroup analyses to explore the relationship between WWI and OSA.

RESULTS

After adjusting for all covariates, each unit increase in WWI was associated with a 30% increase in OSA prevalence (odds ratio = 1.30, 95% confidence interval: 1.20-1.40).

CONCLUSIONS

These findings suggest that WWI, an index reflecting abdominal obesity, can provide important insights into OSA risk assessment. Its strong association with OSA highlights its potential utility in predicting OSA prevalence, particularly among diverse subpopulations. The WWI was associated with a higher prevalence of OSA among US adults and may serve as a valuable tool for risk assessment, early screening, and intervention strategies in clinical practice.

Unraveling the relationship between obstructive sleep apnea and osteoarthritis: A multivariate mendelian randomization highlighting the role of BMI as a confounding factor

BACKGROUND

Osteoarthritis (OA) and obstructive sleep apnea (OSA) are prevalent chronic conditions with emerging evidence suggesting a potential link. However, the causality of this association remains unclear, possibly influenced by confounders like high body mass index (BMI). This study aimed to explore causal relationships between OA and OSA using Mendelian randomization (MR).

METHODS

MR analysis was performed to assess causality between OA and OSA. Inverse variance weighting (IVW) was the primary MR method, complemented by sensitivity analyses, including MR steiger, MR-Egger, MR-PRESSO, weighted median, heterogeneity tests, and leave-one-out approaches to evaluate pleiotropy and confirm the robustness of the causal estimates. To exclude confounding effects of BMI, we also used a multivariate MR (MVMR).

RESULTS

After adjusting for BMI through MVMR, no significant causal relationship was identified between genetically predicted OSA and OA phenotypes, including knee (KOA) and hip osteoarthritis (HOA), suggesting that obesity largely drives the observed relationship between these conditions. Similarly, MR steiger doesn't support a causal effect from OA on OSA. Sensitivity analyses confirmed the robustness of these results, with no significant evidence of horizontal pleiotropy or heterogeneity affecting outcomes. The findings indicate that BMI acts as a critical confounder in the relationship between OSA and OA, rather than OSA directly contributing to OA development.

CONCLUSIONS

Our findings indicate that there is no significant causal relationship between genetically predicted OSA and OA after adjusting for BMI. These findings underscore obesity as the primary shared risk factor, highlighting the importance of weight management as a key strategy for mitigating the risks of both conditions. Future research should aim to validate these findings in diverse populations and explore other metabolic pathways that may contribute to these complex associations.

Patient proximity to follow-up care after bariatric surgery: Does it matter?

One factor that may play a significant role in the follow-up care compliance and long-term weight loss of post-bariatric surgery patients is the geographical distance from the surgery center to the patient's home address. This is a retrospective review which aims to evaluate whether the distance from a patient's home address to two Gundersen Health System (GHS) facilities (La Crosse and Onalaska, Wisconsin) is predictive of follow-up appointment compliance and subsequent long-term weight loss. 1336 patients undergoing bariatric surgery at GHS between October 15, 2013 and Dec 31, 2022 were included. Patients were grouped according to the distance between their home addresses and GHS with 60 ​% of patients living less than 30 miles from GHS, 33 ​% living 30 to 60 miles from GHS, and the remaining 7.3 ​% living >60 miles away. No significant difference was observed in the distribution of patients falling short, meeting, or exceeding the recommended number of post-operative appointments with a surgery provider based on proximity (p ​= ​0.10). As distance increased, the number of nutrition and behavioral health appointments completed per year decreased [nutrition/dietary appointments (p ​= ​0.046); behavioral health appointments (p ​= ​0.040)]. The pattern of percent excess weight loss (%EWL) over time was significantly different based on distance from home (p ​< ​0.001). Specifically, we found a similar %EWL among all groups in the first year post-operatively but an 18.8 ​% higher %EWL in the >60-mile group compared to the <60-mile group at 5 years (SE ​= ​5.4, P ​= ​0.0014). The lower number of post-op nutrition and behavioral health visits among patients living farther from the surgery center was an expected result, given potentially greater inconvenience of follow-up appointments for these patients. However, there was a paradoxical finding of significantly increased %EWL among patients living >60 miles from the surgery center. Greater distance from the bariatric surgical center was therefore not found to represent a barrier to favorable weight loss outcomes.

Long-term mortality risk in obstructive sleep apnea: the critical role of oxygen desaturation index

BACKGROUND

Mortality predictors in obstructive sleep apnea (OSA) patients yet to be comprehensively understood, especially within large cohorts undergoing long-term follow-up. We aimed to determine the independent predictors of mortality in OSA patients.

METHODS

In our retrospective cohort study, 3,541 patients were included and survival data was obtained from electronic medical records. Demographic characteristics, anthropometric measurements, comorbidities, laboratory tests, and polysomnography parameters were analyzed for the survived and deceased patient groups. Univariate and multivariate Cox regression analyses were performed to determine independent predictors of all-cause mortality in patients followed for at least 5 years.

RESULTS

Among all patients, 2,551 (72%) patients were male, with a mean age of 49.7 years. 231 (6.5%) patients had died. Deceased patients were significantly older and had higher waist-to-hip ratio and Epworth Sleepiness Scale (p < 0.001, p < 0.001, p = 0.003). OSA (nonpositional and not-rapid eye movement-related), periodic limb movements in sleep and Comorbidities of Sleep Apnea Score ≥ 1 were found to be associated with increased mortality (p < 0.001). Systemic immune-inflammation index was also significantly higher in the deceased group (p < 0.001). Higher oxygen desaturation index (ODI) and apnea-hypopnea index (AHI) were associated with increased mortality (p < 0.001). Due to the high correlation between ODI and AHI, two separate multivariate Cox regression models were created. While AHI lost its significance in the multivariate analysis, ODI remained significantly higher in the deceased patient group (HR = 1.007, 1.001-1.013, p = 0.01).

CONCLUSION

ODI, as the only polysomnography parameter, emerged as an independent predictor of mortality in OSA patients.

Effect of continuous positive airway pressure on cardiometabolic risk factors in patients with obstructive sleep apnea: A systematic review and meta-analysis

OBJECTIVE

Cardiometabolic risk factors (CMRFs) play a crucial role in the occurrence and development of cardiovascular diseases. Obstructive sleep apnea (OSA) causes abnormalities of CMRFs. Continuous positive airway pressure (CPAP) is a widely used treatment for OSA. This systematic review and meta-analysis aimed to investigate the effect of CPAP on CMRFs in patients with OSA.

METHODS

A search of PubMed, Cochrane Library, Scopus, Web of Science, and Embase was conducted to find randomized controlled trials up to December 3, 2023. The quality of the studies included was evaluated using the Cochrane Bias Risk Tool 2.0, and a meta-analysis was carried out using Stata15.1 software. The effect sizes for this meta-analysis were represented as the weighted mean difference (WMD) and 95 % confidence interval (CI).

RESULTS

A total of 52 studies with 10,104 participants were analyzed. The results showed that CPAP significantly lowered systolic blood pressure (WMD: -2.04 mmHg; 95%CI: -3.56 to -0.51), diastolic blood pressure (WMD: -1.40 mmHg; 95%CI: -2.36 to -0.44), total cholesterol (WMD: -0.27 mmol/L; 95%CI: -0.51 to -0.04), triglycerides (WMD: -0.02 mmol/L; 95%CI: -0.03 to -0.01), and fasting blood glucose (WMD: -0.15 mmol/L; 95%CI: -0.16 to -0.13) in patients with OSA. However, there was no significant change in low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, waist circumference, or body mass index after CPAP.

CONCLUSION

In summary, this meta-analysis demonstrated that CPAP effectively reduced certain CMRFs in patients with OSA, offering new insights for cardiovascular disease prevention.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, identifier CRD42023456380.

The relationship between obstructive sleep apnea and osteoarthritis: evidence from an observational and Mendelian randomization study

Objectives

Obstructive sleep apnea (OSA) and osteoarthritis (OA) are common comorbidities that significantly impact individuals' quality of life. However, the relationship between OSA and OA remains unclear. This study aims to explore the connection between OSA and OA and evaluate causality using Mendelian randomization (MR).

Methods

A total of 12,454 participants from the National Health and Nutrition Examination Survey (2009-2012) were included. OSA participants were identified based on self-reported interviews. The association between OA and OSA was assessed through multivariable logistic regression analysis. A two-sample MR was employed to investigate the relationship between OSA and OA, specifically hip OA and knee OA, utilizing the inverse variance-weighted (IVW) approach.

Results

Based on the observational study, individuals with OSA exhibited a higher risk of OA (OR = 1.67, 95% CI = 1.40-1.98). IVW demonstrated that the risk of OA (OR = 1.13, 95% CI: 1.05-1.21, p = 0.001), hip OA (OR = 1.11, 95% CI: 1.04-1.18, p = 0.002), and knee OA (OR = 1.08, 95% CI: 1.02-1.14, p = 0.005) was significantly associated with OSA. Reverse MR analyses indicated no effect of OA on OSA. Additionally, body mass index (BMI) was found to mediate 36.9% (95% CI, 4.64-73.2%, p = 0.026) of the OSA effects on OA risk.

Conclusion

The cross-sectional observational analysis unveiled noteworthy associations between OSA and OA. Meanwhile, findings from the MR study provide support for a causal role.

Using Apnea-Hypopnea Duration per Hour to Predict Hypoxemia Among Patients with Obstructive Sleep Apnea

Purpose

To explore the role of the mean apnea-hypopnea duration (MAD) and apnea-hypopnea duration per hour (HAD) in hypoxemia and evaluate whether they can effectively predict the occurrence of hypoxemia among adults with OSA.

Patients and Methods

A total of 144 participants underwent basic information gathering and polysomnography (PSG). Logistic regression models were conducted to evaluate the best index in terms of hypoxemia. To construct the prediction model for hypoxemia, we randomly divided the participants into the training set (70%) and the validation set (30%).

Results

The participants with hypoxemia tend to have higher levels of obesity, diabetes, AHI, MAD, and HAD compared with non-hypoxemia. The most relevant indicator of blood oxygen concentration is HAD (r = 0.73) among HAD, MAD, and apnea-hypopnea index (AHI). The fitness of HAD on hypoxemia showed the best. In the stage of establishing the prediction model, the area under the curve (AUC) values of both the training set and the validation set are 0.95. The increased HAD would elevate the risk of hypoxemia [odds ratio (OR): 1.30, 95% confidence interval (CI): 1.13-1.49].

Conclusion

The potential role of HAD in predicting hypoxemia underscores the significance of leveraging comprehensive measures of respiratory disturbances during sleep to enhance the clinical management and prognostication of individuals with sleep-related breathing disorders.

Targeting Hypercapnia in Chronic Lung Disease and Obesity Hypoventilation: Benefits and Challenges

Hypoventilation is a complication that is not uncommon in chronic obstructive pulmonary disease and calls for both medical treatment of the underlying disease and, frequently, noninvasive ventilation either during exacerbations requiring hospitalization or in a chronic state in the patient at home. Obesity hypoventilation syndrome by definition is associated with ventilatory failure and hypercapnia. It may or may not be accompanied by obstructive sleep apnea, which when detected becomes an additional target for positive airway pressure treatment. Intensive research has not completely resolved the best choice of treatment, and the simplest modality, continuous positive airway pressure, may still be entertained.

Update on the epidemiology of obstructive sleep apnea syndrome in Central Eastern Tunisia over 11 years

Introduction

obstructive sleep apnea syndrome (OSAS) is the most common sleep-related breathing disorder. Knowledge about OSAS incidence trends could be extremely useful in assessing health needs and implementing preventive measures accordingly. This study aimed at the epidemiological and clinical specificities of OSAS and to give an update on its current chronological trends.

Methods

we conducted a retrospective study including all cases of OSAS diagnosed over 11 years, from January 1, 2012, to December 31, 2022, at the Sleep Unit of the Neurophysiology Department of the Sahloul University Hospital, Tunisia.

Results

overall, 848 new cases of OSAS were diagnosed. The mean annual number of OSAS cases was 74.8/year. The crude incidence rate (CIR) was 12.3/100000 inhabitants/year, it was significantly increasing over the years (rho=0.7; p=0.01). The median age was 56 (IQR= [48-64]) years, it increased significantly during the study period from 54 years (IQR= [43-63]) in 2012 to 58 years (IQR= [50.5-65]) in 2022 (rho=0.7; p=0.015). The median BMI was 35.5 (IQR= [31.3-40.3]) kg/m2. The median BMI of patients diagnosed with OSAS increased significantly from 34.6 kg/m2 to 38.3 kg/m2 (rho=0.75; p=0.008). This equated to an annual increase in median BMI of 0.41 kg/m2. The median AHI showed a significant upward trend for all patients, rising from 26.30 events/h in 2012 to 34.07 events/h in 2022 (rho=0.68; p=0.02).

Conclusion

the CIR of OSAS is related to BMI and age. Thus, we assume that it will continue to increase in the coming years with the rise in obesity and the aging of the population.

Comorbidity of patients with noncommunicable diseases in general practice. Eurasian guidelines

Создание руководства поддержано Советом по терапевтическим наукам отделения клинической медицины Российской академии наук.

Effect of different anti-cardiovascular disease treatments on the severity of obstructive sleep apnea

Obstructive sleep apnea (OSA) and cardiovascular co-morbidities have a mutually reinforcing effect, but existing studies have focussed only on the improvement of the associated co-morbidities by treatment for OSA. To provide fresh guidelines for the treatment of OSA from a co-morbidity standpoint, we conducted a systematic search of Web of Science, PubMed, EMBASE, and the Cochrane Library for articles published from inception up to 2 May 2023. Fourteen original studies of patients with OSA with cardiovascular co-morbidities and who received related treatment were included in the analysis. We found that diuretic treatment can reduce the apnea-hypopnea index in patients with OSA and hypertension (-19.41/h, p = 1.0 × 10-5 ), aldosterone-angiotensin inhibitors also have a 9.19/h reduction (p = 0.003), while the effect of renal sympathetic denervation is insignificant (-2.32/h, p = 0.19). The short-term treatment (<4 weeks) did not show an improvement (-2.72/h, p = 0.16), while long-term treatment (>4 weeks) produced surprising outcomes (-12.78/h, p = 0.002). Patients with milder disease (baseline AHI < 35/h) had insignificant improvements (-1.05/h, p = 0.46), whereas those with more severe disease (baseline AHI > 35/h) could achieve satisfactory outcomes (-14.74/h, p < 0.00001). In addition, it also showed some improvement in the oxygen desaturation index and blood oxygen. Our results support the additional benefit of antihypertensive treatment for OSA symptoms, and the efficacy can be affected by different therapy, treatment duration, and severity levels. It could be useful in developing clinical therapy, educating patients, and exploring interaction mechanisms. The proposal was registered with PROSPERO (CRD42022351206).

Risk of Sleep Apnea Is Associated with Abdominal Obesity Among Asian Americans: Comparing Waist-to-Hip Ratio and Body Mass Index

OBJECTIVE

This study examines associations between the risk of sleep apnea and abdominal obesity (assessed by waist-to-hip ratio (WHR)) and general obesity (assessed by body mass index (BMI)) in a sample of Chinese and Korean American immigrants.

METHODS

The dataset included Chinese and Korean participants aged 50-75 who were recruited from primary care physicians' clinics from April 2018 to June 2020 in the Baltimore-Washington D.C. Metropolitan area (n = 394). Abdominal obesity was determined if WHR ≥ 0.9 in men and WHR ≥ 0.85 in women. General obesity was determined if BMI ≥ 30. The risk of sleep apnea was determined by using the Berlin questionnaire. Poisson regression models examined associations between sleep apnea risk and obesity. Models controlled for socio-demographic risk factors.

RESULTS

Twelve percent of the study participants were classified as a high risk for sleep apnea, and 75% had abdominal obesity whereas 6.4% had general obesity. High risk of sleep apnea was positively associated with abdominal obesity (PR = 1.31, 95% CI: 1.17-1.47) and general obesity (PR = 2.19, 95% CI: 0.90-5.32), marginally significant at p < 0.1).

CONCLUSIONS

Chinese and Korean immigrants living in the USA who are at high risk of sleep apnea have higher abdominal obesity, even after accounting for sociodemographic characteristics. Abdominal obesity may be a better indicator than general obesity when examining the risk of sleep apnea among Asian Americans.

INFORMATION ON CLINICAL TRIAL

Name: Screening To Prevent ColoRectal Cancer (STOP CRC) among At-Risk Asian American Primary Care Patients NCT Number: NCT03481296; Date of registration: March 29, 2018 URL: https://clinicaltrials.gov/ct2/show/NCT03481296?term=Sunmin+Lee&draw=2&rank=1.

The Effects of Adenotonsillectomy for Obstructive Sleep Apnea on Growth Trajectory in Children With Obesity

OBJECTIVE

To analyze the growth trajectory of children with obesity before and after adenotonsillectomy (T&A). We hypothesize that T&A will not affect the growth trajectory but children in a multidisciplinary weight management program (MWMP) will have a healthier growth trajectory.

STUDY DESIGN

Retrospective review.

SETTING

Tertiary Children's Hospital.

METHODS

Body mass index (BMI) trajectories of nonsyndromic children with obesity and obstructive sleep apnea (OSA) who underwent T&A were analyzed. A linear mixed effects model was fit to the BMI expressed as a percentage of the 95th percentile (%BMIp95 ) data. Covariates included demographic variables, pre- and postoperative participation in an MWMP, baseline obesity class, and time. We explored clinically meaningful interactions. BMI slope estimates before and after surgery were calculated and compared for baseline obesity classification and postoperative MWMP visits.

RESULTS

A total of 177 patients, 58% male with a mean age of 9.7 years at the time of surgery, were studied. Higher baseline obesity class (II and III), time, the interaction between obesity class III and elapsed time relative to surgical date, and the interaction between obesity class III and the postsurgical period were all significantly associated with the outcome of %BMIp95 (P < .05). There was a significantly higher %BMIp95 trajectory following surgery in patients with baseline obesity class III who did not have any postoperative MWMP visits (P < .001). Preoperative obesity visits, however, were not significantly associated with postoperative growth.

CONCLUSION

The association between T&A and weight trajectory depends upon obesity class and participation in a MWMP. Coordinated care of children with obesity between otolaryngologists and an MWMP may improve OSA and obesity outcomes.

LEVEL OF EVIDENCE

The level of evidence: 3.

Association between Tonsillectomy and Cardiovascular Diseases in Adults

This study aimed to evaluate the association between tonsillectomy and cardiovascular diseases (CVDs) in the Korean adult population. Using data from the 2002-2015 Korean National Health Insurance Service-Health Screening Cohort, a total of 1082 participants aged 40 years or older who had undergone tonsillectomy were matched with 4328 control individuals for age, sex, income, and region of residence. We evaluated the incidence of CVDs in both the tonsillectomy and control groups and calculated the hazard ratios (HRs) of stroke, ischemic heart disease (IHD), and heart failure (HF) for participants who underwent tonsillectomy using a stratified Cox proportional hazard model. The incidence rates of stroke (81.3 vs. 46.6 per 10,000 person-years) and IHD (112.3 vs. 64.9 per 10,000 person-years) were significantly higher in patients who had undergone tonsillectomy than in the control group. After adjustment, the tonsillectomy group exhibited a 1.78-fold and 1.60-fold higher occurrence of stroke (CI = 1.32-2.42, p < 0.001) and IHD (CI = 1.24-2.08, p < 0.001), respectively, compared to the control group. However, there was no significant difference in the incidence rate of tonsillectomy and control groups (11.1 vs. 6.1 per 10,000 person-years). The HR of HF did not differ significantly between the tonsillectomy and control groups in the adjusted model (p = 0.513). We identified a significant relationship between a history of tonsillectomy and occurrence of stroke/IHD in the Korean adult population.

Insights into the Use of Point-of-Care Ultrasound for Diagnosing Obstructive Sleep Apnea

Obstructive sleep apnea (OSA) is a sleeping disorder caused by complete or partial disturbance of breathing during the night. Existing screening methods include questionnaire-based evaluations which are time-consuming, vary in specificity, and are not globally adopted. Point-of-care ultrasound (PoCUS), on the other hand, is a painless, inexpensive, portable, and useful tool that has already been introduced for the evaluation of upper airways by anesthetists. PoCUS could also serve as a potential screening tool for the diagnosis of OSA by measuring different airway parameters, including retropalatal pharynx transverse diameter, tongue base thickness, distance between lingual arteries, lateral parapharyngeal wall thickness, palatine tonsil volume, and some non-airway parameters like carotid intima-media thickness, mesenteric fat thickness, and diaphragm characteristics. This study reviewed previously reported studies to highlight the importance of PoCUS as a potential screening tool for OSA.

International Consensus Statement on Obstructive Sleep Apnea

BACKGROUND

Evaluation and interpretation of the literature on obstructive sleep apnea (OSA) allows for consolidation and determination of the key factors important for clinical management of the adult OSA patient. Toward this goal, an international collaborative of multidisciplinary experts in sleep apnea evaluation and treatment have produced the International Consensus statement on Obstructive Sleep Apnea (ICS:OSA).

METHODS

Using previously defined methodology, focal topics in OSA were assigned as literature review (LR), evidence-based review (EBR), or evidence-based review with recommendations (EBR-R) formats. Each topic incorporated the available and relevant evidence which was summarized and graded on study quality. Each topic and section underwent iterative review and the ICS:OSA was created and reviewed by all authors for consensus.

RESULTS

The ICS:OSA addresses OSA syndrome definitions, pathophysiology, epidemiology, risk factors for disease, screening methods, diagnostic testing types, multiple treatment modalities, and effects of OSA treatment on multiple OSA-associated comorbidities. Specific focus on outcomes with positive airway pressure (PAP) and surgical treatments were evaluated.

CONCLUSION

This review of the literature consolidates the available knowledge and identifies the limitations of the current evidence on OSA. This effort aims to create a resource for OSA evidence-based practice and identify future research needs. Knowledge gaps and research opportunities include improving the metrics of OSA disease, determining the optimal OSA screening paradigms, developing strategies for PAP adherence and longitudinal care, enhancing selection of PAP alternatives and surgery, understanding health risk outcomes, and translating evidence into individualized approaches to therapy.

Relationship Between Hyperuricemia-Waist Phenotype and Obstructive Sleep Apnea in Type 2 Diabetes Mellitus

Objective

This study aimed to propose the hyperuricemia-waist (HUAW) phenotype and investigate the relationship between the HUAW phenotype and obstructive sleep apnea (OSA) in type 2 diabetes mellitus (T2DM).

Methods

We enrolled 255 patients with T2DM (165 male and 90 female) from the First Hospital of Qinhuangdao. The sleep test was performed, and serum uric acid (UA) levels and waist circumference (WC) were calculated. The HUAW phenotype was defined as serum UA concentrations ≥420 μmol/L and WC ≥90 cm (male) and ≥85 cm (female). The participants were categorized into four phenotype groups based on the mentioned cutoffs: normal WC and normal UA concentrations (group A); normal WC and elevated UA concentrations (group B); enlarged WC and normal UA concentrations (group C); and enlarged WC and elevated UA concentrations (group D). Among these participants, 17.6% were characterized by the HUAW phenotype, 80.0% had OSA, and 47.0% had moderate-to-severe OSA. The prevalence of OSA was 43.4%, 71.4%, 89.7%, and 97.8% in groups A, B, C, and D, respectively. The prevalence of moderate-to-severe OSA was 7.5%, 28.6%, 56.9%, and 72.7% in groups A, B, C, and D, respectively. After adjusting for age, sex, duration of diabetes, glycosylated hemoglobin A1c, smoking, and drinking, the HUAW phenotype was found to be significantly associated with OSA and moderate-to-severe OSA.

Conclusion

The present study proposed the HUAW phenotype and demonstrated that in T2DM, the HUAW phenotype was associated with OSA, especially with moderate-to-severe OSA. Unlike T2DM without the HUAW phenotype, T2DM with the HUAW phenotype showed a significantly higher prevalence of OSA, especially moderate-to-severe OSA. Thus, early sleep studies should be routinely examined in individuals with T2DM who display the HUAW phenotype.

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

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

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.

Prognostic Implications of OSA in Acute Coronary Syndrome by Obesity Status

BACKGROUND

A close relationship exists between OSA and obesity. The impact of obesity on the prognostic significance of OSA in patients with acute coronary syndrome (ACS) remains unclear.

RESEARCH QUESTION

Do the effects of OSA on subsequent cardiovascular events in patients with ACS vary with obesity status?

STUDY DESIGN AND METHODS

This is a prospective cohort study. Patients 18 to 85 years of age and hospitalized for ACS were consecutively enrolled and underwent portable sleep monitoring after clinical stabilization. OSA was defined as an apnea hypopnea index ≥ 15 events/h. The primary end point was major adverse cardiovascular and cerebrovascular event (MACCE), including cardiovascular death, hospitalization for ACS, stroke, ischemia-driven revascularization, or hospitalization for heart failure.

RESULTS

Among 1,920 patients enrolled (84.5% men; mean age ± SD, 56.4 ± 10.5 years), 1,013 (52.8%) had OSA, and 718 (37.4%) were obese (BMI ≥ 28 kg/m²). During 2.9 years (1.5, 3.6) follow up, the incidence of MACCE was significantly higher in patients with obesity than in patients without obesity (hazard ratio [HR], 1.29; 95% CI, 1.06-1.58; P = .013). Although the prevalence of OSA was lower in patients without obesity than in those with obesity (43.9% vs 67.5%, P < .001), OSA independently predicted the incidence of MACCE only in patients without obesity (adjusted HR, 1.34; 95% CI, 1.03-1.75; P = .03), but not in patients with obesity (adjusted HR, 1.10; 95% CI, 0.78-1.55; P = .58). No significant interaction between obesity and OSA was noted (P for interaction = .35). The incremental risk associated with OSA in patients without obesity might be explained by more hospitalization for ACS and ischemia-driven revascularization.

INTERPRETATION

For patients with ACS, OSA was independently associated with an increased risk of subsequent events, particularly among patients without obesity. These findings highlight the importance of identifying OSA in nonobese patients with ACS.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov; No.: NCT03362385; URL: www.

CLINICALTRIALS

gov.

Duration of respiratory events in obstructive sleep apnea: Factors influencing the duration of respiratory events

Several factors influence respiratory event duration during sleep. In general, women have shorter respiratory events compared to men as it appears that women have a more reactive upper airway contributing to the occurrence of short events. In addition, the increased amount of adipose tissue in the upper airways should make the reopening of the upper airways more difficult, leading to long respiratory events. Nevertheless, an increase in body mass index decreases the median duration of apneas, hypopneas, and desaturations in all OSA severity categories. Also, respiratory events are longer in older adults compared to younger ones, and the most likely mechanism explaining this phenomenon appears to be the increased circulatory delay associated with aging. Several studies have also shown that apnea events are longer in rapid eye movement sleep compared to non-rapid eye movement sleep. The main mechanism behind these differences appears to be the greater pharyngeal muscle relaxation during rapid eye movement sleep. Finally, sleeping position affects the duration of respiratory events; apneas and hypopneas are longer in the supine compared to lateral postures regardless of the severity of OSA. In the present report, we discuss the best-known factors influencing the duration of abnormal breathing events during sleep.

Alterations of cholesterol synthesis and absorption in obstructive sleep apnea: Influence of obesity and disease severity

BACKGROUND AND AIMS

Obstructive sleep apnea (OSA) is closely linked to obesity and related adverse metabolic changes, including dyslipidemia. However, it is not clear whether OSA is an independent contributing factor to dyslipidemia, or the observed association is a reflection of a concomitant presence of obesity. Additionally, dyslipidemia is usually evaluated through measurement of parameters of routine lipid status, while more precise evaluation of lipid homeostasis is rarely performed in OSA. In this study, we analyzed markers of cholesterol synthesis and absorption in patients with OSA with respect to the presence of obesity and the disease severity.

METHODS AND RESULTS

This study enrolled 116 OSA patients. Concentrations of non-cholesterol sterols (NCS), measured by LC-MS/MS, were used as markers of cholesterol synthesis and absorption. Apnea-hypopnea index (AHI) and oxygen saturation (SaO₂) were utilized as markers of OSA severity. Serum lipid status parameters were determined by routine enzymatic methods. Markers of cholesterol synthesis were increased (P = 0.005), whilst markers of cholesterol absorption decreased (P = 0.001) in obese OSA patients. Cholesterol synthesis/absorption ratio was elevated in obese subjects (P < 0.001). Concentration of cholesterol synthesis marker lathosterol was significantly higher in subjects with severe OSA (P = 0.014) and we observed a trend of decreased cholesterol absorption in these patients. AHI was revealed as an independent determinant of lathosterol concentration (P = 0.022).

CONCLUSIONS

Our results suggest that the presence of obesity and severe forms of OSA is characterized by elevated endogenous cholesterol synthesis. AHI was singled out as an independent determinant of the serum level of cholesterol synthesis marker lathosterol.

Gender-specific factors contributing to visceral obesity including the sleep-obesity relationship: a large-scale cross-sectional study from East Asia

Our study aimed to evaluate the relationship between visceral obesity and its associated factors, especially sleep duration in East Asia. We conducted univariate and multivariate analyses using the data of 2538 participants (mean age 56.4 ± 10.8 years) who underwent medical checkups and computed tomography of the abdomen to calculate the visceral fat area from 2008 to 2020. We additionally performed logistic regression analyses using each sleep-duration group (< 5, 5-6, 6-7, 7-8, and ≥ 8 h) and their respective propensity scores as covariates. According to the criteria of visceral obesity(a visceral fat area ≥ 100 cm²), 1147 of 1918 men (59.8%) and 131 of 620 women (21.1%) had visceral obesity. In multivariate analyses, visceral obesity was significantly associated with age, body mass index and triglyceride in both genders, high-density lipoproteins, uric acid levels, and daily alcohol consumption in men; and glycated hemoglobin (HbA1c) in women. In both multivariate and propensity score matching analyses, sleep duration of > 8 h and visceral obestiy showed a positive association in men but a negative association in women with statistical significance. In conclusion, our large-scale cross-sectional study in East Asia identified various gender-specific factors associated with visceral obesity including the long sleep duration.

The influence of nocturnal use of complete dentures on cardiorespiratory parameters of patients with obstructive sleep apnea: a systematic review and meta-analysis

OBJECTIVE

To assess whether wearing complete dentures during sleep influences the cardiorespiratory parameters of patients with obstructive sleep apnea (OSA).

MATERIALS AND METHODS

A systematic review was performed based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to determine whether wearing complete dentures during sleep influences the cardiorespiratory parameters of patients with OSA. An electronic search was performed in four databases, PubMed/MEDLINE, Cochrane Library, Web of Science, and SCOPUS, and in the gray literature (TRIALS) until November 2021. This review included clinical trials, randomized clinical trials, and studies in which patients using conventional complete dentures were diagnosed with OSA using polysomnography and the cardiorespiratory parameters were measured using oximetry or polysomnography during sleep.

RESULTS

In total, 788 references were found in the database, and 12 articles were selected for full reading. Six articles were selected for qualitative and quantitative analyses after applying the inclusion and exclusion criteria and reading the full article. The meta-analysis showed that mean oxygen saturation (SpO₂) increased with the use of complete dentures (p = 0.001), but the other parameters showed no significant differences between those wearing and not wearing dentures during sleep.

CONCLUSIONS

The mean SpO₂ reduced in patients wearing complete dentures, but the other cardiorespiratory parameters evaluated were not affected.

CLINICAL RELEVANCE

This study indicates a possible influence of the use of complete dentures on the mean SpO₂ during sleep. The use of complete denture could aid other treatments in improving respiratory and sleep quality.

Can Weight Loss Improve the Cardiovascular Outcomes of Patients with Obesity and Obstructive Sleep Apnea?

Cardiovascular events are the primary cause of mortality in patients with obstructive sleep apnea and obesity. The rising prevalence of obstructive sleep apnea in recent decades has been linked to increasing rates of obesity. Obstructive sleep apnea has also been linked with many different cardiovascular diseases including coronary artery disease, stroke, heart failure, hypertension, and atrial fibrillation. Obesity is an increasing health concern globally, in part because obesity complications such as hypertension, diabetes, and obstructive sleep apnea increase the risk of cardiovascular diseases. More than 10% weight loss may be required to prevent or reverse obesity complications. Treatment approaches to obesity include nutritional therapy, exercise therapy, pharmacotherapy, and surgical therapies. This review intends to identify the effects of weight loss on cardiovascular outcomes in patients with obesity and obstructive sleep apnea. Despite the strong association between cardiovascular diseases and obstructive sleep apnea, randomized trials have failed to demonstrate that treatment of obstructive sleep apnea reduces cardiovascular events, even in patients with established cardiovascular diseases. Weight loss in patients with obstructive sleep apnea improves HbA1c, systolic blood pressure, HDL cholesterol, and triglycerides, but thus far no changes in cardiovascular events have been shown. The combination of weight loss with continuous positive airway pressure (CPAP) appears more beneficial than either treatment in isolation. Large well-controlled trials in patients with obstructive sleep apnea to assess the effects of different weight reduction programs on cardiovascular disease are still needed.

OBSTRUCTIVE SLEEP APNEA SYNDROME RISK IN PATIENTS WITH NON-ALCOHOLIC FATTY LIVER DISEASE IS ASSOCIATED WITH OBESITY AND PRESENCE OF NASH

BACKGROUND

Non-alcoholic fatty liver disease (NAFLD) is the most common form of liver disease and refers to a wide spectrum of histological abnormalities ranging from simple steatosis (HE) to non-alcoholic steatohepatitis (NASH), fibrosis, cirrhosis and hepatocellular carcinoma.

OBJECTIVE

To assess the risk of obstructive sleep apnea syndrome (OSAS) and relating it to demographic, biochemical and histological data in patients with non-alcoholic fatty liver disease.

METHODS

Cross-sectional cohort study in individuals with biopsy-proven NAFLD. Anthropometric and biochemical parameters, presence of metabolic syndrome and insulin resistance were evaluated. The Berlin Questionnaire (BQ) was applied to assess the risk of apnea and a food record was requested. Based on the BQ, participants were classified as high or low risk for OSAS. In the correlation of sleep apnea with the severity of NAFLD, presence of nonalcoholic steatohepatitis (NASH) and the degree of liver fibrosis were evaluated. Statistical analysis used the chi-square test, Student's t and bivariate logistic regression; values were expressed as mean ± standard deviation. This research project was approved by the Ethics Committee.

RESULTS

Regarding the parameters evaluated, significant differences were observed between the groups in terms of body mass index (BMI), waist and neck circumference. In the histological evaluation, patients classified as high risk were more likely to have fibrosis and NASH. In bivariate regression, the BMI, presence of fibrosis and steatohepatitis in the biopsy were independently associated with an elevated risk of the syndrome.

CONCLUSION

A high prevalence of risk for OSAS was observed in the studied group, with a higher risk being independently associated with BMI and presence of steatohepatitis, suggesting that it is a factor associated with the severity of the disease.

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

STUDY OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Obesity, Sex, Snoring and Severity of OSA in a First Nation Community in Saskatchewan, Canada

Sleep disorders have been related to body weight, social conditions, and a number of comorbidities. These include high blood pressure and type 2 diabetes, both of which are prevalent in the First Nations communities. We explored relationships between obstructive sleep apnea (OSA) and risk factors including social, environmental, and individual circumstances. An interviewer-administered survey was conducted with adult participants in 2018−2019 in a First Nations community in Saskatchewan, Canada. The survey collected information on demographic variables, individual and contextual determinants of sleep health, and objective clinical measurements. The presence of OSA was defined as an apnea−hypopnea index (AHI) ≥5. Multiple ordinal logistic regression analysis was conducted to examine relationships between the severity of OSA and potential risk factors. In addition to the survey, 233 men and women participated in a Level 3 one-night home sleep test. Of those, 105 (45.1%) participants were reported to have obstructive sleep apnea (AHI ≥ 5). Mild and moderately severe OSA (AHI ≥ 5 to <30) was present in 39.9% and severe OSA (AHI ≥ 30) was identified in 5.2% of participants. Being male, being obese, and snoring loudly were significantly associated with severity of OSA. The severity of OSA in one First Nation appears relatively common and may be related to mainly individual factors such as loud snoring, obesity, and sex.

Prediction of Moderate to Severe Obstructive Sleep Apnea Using Neck Computed Tomography With Computational Fluid Dynamics Study

BACKGROUND

Moderate to severe obstructive sleep apnea (OSA) is associated with cardiovascular disease. Polysomnography is time intensive and difficult to access for diagnosis of OSA. Neck computed tomography (CT) provides upper airway delineation but not diagnostic criteria for moderate to severe OSA. We explored neck CT with computational fluid dynamics (CFD) study for airway pressure and airflow velocity to predict moderate to severe OSA.

METHODS

Enrolled from February 1, 2020, to June 30, 2021, patients with OSA with overnight oxygen desaturation (sPO2 <90%) received awake neck CT with a CFD study of their airway pressure and airflow velocity. CTL12 and CTL34 were defined as airflow velocity <3 and ≥3 m/s, respectively, and airway pressure <10 and ≥10 pa, respectively, in the narrowest upper airway.

RESULTS

Sixty-two patients (42 male and 20 female; mean age: 50.4 ± 14.6 years) were included; 12 and 50 patients had mild OSA and moderate to severe OSA, respectively. The minimum sPO2 in the supine position was 80.7 ± 9.1%. The total time of sPO2 <90% at overnight oximetry was 29.3 ± 51.1 min. Most (85.5%) neck CT examinations with CFD study presented CTL34. Patients with CTL34 had a lower minimum sPO2 in the supine position (78.4 vs. 88.1%, P = 0.004) and longer duration of sPO2 <90% at overnight oximetry (33.9 vs. 1.9 min, P = 0.001) than those with CTL12. The values of the area under the receiver operating characteristic curves of airway pressure and of airflow velocity at the narrowest upper airway were 0.788 and 0.733, respectively.

CONCLUSION

Neck CT with CFD study of airway pressure and airflow velocity may provide a quick prediction of moderate to severe OSA.

Airway morphology and its influence on OSA severity and surgical intervention: a retrospective study

Introduction: The aim was to assess the relationship between airway morphology and surgical intervention in a cohort of patients presenting with increased body mass index (BMI) and a confirmed diagnosis of obstructive sleep apnoea (OSA). A secondary aim was to revisit the relationship between morphology and OSA severity.

Methods: A retrospective analysis was conducted of pre-operative maxillofacial 3D-CT scans of thirty-two patients with a confirmed diagnosis of OSA who received treatment from an ear nose and throat specialist (ENT). Lateral cephalograms were imported into Quick Ceph Studio (Quick Ceph Systems Inc, San Diego, CA, USA) after which linear and angular measurements of selected hard and soft tissues were obtained. 3D-CT images were loaded into the software program 3dMDVultus (3dMD) which permitted 3D visualisation of the airway. Measurements were repeated 3 times on the images of six patients after an interval of two weeks to establish the intraclass correlation coefficient (ICC) for intra-examiner accuracy and reliability. Logistic regression was applied to determine the relationships between morphology, OSA and surgical treatments.

Results: A positive correlation was found between age and the apnoea-hypopnea index (AHI). Morphological measurements of the airway did not exhibit a positive relationship with OSA severity. Posterior airway space at the level of the uvula and tongue, the length of the soft palate and position of the hyoid bone were significantly associated with BMI. No variables were found to be correlated with uvulopalatopharyngoplasty (UPPP) surgery. Notwithstanding, airway length and posterior airway space at the level of the uvula tip were significantly associated with tongue channelling.

Conclusions: Radiographic airway assessment is an invaluable and opportunistic tool for screening OSA but requires judicial use in its prescription and interpretation. There is little correlation between OSA severity and airway morphology and between surgical intervention and morphology. Additional factors need to be considered before a treatment modality is considered and is best managed in a multidisciplinary setting.

Gender Differences in the Context of Obstructive Sleep Apnea and Metabolic Diseases

The relationship between obstructive sleep apnea (OSA) and endocrine and metabolic disease is unequivocal. OSA, which is characterized by intermittent hypoxia and sleep fragmentation, leads to and exacerbates obesity, metabolic syndrome, and type 2 diabetes (T2D) as well as endocrine disturbances, such as hypothyroidism and Cushing syndrome, among others. However, this relationship is bidirectional with endocrine and metabolic diseases being considered major risk factors for the development of OSA. For example, polycystic ovary syndrome (PCOS), one of the most common endocrine disorders in women of reproductive age, is significantly associated with OSA in adult patients. Several factors have been postulated to contribute to or be critical in the genesis of dysmetabolic states in OSA including the increase in sympathetic activation, the deregulation of the hypothalamus-pituitary axis, the generation of reactive oxygen species (ROS), insulin resistance, alteration in adipokines levels, and inflammation of the adipose tissue. However, probably the alterations in the hypothalamus-pituitary axis and the altered secretion of hormones from the peripheral endocrine glands could play a major role in the gender differences in the link between OSA-dysmetabolism. In fact, normal sleep is also different between men and women due to the physiologic differences between genders, with sex hormones such as progesterone, androgens, and estrogens, being also connected with breathing pathologies. Moreover, it is very well known that OSA is more prevalent among men than women, however the prevalence in women increases after menopause. At the same time, the step-rise in obesity and its comorbidities goes along with mounting evidence of clinically important sex and gender differences. Metabolic and cardiovascular diseases, seen as a men's illness for decades, presently are more common in women than in men and obesity has a higher association with insulin-resistance-related risk factors in women than in men. In this way, in the present manuscript, we will review the major findings on the overall mechanisms that connect OSA and dysmetabolism giving special attention to the specific regulation of this relationship in each gender. We will also detail the gender-specific effects of hormone replacement therapies on metabolic control and sleep apnea.

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

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

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

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

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

Clinical Trial registration: DRKS00010498

Machine learning approaches for screening the risk of obstructive sleep apnea in the Taiwan population based on body profile

(a) Objective: Obstructive sleep apnea syndrome (OSAS) is typically diagnosed through polysomnography (PSG). However, PSG incurs high medical costs. This study developed new models for screening the risk of moderate-to-severe OSAS (apnea-hypopnea index, AHI ≥15) and severe OSAS (AHI ≥30) in various age groups and sexes by using anthropometric features in the Taiwan population.(b) Participants: Data were derived from 10,391 northern Taiwan patients who underwent PSG.(c) Methods: Patients' characteristics - namely age, sex, body mass index (BMI), neck circumference, and waist circumference - was obtained. To develop an age- and sex-independent model, various approaches - namely logistic regression, k-nearest neighbor, naive Bayes, random forest (RF), and support vector machine - were trained for four groups based on sex and age (men or women; aged <50 or ≥50 years). Dataset was separated independently (training:70%; validation: 10%; testing: 20%) and Cross-validated grid search was applied for model optimization. Models demonstrating the highest overall accuracy in validation outcomes for the four groups were used to predict the testing dataset.(d) Results: The RF models showed the highest overall accuracy. BMI was the most influential parameter in both types of OSAS severity screening models.(e) Conclusion: The established models can be applied to screen OSAS risk in the Taiwan population and those with similar craniofacial features.

Circadian Clocks, Sleep, and Metabolism

A molecular circadian clock exists not only in the brain, but also in most cells of the body. Research over the past two decades has demonstrated that it directs daily rhythmicity of nearly every aspect of metabolism. It also consolidates sleep-wake behavior each day into an activity/feeding period and a sleep/fasting period. Otherwise, sleep-wake states are mostly controlled by hypothalamic and thalamic regulatory circuits in the brain that direct overall brain state. Recent evidence suggests that hypothalamic control of appetite and metabolism may be concomitant with sleep-wake regulation, and even share the same control centers. Thus, circadian control of metabolic pathways might be overlaid by sleep-wake control of the same pathways, providing a flexible and redundant system to modify metabolism according to both activity and environment.

A Fuzzy Neural Network Model for Rapid Prediction of Optimal Positive Airway Pressures in OSAS Patients

Manual titration of positive airway pressure (PAP) is a gold standard to provide an optimal pressure for the treatment of obstructive sleep apnea-hypopnea syndrome (OSAS). Since manual titration studies were costly and time-consuming, many statistical models for predicting effective PAPs were reported. However, the prediction accuracies of the models associated with nocturnal parameters still remain low. This study proposes a fuzzy neural prediction network (FNPN) with input candidate variables, selected among easily available measurements (e.g., body mass index (BMI), waist circumstance (WC), and body composition) and OSAS related questionnaires, to rapidly predict an optimal PAP. The FNPN comprises fuzzy rules and is characterized with the ability of automatic rule growing and pruning from training data. A total of 147 participants from April 2018 to April 2019 were enrolled in Taichung Veterans General Hospital, Taiwan. After two selection processes for feature extraction, WC and BMI were the significant variables for entering the FNPN to predict optimal PAP. Experimental results showed that the average successful prediction rate of the proposed method was 71.8%. This study also found that Epworth sleepiness scales (ESS) and body composition, such as visceral fat area and percent body fat, were excluded in the final prediction model. Compared with existing models, the proposed prediction approach provided a rapid prediction of optimal PAP with higher accuracy.

Eat, breathe, sleep with Osteogenesis Imperfecta

BACKGROUND

Although Osteogenesis Imperfecta (OI) affects the connective tissue causing extremely brittle bones with consequent skeletal deformities, it is important to go beyond bones. Indeed, the quality of life in OI does not only depend on bones status, as OI might affect also other important functions. We have therefore implemented a multidisciplinary study to assess lung function, breathing pattern, sleep quality and nutritional status in 27 adult OI type III and IV patients (median age: 34.6 years; 19 women; 14 type III).

RESULTS

According to nocturnal oxygen desaturation, two groups were identified: 13 patients with (OI_OSA, incidence: 48.2%) and 14 without (no_OSA) obstructive sleep apnea. The former was characterized by higher spinal and ribcage deformity, by more restrictive lung function, by paradoxical thoracic breathing in supine position, by rapid and shallow breathing, by higher body mass index, by longer neck and waist circumferences; by higher abdominal volume and by greater percentage of body fat mass, particularly localized in the trunk. The best predictor of OI_OSA was the negative value of the supine ribcage contribution to tidal volume, followed by the ratio between the neck and the waist circumferences with body height and the supine thoraco-abdominal volumes phase shift angle.

CONCLUSIONS

The pathophysiology of OI ensued a dangerous vicious circle, in which breathing, sleep and nutritional status are tightly linked, and they might all end up in negatively affecting the quality of life. The vicious circle is fed by some intrinsic characteristics of the disease (thoracic, cranial and mandibular deformities) and some bad daily habits of the patients (i.e. physical inactivity and low dietary quality). The former impacts on restricting the respiratory function, the latter makes Olers more prone to experience overweight or obesity. The main consequence is a high incidence of obstructive sleep apnea, which remains an underdiagnosed disorder in individuals with severe OI who are obese, with a neck to height ratio over than 31.6%, and characterized by paradoxical breathing in supine position. A multidisciplinary approach, including evaluations of breathing, sleep and nutrition, is required to better manage the disease and fulfil the maximizing well-being of OI patients.

Obstructive Sleep Apnea Is Associated With Low Testosterone Levels in Severely Obese Men

Background

Disrupted sleep affects cardio-metabolic and reproductive health. Obstructive sleep apnea syndrome represents a major complication of obesity and has been associated with gonadal axis activity changes and lower serum testosterone concentration in men. However, there is no consistent opinion on the effect of obstructive sleep apnea on testosterone levels in men.

Objective

The aim of this study was to determine the influence of obstructive sleep apnea on total and free testosterone levels in severely obese men.

Materials and methods

The study included 104 severely obese (Body Mass Index (BMI) ≥ 35 kg/m2) men, aged 20 to 60, who underwent anthropometric, blood pressure, fasting plasma glucose, lipid profile, and sex hormone measurements. All participants were subjected to polysomnography. According to apnea-hypopnea index (AHI) patients were divided into 3 groups: <15 (n = 20), 15 - 29.9 (n = 17) and ≥ 30 (n = 67).

Results

There was a significant difference between AHI groups in age (29.1 ± 7.2, 43.2 ± 13.2, 45.2 ± 10.2 years; p < 0.001), BMI (42.8 ± 5.9, 43.2 ± 5.9, 47.1 ± 7.8 kg/m2; p = 0.023), the prevalence of metabolic syndrome (MetS) (55%, 82.4%, 83.6%, p = 0.017), continuous metabolic syndrome score (siMS) (4.01 ± 1.21, 3.42 ± 0.80, 3.94 ± 1.81, 4.20 ± 1.07; p = 0.038), total testosterone (TT) (16.6 ± 6.1, 15.2 ± 5.3, 11.3 ± 4.44 nmol/l; p < 0.001) and free testosterone (FT) levels (440.4 ± 160.8, 389.6 ± 162.5, 294.5 ± 107.0 pmol/l; p < 0.001). TT level was in a significant negative correlation with AHI, oxygen desaturation index (ODI), BMI, MetS and siMS. Also, FT was in a significant negative correlation with AHI, ODI, BMI, age, MetS and siMS. The multiple regression analysis revealed that both AHI and ODI were in significant correlation with TT and FT after adjustment for age, BMI, siMS score and MetS components.

Conclusion

Obstructive sleep apnea is associated with low TT and FT levels in severely obese men.

A meta-analysis and trial sequential analysis of serum copeptin level in adult patients with Obstructive Sleep Apnoea Syndrome

OBJECTIVE

Copeptin can act as a stable biomarker in inflammation and stress response that obstructive sleep apnoea syndrome (OSAS), can induce oxidative stress and consequently promotes systemic inflammation. The purpose of the study is to appraise serum copeptin level in adult patients with OSAS compared to the controls.

MATERIAL AND METHODS

Electronic search was done in the databases of PubMed/Medline, Web of Science, Scopus, and Cochrane Library until June 2021, without any restrictions. For comparison of the serum copeptin level between groups, the mean difference (MD) and 95% confidence interval (CI) were calculated by the Review Manager 5.3 software. Trial sequential analysis (TSA) was used by applying TSA software.

RESULTS

Among the databases, five articles (involving 495 OSAS patients and 135 controls) were included. To report the serum copeptin level in OSAS patients compared to controls, the pooled OR became 12.21pg/mL (95%CI: 2.31 to 22.11; P=0.02) and also the pooled OR for comparison of serum copeptin level in severe versus moderate/mild OSAS patients was 5.96pg/mL (95%CI: 1.46 to 10.47; P=0.009). The results of TSA illustrated that the Z-curve has not crossed the monitoring boundary curves and did not reach the required information size.

CONCLUSIONS

The main findings recommended that copeptin had a significantly higher serum level in OSAS patients compared to controls, as well as a significantly higher level in severe patients compared to mild/moderate OSAS patients for the serum level of copeptin.

Higher refined cereal grain intake is positively associated with apnoea-hypopnoea index in patients with obstructive sleep apnoea

BACKGROUND

Given that obesity is a well-known risk factor for obstructive sleep apnoea (OSA) development, dietary habits may be involved in its pathogenesis. However, little is known about the associations between dietary habits and OSA severity. The present study aimed to investigate possible associations between cereal grain intake and apnoea/hypopnoea indices in OSA patients.

METHODS

This was a cross-sectional study of 269 patients (21-70 years; 73.2% males) diagnosed with OSA via an attended in-hospital polysomnography. Information on demographics, medical history, anthropometric indices and lifestyle habits were collected at enrolment. Biochemical measurements were performed in all study participants using standard procedures. Cereal grain consumption was evaluated using a validated food frequency questionnaire. Severe OSA was defined as having an apnoea-hypopnoea index ≥30 events h^-1 .

RESULTS

In adjusted analyses, higher intake of refined cereal grains was positively associated with apnoea-hypopnoea index (p_trend = 0.022), after adjusting for age, sex, socio-economic parameters, smoking habits, waist circumference, physical activity level, adequacy of night-time sleep, diet's quality as assessed by a relevant score, insulin resistance and C-reactive protein levels). Multiple logistic regression analysis also showed that energy-adjusted refined grain intake was associated with increased likelihood of severe OSA (odds ratio = 1.56, 95% confidence interval = 1.06-2.30). Νo association between apnoea/hypopnoea indices and non-refined grain intake was observed in this study.

CONCLUSIONS

The findings show that obstructive sleep apnoea (OSA) is associated with cereal grain intake and suggest that a higher intake of refined cereal grains may be a risk factor for OSA severity.

Practical Approaches to Treating Obesity: Patient and Healthcare Professional Perspectives

Obesity is a chronic and treatable disease carrying risk for numerous health complications, including cardiovascular disease, respiratory disease, type 2 diabetes mellitus and certain cancers. While there is a great need to address the topic in clinical practice, healthcare professionals (HCPs) often struggle to initiate conversations about weight. In this paper, guidance on how to raise and address the subject of weight with individuals is provided from an HCP and patient perspective using the 5As framework. This model facilitates advising individuals on the benefits of weight loss and supports them to develop achievable and sustainable weight management plans. With obesity rates still rising across the globe, it is imperative that more HCPs become skilled in raising and addressing the issue.

Improvement in BMI z-score following adenotonsillectomy in adolescents aged 12-18 years: a retrospective cohort study

BACKGROUND

Characteristics of obstructive sleep apnea (OSA) changes with age. Infants, toddlers and prepubertal children with OSA are usually underweight and may suffer from failure to thrive (FTT). Adenotonsillectomy (T&A) is the first line of treatment for OSA in childhood. In adults OSA is commonly associated with obesity and the metabolic syndrome. The change in body mass index (BMI) in adolescents with OSA following T&A was only sporadically studied. Thus, we peruse to examine the BMI z-score change following T&A in adolescents.

METHODS

Clalit Health Services is the largest health care organization in Israel with the largest patient registry (more than 50% of the population). Two hundred and forty two adolescents aged 12-18 who underwent T&A between 2006 and 2015 were identified in the Clalit registry and their characteristics including height and weight were retrieved. The BMI z-score of these adolescents at baseline (up to 3 months prior to T&A) and during the consecutive 3 years after T&A were analyzed and compared.

RESULTS

Changes in BMI Z-score were observed to all directions following T&A with overall small increase, not statistically significant (P = 0.26) from a median of 0.79 prior to T&A to a median of 0.835 after it. There was a minimal trend toward BMI z-score reduction in overweight children (n = 74) from 1.508 to 1.48 following T&A (p = NS), and in obese children (n = 33) from 2.288 to 2.000 (P = 0.06, 2 tailed). Interestingly thin individuals (n = 6) increased their BMI z-score following T&A from - 2.4 to - 0.59 (p = 0.046).

CONCLUSIONS

Adolescents show variable changes in their BMI z-score following T&A. In this aspect their BMI z-score change is closer to the change seen in adults treated for OSA and not that of young children. The changes observed show a trend toward normalization of the BMI z-score such that overweight children tend to decrease their BMI z-score while thin individuals tend to increase it.

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

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

Age-specific markers of adiposity in patients with obstructive sleep apnea

OBJECTIVES

Adiposity can have varying effects on the individual depending upon its distribution pattern. We assessed age-related distribution of adipose tissue by anthropometric measures and bioelectrical impedance analysis, as well as their association with obstructive sleep apnea (OSA) severity.

METHODS

Participants were 169 elderly (aged ≥ 65 years) and 142 non-elderly (aged < 65 years) referred for overnight polysomnography. The associations between obesity parameters and apnea-hypopnea index (AHI) were determine by univariate and multivariate linear regression analyses. Area under receiver operating characteristic curve (AUC) was used to access the predicting performance of some parameters.

RESULTS

Compared with non-elderly, elderly showed higher conicity index and visceral adiposity (VA)/subcutaneous adiposity (SA), lower body mass index (BMI), neck circumference, waist circumference, hip circumference and SA. Multiple regression analyses revealed that VA and VA/SA were independently associated with AHI in elderly (explained 17.2% of the AHI ^0.5 variability), while BMI and VA/SA were independently associated with AHI in non-elderly (explained 25.9% of the AHI ^0.5 variability), after adjusting for age, sex, cigarette smoking, alcohol drinking and main comorbidities. In elderly, VA over 128 cm² and VA/SA less than 0.41 resulted in sensitivity, specificity and AUC of 0.382, 0.790, 0.580 and 0.176, 0.947, 0.553 in predicting moderate-to-severe OSA, respectively. In non-elderly, BMI over 24.7 kg/m² and VA/SA over 0.54 resulted in sensitivity, specificity and AUC of 0.883, 0.484, 0.704 and 0.550, 0.710, 0.667 in predicting moderate-to-severe OSA, respectively.

CONCLUSIONS

VA is strongly associated with OSA severity in elderly, independently of general obesity as per BMI standards, while general adiposity appears to be more strongly associated with OSA severity in non-elderly. Our study supports age-specific approaches should be developed with respect to prediction and treatment of OSA.

Objectively assessed sleep-disordered breathing during pregnancy and infant birthweight

BACKGROUND

Sleep-disordered breathing (SDB) in pregnancy is associated with adverse maternal outcomes. The relationship between SDB and infant birthweight is unclear. This study's primary aim is to determine if objectively measured SDB in pregnancy is associated with infant birthweight.

METHODS

We measured SDB objectively in early (6-15 weeks' gestation) and mid (22-31 weeks' gestation) pregnancy in a large cohort of nulliparous women. SDB was defined as an Apnea-Hypopnea Index ≥5 and in secondary analyses we also examined measures of nocturnal hypoxemia. We used a modified Poisson regression approach to estimate relative risks (RR) of large-for-gestational-age (LGA: >90th percentile for gestational age) and small-for-gestational-age (SGA: <10th percentile for gestational age) birthweights.

RESULTS

The prevalence of early-pregnancy SDB was nearly 4%. The incidence of mid-pregnancy SDB was nearly 6.0%. The prevalence of LGA and SGA was 7.4% and 11.9%, respectively. Early-pregnancy SDB was associated with a higher risk of LGA in unadjusted models (RR 2.2, 95% CI 1.3-3.5) but not BMI-adjusted models (aRR 1.0, 95% CI 0.6-1.8). Mid-pregnancy SDB was not associated with SGA or LGA. Mid-pregnancy nocturnal hypoxemia (% of sleep time <90% oxygen saturation) and increasing nocturnal hypoxemia from early to mid-pregnancy were associated with a higher risk of LGA in BMI-adjusted models. SDB and nocturnal hypoxemia were not associated with SGA.

CONCLUSIONS

SDB in pregnancy was not associated with an increased risk of LGA or SGA birthweight, independent of BMI. Some measures nocturnal hypoxemia were associated with an increase in LGA risk, independent of BMI. ClinicalTrials.gov Registration number NCT02231398.