Effects of Weight Loss on Obstructive Sleep Apnea Severity. Ten-Year Results of the Sleep AHEAD Study

Potential Therapeutic Targets in Obesity, Sleep Apnea, Diabetes, and Fatty Liver Disease

Obesity and metabolic syndrome affect the majority of the US population. Patients with obesity are at increased risk of developing type 2 diabetes (T2DM), obstructive sleep apnea (OSA), and metabolic dysfunction-associated steatotic liver disease (MASLD), each of which carry the risk of further complications if left untreated and lead to adverse outcomes. The rising prevalence of obesity and its comorbidities has led to increased mortality, decreased quality of life, and rising healthcare expenditures. This phenomenon has resulted in the intensive investigation of exciting therapies for obesity over the past decade, including more treatments that are still in the pipeline. In our present report, we aim to solidify the relationships among obesity, T2DM, OSA, and MASLD through a comprehensive review of current research. We also provide an overview of the surgical and pharmacologic treatment classes that target these relationships, namely bariatric surgery, the glucagon-like peptide-1 (GLP-1), glucose-dependent insulinotropic polypeptide (GIP), and glucagon receptor agonists.

Plant-based and vegetarian diets are associated with reduced obstructive sleep apnoea risk

Introduction

Obstructive sleep apnoea (OSA) and obesity commonly coexist. Weight loss and exercise are recommended management options for OSA. However, most of the current evidence on diet and OSA is focused on calorie restriction rather than diet quality. The aim of the present study was to determine the association of plant-based dietary indices (PDI) with OSA risk.

Methods

Cross-sectional data from 14 210 participants of the National Health and Nutrition Examination Survey who provided dietary information using the 24-hour recall method were used. PDI - including healthy (hPDI), unhealthy (uPDI) and pro-vegetarian diet index (PVDI) - were determined. OSA risk was determined using the STOP-BANG questionnaire. Logistic regression was used to determine the relationship between dietary indices and OSA risk.

Results

Higher adherence to PDI (odds ratio (OR)Q5 versus Q1=0.81; 95% confidence interval (CI): 0.66-1.00), hPDI (OR=0.83; 95% CI: 0.69-1.01) and PVDI (OR=0.84; 95% CI: 0.68-1.05) was inversely associated with OSA risk, whereas higher consumption of an unhealthy plant-based diet (OR=1.22; 95% CI: 1.00-1.49) was positively associated with OSA. Sex differences in estimates were observed for PDI in males (OR=0.71; 95% CI: 0.56-0.90) versus females (OR=0.93; 95% CI: 0.68-1.28), hPDI in males (OR=0.90; 95% CI: 0.68-1.18) versus females (OR=0.77; 95% CI: 0.54-1.09) and uPDI in males (OR=1.13; 95% CI: 0.89-1.44) versus females (OR=1.42; 95% CI: 1.03-1.97) but not for PVDI.

Conclusions

Higher adherence to a healthy plant-based diet is associated with reduced OSA risk, while an unhealthy plant-based diet has a positive association. The magnitude of these associations differs by sex. Further longitudinal studies are warranted.

Obstructive sleep apnoea in obesity: A review

Obstructive sleep apnea is a common comorbidity that occurs in individuals with obesity. It classically manifests with excessive daytime sleepiness, resulting in reduced quality of life, workplace productivity, and an increased risk of motor vehicle accidents. Weight gain plays an important role in its pathogenesis through worsening upper airway collapsibility, and current treatment options are targeted towards mechanically overcoming upper airway obstruction and weight loss. Continuous positive airway pressure therapy remains the most widely prescribed treatment for obstructive sleep apnea but poor tolerance is a common barrier to effective treatment. Sustainable weight loss is an important treatment option but can be difficult to achieve without bariatric surgery. The recent advances in incretin-based pharmacotherapies represent a promising avenue not only in achieving long-term weight loss but also in treating obstructive sleep apnoea and alleviating the burden of its symptoms and comorbidities.

Approach the Patient With Obstructive Sleep Apnea and Obesity

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

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.

Recommended assessment and management of sleep disordered breathing in patients with atrial fibrillation, hypertension and heart failure: Taiwan Society of Cardiology/Taiwan Society of sleep Medicine/Taiwan Society of pulmonary and Critical Care Medicine joint consensus statement

Sleep disordered breathing (SDB) is highly prevalent and may be linked to cardiovascular disease in a bidirectional manner. The Taiwan Society of Cardiology, Taiwan Society of Sleep Medicine and Taiwan Society of Pulmonary and Critical Care Medicine established a task force of experts to evaluate the evidence regarding the assessment and management of SDB in patients with atrial fibrillation (AF), hypertension and heart failure with reduced ejection fraction (HFrEF). The GRADE process was used to assess the evidence associated with 15 formulated questions. The task force developed recommendations and determined strength (Strong, Weak) and direction (For, Against) based on the quality of evidence, balance of benefits and harms, patient values and preferences, and resource use. The resulting 11 recommendations are intended to guide clinicians in determining which the specific patient-care strategy should be utilized by clinicians based on the needs of individual patients.

Obstructive sleep apnea heterogeneity and autonomic function: a role for heart rate variability in therapy selection and efficacy monitoring

Obstructive sleep apnea is a highly prevalent sleep-related breathing disorder, resulting in a disturbed breathing pattern, changes in blood gases, abnormal autonomic regulation, metabolic fluctuation, poor neurocognitive performance, and increased cardiovascular risk. With broad inter-individual differences recognised in risk factors, clinical symptoms, gene expression, physiological characteristics, and health outcomes, various obstructive sleep apnea subtypes have been identified. Therapeutic efficacy and its impact on outcomes, particularly for cardiovascular consequences, may also vary depending on these features in obstructive sleep apnea. A number of interventions such as positive airway pressure therapies, oral appliance, surgical treatment, and pharmaceutical options are available in clinical practice. Selecting an effective obstructive sleep apnea treatment and therapy is a challenging medical decision due to obstructive sleep apnea heterogeneity and numerous treatment modalities. Thus, an objective marker for clinical evaluation is warranted to estimate the treatment response in patients with obstructive sleep apnea. Currently, while the Apnea-Hypopnea Index is used for severity assessment of obstructive sleep apnea and still considered a major guide to diagnosis and managements of obstructive sleep apnea, the Apnea-Hypopnea Index is not a robust marker of symptoms, function, or outcome improvement. Abnormal cardiac autonomic modulation can provide additional insight to better understand obstructive sleep apnea phenotyping. Heart rate variability is a reliable neurocardiac tool to assess altered autonomic function and can also provide cardiovascular information in obstructive sleep apnea. Beyond the Apnea-Hypopnea Index, this review aims to discuss the role of heart rate variability as an indicator and predictor of therapeutic efficacy to different modalities in order to optimise tailored treatment for obstructive sleep apnea.

Effect of Weight Loss on the Apnea Hypopnea Index is Related to Waist Circumference in Chinese Adults with Overweight and Obesity

Purpose

The present study aimed to evaluate the efficiency of traditional anthropometric and body composition parameters in predicting apnea hypopnea index (AHI) change after weight loss.

Patients and Methods

Chinese adults with overweight and obesity were included into this study containing two parts. A cross-sectional study was conducted in 137 individuals using the baseline data from two weight loss intervention trials. The second part was the weight-loss intervention study conducted in 60 overweight and obese patients with obstructive sleep apnea (OSA). All participants underwent physical examination, bioelectrical impedance analysis and overnight polysomnography. Multivariate linear regression models were used to identify the most accurate parameters to predict AHI and the mediation analysis to evaluate the mediators between weight loss and AHI reduction.

Results

Waist circumference (WC), body mass index and fat mass were positively associated with AHI after adjusting multiple collinearities in the cross-sectional study. After weight-loss intervention, body weight decreased from 94.6 ± 15.3 to 88.0 ± 13.9 kg, and AHI decreased from 41.9 (13.0,66.9) to 20.7 (8.7,51.2) events/h. Among these parameters, only percentage changes in WC and AHI across the intervention were positively intercorrelated after controlling for covariates (adjusted r = 0.271, P = 0.041). The mediation analysis supported WC as a mediator between weight loss and AHI reduction (standardized indirect effect [95% CI] = 4.272[0.936,7.999]).

Conclusion

Both general and abdominal obesity are of high prognostic value for OSA. WC as an easily accessible parameter mediates the effects of weight loss in decreasing OSA severity.

Association of modifiable risk factors with obstructive sleep apnea: a Mendelian randomization study

BACKGROUND

The risk factors involved in obstructive sleep apnea (OSA) have not been clearly identified yet. We attempted to systematically investigate genetically predicted modifiable risk factors and lifestyle behaviors associated with OSA.

METHODS

The association between 34 risk factors and OSA was evaluated using the two-sample Mendelian randomization (MR). Genetic variants for risk factors were acquired from European-descent genome-wide studies. Data sources for OSA were extracted from FinnGen study with 16,761 cases and 201,194 controls. The primary analysis chosen was the inverse-variance weighted method.

RESULTS

MR analyses provide evidence of genetically predicted poor overall health rating (odds ratio (OR), 2.82; 95% confidence interval (CI), 1.95-4.08), nap during day (OR, 2.01; 95% CI, 1.37-2.93), high body mass index (BMI) (OR, 1.14; 95% CI, 1.09-1.19), increased body fat mass (OR, 1.83; 95% CI, 1.83-2.05), elevated body water mass (OR, 1.50; 95% CI, 1.31-1.70) and hypertension (OR, 1.81; 95% CI, 1.34-2.45) were associated with higher OSA risk, while high education level (OR, 0.55; 95% CI, 0.40-0.75) correlated with reduced OSA risk. Suggestive evidence was obtained for smoking and waist-to-hip ratio (WHR) with higher OSA odds, and vigorous physical activity, and HDL cholesterol with lower OSA odds. After adjusting for BMI using multivariable MR analysis, the effects of smoking, WHR, vigorous physical activity, and HDL-cholesterol were fully attenuated.

CONCLUSIONS

This MR study indicates that overall health rating, nap during day, BMI, body fat mass, body water mass, hypertension, and education are causally associated with the risk of OSA, which means that these modifiable risk factors are key targets for OSA prevention.

Comprehensive home-based telerehabilitation in a morbidly obese male patient with severe obstructive sleep apnea. A case report

BACKGROUND

Rehabilitation may be an effective additional treatment method in patients with obstructive sleep apnea (OSA). Physical exercise, weight reduction, pulmonary rehabilitation, and myofunctional therapy (MT) represent beneficial components of rehabilitation recommended as a possible adjunct to standard OSA treatment.

METHODS AND RESULTS

A 54-year-old man with morbid obesity, long-lasting snoring, breathing pauses, frequent waking, as well as persistent drowsiness and fatigue during the day underwent polysomnography (PSG) to investigate suspected OSA. Severe OSA was confirmed by PSG and a 12-week comprehensive, home-based telerehabilitation program (tele-RHB program) along with continuous positive airway pressure (CPAP) therapy was implemented. The tele-RHB program included regular teleconsultations, aerobic-endurance training, MT, inspiratory and expiratory muscle training, as well as recommendations on proper nutrition, a healthy lifestyle, and behavioral changes. Following the treatment, the patient's quality of life (QoL), exercise capacity, lung function, and OSA severity significantly improved. The patient achieved an overall 19.9 kg reduction in weight, of which 16.2 kg was body fat, and his apnea-hypopnea index decreased by 42.6 episodes/hour.

CONCLUSION

Our case report suggests that the comprehensive home-based tele-RHB program adjunct to CPAP therapy may be a novel approach for improving OSA severity, a patient's QoL, exercise capacity, lung function and body composition. It is important to note that such a program should be optional, however it may be needed to achieve the highest possible overall improvement in a patient's life. Further clinical investigations are needed to determine the therapeutic efficacy and clinical potential of this tele-RHB program.

Genetic association between coffee/caffeine consumption and the risk of obstructive sleep apnea in the European population: a two-sample Mendelian randomization study

BACKGROUND

The association between coffee/caffeine consumption and obstructive sleep apnea (OSA) risk remains unclear.

PURPOSE

To determine the relationship between coffee/caffeine consumption and the risk of OSA, using the Mendelian randomization (MR) method in the European population.

METHODS

Two sets of coffee consumption-associated genetic variants were, respectively, extracted from the recent genome-wide meta-analysis (GWMA) and genome-wide association study (GWAS) of coffee consumption. Taking other caffeine sources into account, genetic variants associated with caffeine consumption from tea and plasma caffeine (reflecting total caffeine intake) were also obtained. The inverse variance weighted (IVW) technique was utilized as the primary analysis, supplemented by the MR-Egger, weighted-median, and MR-Pleiotropy RESidual Sum and Outlier (PRESSO) techniques. Leave-one-out (LOO) analysis was performed to assess whether the overall casual estimates were driven by a single SNP. Additional sensitivity analyses were performed using similar methods, while the genetic variants associated with confounders, e.g., body mass index and hypertension, were excluded.

RESULTS

The IVW method demonstrated that coffee consumption GWMA (OR: 1.065, 95% CI 0.927-1.224, p = 0.376), coffee consumption GWAS (OR: 1.665, 95% CI 0.932-2.977, p = 0.086), caffeine from tea (OR: 1.198, 95% CI 0.936-1.534, p = 0.151), and blood caffeine levels (OR: 1.054, 95% CI 0.902-1.231, p = 0.508) were unlikely to be associated with the risk of OSA. The other three methods presented similar results, where no significant associations were found. No single genetic variant was driving the overall estimates by the LOO analysis. These findings were also supported by the sensitivity analyses with no confounding genetic variants.

CONCLUSION

Our study found no association between coffee/caffeine consumption and the risk of OSA.

The relationship between aerodynamic characteristics of the upper airway and severity of obstructive sleep apnea in adults

OBJECTIVE

To investigate the relationship between aerodynamic characteristics of the upper airway and severity of obstructive sleep apnea (OSA) in adults.

METHODS

Ninety-seven adult OSA patients underwent polysomnography and cone beam computed tomography (CBCT). The anatomical and aerodynamic characteristics were measured based on CBCT images and computational fluid dynamics modelling of the upper airway.

RESULTS

After controlling for patients' gender, age, and body mass index (BMI), the maximum velocity during inspiration (In-Vmax) led to the largest increase in the explanatory power of apnea-hypopnea index (AHI) variation. The In-Vmax was closely correlated with the minimum axial area, and their relationship was represented by an inversely proportional fitted curve.

CONCLUSIONS

The In-Vmax was the most relevant to OSA severity, and it could be used to assist in recognizing severe OSA patients and as a primary variable to evaluate treatment outcomes of OSA. The In-Vmax was closely related to the most constricted area of the upper airway.

Giving weight to incretin-based pharmacotherapy for obesity-related sleep apnea: a revolution or a pipe dream?

Obesity is a chronic disease affecting over 670 million adults globally, with multiple complications including obstructive sleep apnea (OSA). Substantial weight loss in patients with obesity-related OSA can reduce or even eliminate OSA as well as reduce sleepiness and improve cardio-metabolic health. Evidence suggests that these improvements exceed those that occur with device-based OSA therapies like continuous positive airway pressure which continue to be the first-line of therapy. Resistance to weight management as a first-line strategy to combat OSA could arise from the complexities in delivering and maintaining adequate weight management, particularly in sleep clinic settings. Recently, incretin-based pharmacotherapies including glucagon-like peptide 1 (GLP-1) receptor agonists alone or combined with glucose-dependent insulinotropic polypeptide (GIP) receptor agonists have been developed to target glycemic control in type 2 diabetes. These medications also slow gastric emptying and reduce energy intake. In randomized, placebo-controlled trials of these medications in diabetic and non-diabetic populations with obesity, participants on active medication lost up to 20% of their body weight, with corresponding improvements in blood pressure, lipid levels, physical functioning, and fat mass loss. Their adverse effects are predominantly gastrointestinal-related, mild, and transient. There are trials currently underway within individuals with obesity-related OSA, with a focus on reduction in weight, OSA severity, and cardio-metabolic outcomes. These medications have the potential to substantially disrupt the management of OSA. Pending coming data, we will need to consider pharmacological weight loss as a first-line therapy and how that influences training and management guidelines.

Longitudinal risk factors for obstructive sleep apnea: A systematic review

Despite substantial disease burden, existing evidence on the risk factors for obstructive sleep apnea (OSA) have been derived primarily from cross-sectional studies without determining temporality. Therefore, we aimed to systematically synthesize the literature on longitudinal risk factors for sleep study-assessed OSA and questionnaire-assessed probable OSA from cohort studies in the general adult population settings. We systematically searched Embase and Medline (on OVID) databases. Eleven studies met the inclusion criteria. Meta-analyses were not conducted due to methodological heterogeneity of exposure and outcome measurements. There was consistent evidence that weight gain was associated with incident (n = 2) and greater severity (n = 2) of OSA. One study each observed an association of higher baseline body-mass index, male sex, asthma, a specific genetic polymorphism in rs12415421, and insulin resistance/hyperglycemia, with incident OSA. Long-term exposure to ambient air pollution (NO2, n = 1) was associated with OSA, and menopausal transitions (n = 1) with higher apnea-hypopnea index. There were no eligible studies on long-term smoking or alcohol use. In conclusion, approximately 10% increase in weight, especially in males, might alert clinicians to consider potential or worsening OSA. Large, well-designed longitudinal studies are needed to consolidate knowledge on other associations with OSA development, especially on potentially modifiable risk factors.

Weight Loss and Sleep, Current Evidence in Animal Models and Humans

Sleep is a vital process essential for survival. The trend of reduction in the time dedicated to sleep has increased in industrialized countries, together with the dramatic increase in the prevalence of obesity and diabetes. Short sleep may increase the risk of obesity, diabetes and cardiovascular disease, and on the other hand, obesity is associated with sleep disorders, such as obstructive apnea disease, insomnia and excessive daytime sleepiness. Sleep and metabolic disorders are linked; therefore, identifying the physiological and molecular pathways involved in sleep regulation and metabolic homeostasis can play a major role in ameliorating the metabolic health of the individual. Approaches aimed at reducing body weight could provide benefits for both cardiometabolic risk and sleep quality, which indirectly, in turn, may determine an amelioration of the cardiometabolic phenotype of individuals. We revised the literature on weight loss and sleep, focusing on the mechanisms and the molecules that may subtend this relationship in humans as in animal models.

Preoperative risk evaluation and perioperative management of patients with obstructive sleep apnea: a narrative review

Obstructive sleep apnea (OSA) is a common sleep-breathing disorder associated with significant comorbidities and perioperative complications. This narrative review is aimed at comprehensively overviewing preoperative risk evaluation and perioperative management strategies for patients with OSA. OSA is characterized by recurrent episodes of upper airway obstruction during sleep leading to hypoxemia and arousal. Anatomical features, such as upper airway narrowing and obesity, contribute to the development of OSA. OSA can be diagnosed based on polysomnography findings, and positive airway pressure therapy is the mainstay of treatment. However, alternative therapies, such as oral appliances or upper airway surgery, can be considered for patients with intolerance. Patients with OSA face perioperative challenges due to difficult airway management, comorbidities, and effects of sedatives and analgesics. Anatomical changes, reduced upper airway muscle tone, and obesity increase the risks of airway obstruction, and difficulties in intubation and mask ventilation. OSA-related comorbidities, such as cardiovascular and respiratory disorders, further increase perioperative risks. Sedatives and opioids can exacerbate respiratory depression and compromise airway patency. Therefore, careful consideration of alternative pain management options is necessary. Although the association between OSA and postoperative mortality remains controversial, concerns exist regarding adverse outcomes in patients with OSA. Understanding the pathophysiology of OSA, implementing appropriate preoperative evaluations, and tailoring perioperative management strategies are vital to ensure patient safety and optimize surgical outcomes.

Obesity, Bariatric Surgery and Obstructive Sleep Apnea-A Narrative Literature Review

The purpose of this review was to analyze the available literature on the subject of obesity and obstructive sleep apnea. We searched for available articles for the time period from 2013 to 2023. Obesity is listed as one of the most important health issues. Complications of obesity, with obstructive sleep apnea (OSA) listed among them, are common problems in clinical practice. Obesity is a well-recognized risk factor for OSA, but OSA itself may contribute to worsening obesity. Bariatric surgery is a treatment of choice for severely obese patients, especially with present complications, and remains the only causative treatment for patients with OSA. Though improvement in OSA control in patients after bariatric surgery is well-established knowledge, the complete resolution of OSA is achieved in less than half of them. The determination of subpopulations of patients in whom bariatric surgery would be especially advantageous is an important issue of OSA management. Increasing the potential of non-invasive strategies in obesity treatment requires studies that assess the efficacy and safety of combined methods.

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.

Designing a program to support weight loss for patients attending the sleep medicine clinic: a qualitative study

STUDY OBJECTIVES

Excess body weight is the most important risk factor in sleep-disordered breathing. Weight loss is a treatment alternative to positive airway pressure therapy, but there is a knowledge gap of what is feasible, acceptable, and sustainable in this population. We seek to add the voices of sleep medicine patients and providers to the medical literature to understand what makes this population unique when considering weight loss, and what we can do differently to create more sustainable weight loss interventions.

METHODS

We conducted one-on-one semistructured interviews with 12 patients with obstructive sleep apnea/obesity hypoventilation syndrome and obesity and with 9 sleep medicine providers regarding previous weight loss efforts, perceptions of barriers to and facilitators of weight loss, and potential components of a program to support those with sleep apnea and excess weight.

RESULTS

Patients indicated they appreciated direct conversation with their sleep physician regarding weight loss and providers felt the patient population was generally very receptive to weight loss conversations. Patients emphasized the most important aspects of a future weight loss program would be personalized diet, exercise, accountability, integration of technology, and an individualized approach to addressing the psychological aspects of eating.

CONCLUSIONS

This is a unique population of patients who are very receptive to conversations about weight loss. We plan to use this data to inform a future weight loss program based in health coaching to address the specific needs of this population.

CITATION

Dupuy-McCauley K, Benzo R, Barwise A. Designing a program to support weight loss for patients attending the sleep medicine clinic: a qualitative study. J Clin Sleep Med. 2023;19(3):459-471.

Respiratory complications of obesity: from early changes to respiratory failure

Obesity is a significant and increasingly common cause of respiratory compromise. It causes a decrease in static and dynamic pulmonary volumes. The expiratory reserve volume is one of the first to be affected. Obesity is associated with reduced airflow, increased airway hyperresponsiveness, and an increased risk of developing pulmonary hypertension, pulmonary embolism, respiratory tract infections, obstructive sleep apnoea and obesity hypoventilation syndrome. The physiological changes caused by obesity will eventually lead to hypoxic or hypercapnic respiratory failure. The pathophysiology of these changes includes a physical load of adipose tissue on the respiratory system and a systemic inflammatory state. Weight loss has clear, well-defined benefits in improving respiratory and airway physiology in obese individuals.

Obstructive sleep apnoea-hypopnoea syndrome: state of the art

Obstructive sleep apnoea-hypopnoea syndrome (OSAHS) is an extremely common sleep-related breathing disorder (SRBD) characterised by complete or partial collapse of the upper airways. These nocturnal phenomena cause high-frequency hypoxemic desaturations (or intermittent hypoxia, IH) during sleep and alterations in gas exchange. The result of IH is the development or worsening of cerebro-cardio-vascular, metabolic and other diseases, which cause a high risk of death. Hence, OSAHS is a multifactorial disease affecting several organs and systems and presenting with various clinical manifestations involving different medical branches. Although it has been estimated that about one billion individuals worldwide are affected by OSAHS, this SRBD remains underestimated also due to misinformation regarding both patients and physicians. Therefore, this review aims to provide information on the main symptoms and risk factors for the detection of individuals at risk of OSAHS, as well as to present the diagnostic investigations to be performed and the different therapeutic approaches. The scientific evidence reported suggest that OSAHS is an extremely common and complex disorder that has a large impact on the health and quality of life of individuals, as well as on healthcare expenditure. Moreover, given its multifactorial nature, the design and implementation of diagnostic and therapeutic programmes through a multidisciplinary approach are necessary for a tailor-made therapy for each patient.

Obesity and diabetes: the final frontier

INTRODUCTION

Obesity is a key target in the treatment and prevention of diabetes and independently to reduce the burden of cardiovascular disease. We reviewed the options now available and anticipated to deal with obesity.

AREAS COVERED

We considered the epidemiology, genetics, and causation of obesity and the relationship to diabetes, and the dietary, pharmaceutical, and surgical management of the condition. The literature search covered both popular media via Google Search and the academic literature as indexed on PubMed with search terms including obesity, childhood obesity, adipocytes, insulin resistance, mechanisms of satiety, bariatric surgery, GLP-1 receptor agonists, and SGLT2 inhibitors.

EXPERT OPINION

Although bariatric surgery has been the primary approach to treating obese individuals, the emergence of agents impacting the brain satiety centers now promises effective, non-invasive treatment of obesity for individuals with and without diabetes. The GLP-1 receptor agonists have assumed the primary role in treating obesity with significant weight loss. Long-term results with semaglutide and tirzepatide are now approaching the success seen with bariatric surgery. Future agents combining the benefits of satiety control and thermogenesis to dissipate caloric excess are under investigation.

Body weight and obstructive sleep apnea: a mathematical relationship between body mass index and apnea-hypopnea index in veterans

STUDY OBJECTIVES

A high body mass index (BMI) is a risk factor for obstructive sleep apnea. However, to our knowledge there is no reported equation that quantifies the relationship between weight, as measured by BMI, and apnea severity, as assessed by the apnea-hypopnea index (AHI). Our objective was to find a mathematical relationship between BMI and AHI.

METHODS

We prospectively recruited 434 veterans from our polysomnography laboratory. Veterans already undergoing a sleep study were approached, and those who consented were enrolled. The veterans who enrolled in our study also participated in their scheduled sleep study. This study was approved by our institutional review board.

RESULTS

We found a simple mathematical relationship between BMI and AHI: for every 1-point drop in BMI (corresponding to 5-8 pounds, depending on a person's height), AHI decreases by 6.2%. And limiting BMI to 25-40 kg/m2 (which includes about 80% of the BMIs), then AHI drops by 7.1%. Simply put as a rule of thumb: For every 7-pounds drop in weight, expect a 7% drop in AHI.

CONCLUSIONS

To our knowledge, this is the first simple mathematical equation that associates the severity of weight with the severity of apnea in veterans. This equation can be a practical rule of thumb that can be implemented in clinics to predict the amount of weight a patient needs to lose to decrease their apnea, which might help motivate patients to lose weight.

CITATION

Fattal D, Hester S, Wendt L. Body weight and obstructive sleep apnea: a mathematical relationship between body mass index and apnea-hypopnea index in veterans. J Clin Sleep Med. 2022;18(12):2723-2729.

Semaglutide for Weight Loss: Was It Worth the Weight?

Obesity is a major public health issue with an increasing prevalence worldwide. Excess body fat is associated with various comorbidities, as well as increased overall mortality risk. The benefits of weight loss are evident by the reductions in morbidity and mortality. The foundation for most weight loss programs involves strict lifestyle modification, including dietary change and exercise. Unfortunately, many individuals struggle with weight loss and chronic weight management due to difficulty adhering to long-term lifestyle modification and the metabolic adaptations that promote weight regain. The use of adjunctive pharmacotherapy has been employed to help patients not only achieve greater weight loss than lifestyle modification alone but also to assist with long-term weight management. Historically, antiobesity drugs have produced only modest weight loss and required at least once daily administration. Glucagon-like peptide-1 (GLP-1), a hormone with significant effects on glycemic control and weight regulation, has been explored for use as adjunctive pharmacotherapy for weight loss. Semaglutide, a GLP-1 receptor agonist, was recently approved by the Food and Drug Administration for chronic weight management in adults with obesity or who are overweight. The approval came after the publication of the Semaglutide Treatment Effect in People with Obesity clinical trials. In these 68-week trials, semaglutide 2.4 mg was associated with significantly greater weight loss compared to placebo. Semaglutide differs from other GLP-1 receptor agonists by having a longer half-life and producing greater weight loss. This article provides an overview of the discovery and mechanism of action of semaglutide 2.4 mg, and the clinical trials that led to its approval.

Upper airway modifications after weight loss: a systematic review

OBJECTIVE

Weight loss is one of the most often prescribed treatments to reduce the level of sleep apnea severity; however, objective assessment of airway alterations after loss of weight has only been studied in the last decades. This study aimed at evaluating alterations after weight loss reported in the literature.

METHODS

A literature review was performed in the medical databases: PubMed, Web of Science, Scopus and Embase. A total of 681 articles were found in the databases and after evaluation only 10 studies were selected for data extraction.

RESULTS

Most studies observed an increase of the area in the retropalatal region; some indicating that this increase occurred mostly in the lateral pharyngeal region. Studies with volumetric reconstruction showed a significant reduction in parapharyngeal fat deposits, lateral wall and tongue fat, and volumetric reduction in all soft tissues of the pharynx, pterygoid and genioglossus muscles. Studies evaluating craniofacial bone structures showed a reduction in the airway height by bringing the hyoid closer to the posterior nasal spine and a reduction in the distance from the hyoid to the chin.

CONCLUSION

There is a limited number of studies with a good level of scientific evidence evaluating changes in the upper airways after weight loss and how these changes impact obstructive sleep apnea. The studies included in this review indicate that weight loss increases the airways space by reducing the volume of the parapharyngeal structures, particularly at the retropalatal site, where there is an apparent gain in the lateral area of the airway and hyoid relocation.

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

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

American Association of Clinical Endocrinology Clinical Practice Guideline: Developing a Diabetes Mellitus Comprehensive Care Plan-2022 Update

OBJECTIVE

The objective of this clinical practice guideline is to provide updated and new evidence-based recommendations for the comprehensive care of persons with diabetes mellitus to clinicians, diabetes-care teams, other health care professionals and stakeholders, and individuals with diabetes and their caregivers.

METHODS

The American Association of Clinical Endocrinology selected a task force of medical experts and staff who updated and assessed clinical questions and recommendations from the prior 2015 version of this guideline and conducted literature searches for relevant scientific papers published from January 1, 2015, through May 15, 2022. Selected studies from results of literature searches composed the evidence base to update 2015 recommendations as well as to develop new recommendations based on review of clinical evidence, current practice, expertise, and consensus, according to established American Association of Clinical Endocrinology protocol for guideline development.

RESULTS

This guideline includes 170 updated and new evidence-based clinical practice recommendations for the comprehensive care of persons with diabetes. Recommendations are divided into four sections: (1) screening, diagnosis, glycemic targets, and glycemic monitoring; (2) comorbidities and complications, including obesity and management with lifestyle, nutrition, and bariatric surgery, hypertension, dyslipidemia, retinopathy, neuropathy, diabetic kidney disease, and cardiovascular disease; (3) management of prediabetes, type 2 diabetes with antihyperglycemic pharmacotherapy and glycemic targets, type 1 diabetes with insulin therapy, hypoglycemia, hospitalized persons, and women with diabetes in pregnancy; (4) education and new topics regarding diabetes and infertility, nutritional supplements, secondary diabetes, social determinants of health, and virtual care, as well as updated recommendations on cancer risk, nonpharmacologic components of pediatric care plans, depression, education and team approach, occupational risk, role of sleep medicine, and vaccinations in persons with diabetes.

CONCLUSIONS

This updated clinical practice guideline provides evidence-based recommendations to assist with person-centered, team-based clinical decision-making to improve the care of persons with diabetes mellitus.

Obstructive Sleep Apnea and Nonalcoholic Fatty Liver Disease in the General Population: A Cross-Sectional Study Using Nationally Representative Data

(1) Background: To evaluate the association between obstructive sleep apnea (OSA) and nonalcoholic fatty liver disease (NAFLD) in the general population using a nationally representative sample from South Korea; (2) Methods: This study included 4275 adults aged ≥40 years who completed the snoring, tiredness, observed apnea, high blood pressure, body mass index (BMI), age, neck circumference, and gender (STOP-Bang) questionnaire. The risk of OSA was stratified into low, intermediate, and high grades according to the STOP-Bang score. The prevalence of NAFLD according to the STOP-Bang score was calculated, and the increasing trend was measured. A complex sample multivariable regression analysis with adjustments for possible confounding variables was used to calculate the odds ratio of NAFLD and advanced fibrosis. Subgroup analysis was conducted with stratification based on sex and obesity status; (3) Results: We identified 1021 adults with NAFLD and 3254 adults without NAFLD. The prevalence of NAFLD increased significantly with higher STOP-Bang scores in both men and women. Participants of both sexes with high STOP-Bang scores were more likely to have NAFLD. Compared to non-obese individuals, the risk of NAFLD according to the STOP-Bang score was more intense in obese individuals. With respect to hepatic steatosis, there was no significant association between advanced fibrosis and STOP-Bang score; (4) Conclusions: OSA, the risk of which was measured using the STOP-Bang model, was closely associated with NAFLD in both Korean men and women. Clinicians should consider screening for NAFLD in individuals with a high STOP-Bang score.

Bidirectional relationships of comorbidity with obstructive sleep apnoea

Obstructive sleep apnoea (OSA) is frequently associated with comorbidities that include metabolic, cardiovascular, renal, pulmonary and neuropsychiatric. There is considerable evidence that OSA is an independent risk factor for many of these comorbidities but, more recently, there is evidence that some of these comorbidities may predispose to the development of OSA. Thus, there is growing evidence of a bidirectional relationship between OSA and comorbidity, especially for heart failure, metabolic syndrome and stroke. Potential mechanisms of bidirectional relationships differ in individual comorbidities with fluid retention and redistribution being especially important in heart failure and end-stage renal disease, whereas neural mechanisms may be more important in diabetes mellitus and stroke. The evidence for other comorbidities, such as hypertension and atrial fibrillation, support these being more a consequence of OSA with limited evidence to support a bidirectional relationship. The present review explores the evidence for such bidirectional relationships with a particular perspective on comorbidities that may predispose to OSA. The impact of therapy in bidirectional relationships is also reviewed, which highlights the clinical importance of accurate diagnosis. This aspect is especially true of COPD, where the identification of co-existing OSA has important implications for optimum therapy.

Obstructive sleep apnoea (OSA) is an independent risk factor for comorbidity, especially cardiometabolic. However, some comorbidities may be risk factors for OSA, supporting a bidirectional relationship that may have important implications for treatment.https://bit.ly/3BbJy6V

Asian Pacific Society of Cardiology Consensus Statements on the Diagnosis and Management of Obstructive Sleep Apnoea in Patients with Cardiovascular Disease

Obstructive sleep apnoea (OSA) is strongly associated with cardiovascular disease (CVD). However, evidence supporting this association in the Asian population is scarce. Given the differences in the epidemiology of CVD and cardiovascular risk factors, as well as differences in the availability of healthcare resources between Asian and Western countries, an Asian Pacific Society of Cardiology (APSC) working group developed consensus recommendations on the management of OSA in patients with CVD in the Asia-Pacific region. The APSC expert panel reviewed and appraised the available evidence using the Grading of Recommendations Assessment, Development, and Evaluation system. Consensus recommendations were developed and put to an online vote. Consensus was reached when 80% of votes for a given recommendation were in support of ‘agree’ or ‘neutral.’ The resulting statements provide guidance on the assessment and treatment of OSA in patients with CVD in the Asia-Pacific region. The APSC hopes for these recommendations to pave the way for screening, early diagnosis and treatment of OSA in the Asia-Pacific region.

Current and Novel Treatment Options for OSA

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

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

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 and Obstructive Sleep Apnea

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

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.

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

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

Sleep disorders in people with type 2 diabetes and associated health outcomes: a review of the literature

Sleep disorders are linked to development of type 2 diabetes and increase the risk of developing diabetes complications. Treating sleep disorders might therefore play an important role in the prevention of diabetes progression. However, the detection and treatment of sleep disorders are not part of standardised care for people with type 2 diabetes. To highlight the importance of sleep disorders in people with type 2 diabetes, we provide a review of the literature on the prevalence of sleep disorders in type 2 diabetes and the association between sleep disorders and health outcomes, such as glycaemic control, microvascular and macrovascular complications, depression, mortality and quality of life. Additionally, we examine the extent to which treating sleep disorders in people with type 2 diabetes improves these health outcomes. We performed a literature search in PubMed from inception until January 2021, using search terms for sleep disorders, type 2 diabetes, prevalence, treatment and health outcomes. Both observational and experimental studies were included in the review. We found that insomnia (39% [95% CI 34, 44]), obstructive sleep apnoea (55-86%) and restless legs syndrome (8-45%) were more prevalent in people with type 2 diabetes, compared with the general population. No studies reported prevalence rates for circadian rhythm sleep-wake disorders, central disorders of hypersomnolence or parasomnias. Additionally, several cross-sectional and prospective studies showed that sleep disorders negatively affect health outcomes in at least one diabetes domain, especially glycaemic control. For example, insomnia is associated with increased HbA_1c levels (2.51 mmol/mol [95% CI 1.1, 4.4]; 0.23% [95% CI 0.1, 0.4]). Finally, randomised controlled trials that investigate the effect of treating sleep disorders in people with type 2 diabetes are scarce, based on a small number of participants and sometimes inconclusive. Conventional therapies such as weight loss, sleep education and cognitive behavioural therapy seem to be effective in improving sleep and health outcomes in people with type 2 diabetes. We conclude that sleep disorders are highly prevalent in people with type 2 diabetes, negatively affecting health outcomes. Since treatment of the sleep disorder could prevent diabetes progression, efforts should be made to diagnose and treat sleep disorders in type 2 diabetes in order to ultimately improve health and therefore quality of life.

Association of Glycemia, Lipids, and Blood Pressure With Cognitive Performance in People With Type 2 Diabetes in the Glycemia Reduction Approaches in Diabetes: A Comparative Effectiveness Study (GRADE)

OBJECTIVE

Type 2 diabetes is a risk factor for cognitive impairment. We examined the relation of glycemia, lipids, blood pressure (BP), hypertension history, and statin use with cognition in the Glycemia Reduction Approaches in Diabetes: A Comparative Effectiveness Study (GRADE).

RESEARCH DESIGN AND METHODS

Cross-sectional analyses from GRADE at baseline examined the association of glycemia (hemoglobin A_1c [HbA_1c]), LDL, systolic BP (SBP) and diastolic BP (DBP), hypertension history, and statin use with cognition assessed by the Spanish English Verbal Learning Test, letter and animal fluency tests, and Digit Symbol Substitution Test (DSST).

RESULTS

Among 5,047 GRADE participants, 5,018 (99.4%) completed cognitive assessments. Their mean age was 56.7 ± 10.0 years, and 36.4% were women. Mean diabetes duration was 4.0 ± 2.7 years. HbA_1c was not related to cognition. Higher LDL was related to modestly worse DSST scores, whereas statin use was related to modestly better DSST scores. SBP between 120 and 139 mmHg and DBP between 80 and 89 mmHg were related to modestly better DSST scores. Hypertension history was not related to cognition.

CONCLUSIONS

In people with type 2 diabetes of a mean duration of <5 years, lower LDL and statin use were related to modestly better executive cognitive function. SBP levels in the range of 120-139 mmHg and DBP levels in the range of 80-89 mmHg, but not lower levels, were related to modestly better executive function. These differences may not be clinically significant.

Does Lifestyle Intervention Improve Health of Adults with Overweight/Obesity and Type 2 Diabetes? Findings from the Look AHEAD Randomized Trial

This paper reviews the main findings from the Action for Health in Diabetes (Look AHEAD) Trial, a randomized trial testing the long-term health effects of intensive lifestyle interventions (ILIs) in 5,145 persons with overweight/obesity and type 2 diabetes. Although the primary outcome originally focused on cardiovascular morbidity and mortality, secondary outcomes included a broad range of health parameters related to diabetes and obesity. As the cohort aged, study outcomes were expanded to include health problems affecting geriatric populations, such as cognitive impairment and disability.This review summarizes the history of this trial and presents findings related to a wide range of health outcomes. Studies are reviewed that showed positive impact of ILI on diabetes control and complications, depression, physical health-related quality of life, sleep apnea, incontinence, brain structure, and health care use and costs. Several composite indices were also positively impacted by ILI, including multimorbidity, geriatric syndromes, and disability-free life years. However, there are also some important outcomes that did not show significant differences between the intervention and control, including cardiovascular morbidity and mortality, cancer, cognitive function, and cognitive impairment; for several of these nonsignificant effects, post hoc analyses suggested that there may be differences among subgroups, raising the possibility that ILI may be beneficial to some but potentially harmful to others. The only adverse effects of ILI relative to diabetes support and education were on frailty fractures and the related negative effects on body composition and bone density. Through this review, the manuscript seeks to determine whether weight loss should be encouraged in this population; given the large number of beneficial effects, relative to the small number of adverse effects, the answer appears to be yes.

The relationship between three-dimensional craniofacial and upper airway anatomical variables and severity of obstructive sleep apnoea in adults

OBJECTIVE

The aim of this study was to evaluate the relationship between three-dimensional craniofacial and upper airway anatomical variables and severity of obstructive sleep apnoea (OSA) using cone beam computed tomography (CBCT).

METHODS

This was a prospective observational study, consisted of 95 adult OSA whose polysomnography and CBCT were available. Three-dimensional craniofacial and upper airway anatomical analysis were performed using 12 CBCT variables, including sagittal and vertical jaw relationships, maxillary width, the volume, length and minimum axial area of upper airway. The severity of OSA was evaluated through the apnea-hypopnea index (AHI). A hierarchical regression was performed to analyze the relationship between OSA severity and craniofacial and upper airway anatomical variables after controlling patients' demographic characteristics (gender, age, and BMI).

RESULTS

After controlling patients' gender, age, and BMI, individual CBCT variables including MAA, V-RPA, L-RPA and Go-Me were related to AHI. The final hierarchical regression model with demographic variables in Step 1 and CBCT variables (MAA, L-RPA and Go-Me) in Step 2 indicated that CBCT variables added additional explanatory power for AHI (ΔF(3,88) = 5.176, P = 0.002). Among these variables, L-RPA and Go-Me were statistically significant (P < 0.05).

LIMITATION

The OSA severity was expressed by AHI alone.

CONCLUSIONS

Three-dimensional craniofacial and upper airway morphology played an essential role in OSA severity. The most relevant anatomical characteristic with OSA severity were the length of retropalatal airway and mandibular body, which could be used to recognize severe OSA patients and as estimators for selecting the most appropriate treatment modality for OSA patients.

Contemporary Concise Review 2020: Sleep

Obstructive sleep apnoea (OSA) now affects one-seventh of the world's population. Treatment of even mild OSA can improve daytime sleepiness and quality of life. Recent modifications to uvulopalatopharyngoplasty may make it a more widely applicable treatment option in selected patients with OSA. Diet and exercise have effects on sleep apnoea severity independent of weight loss. Insomnia has become increasingly common during the coronavirus disease 2019 (COVID-19) pandemic.

Effect of Subcutaneous Semaglutide vs Placebo as an Adjunct to Intensive Behavioral Therapy on Body Weight in Adults With Overweight or Obesity: The STEP 3 Randomized Clinical Trial

IMPORTANCE

Weight loss improves cardiometabolic risk factors in people with overweight or obesity. Intensive lifestyle intervention and pharmacotherapy are the most effective noninvasive weight loss approaches.

OBJECTIVE

To compare the effects of once-weekly subcutaneous semaglutide, 2.4 mg vs placebo for weight management as an adjunct to intensive behavioral therapy with initial low-calorie diet in adults with overweight or obesity.

DESIGN, SETTING, AND PARTICIPANTS

Randomized, double-blind, parallel-group, 68-week, phase 3a study (STEP 3) conducted at 41 sites in the US from August 2018 to April 2020 in adults without diabetes (N = 611) and with either overweight (body mass index ≥27) plus at least 1 comorbidity or obesity (body mass index ≥30).

INTERVENTIONS

Participants were randomized (2:1) to semaglutide, 2.4 mg (n = 407) or placebo (n = 204), both combined with a low-calorie diet for the first 8 weeks and intensive behavioral therapy (ie, 30 counseling visits) during 68 weeks.

MAIN OUTCOMES AND MEASURES

The co-primary end points were percentage change in body weight and the loss of 5% or more of baseline weight by week 68. Confirmatory secondary end points included losses of at least 10% or 15% of baseline weight.

RESULTS

Of 611 randomized participants (495 women [81.0%], mean age 46 years [SD, 13], body weight 105.8 kg [SD, 22.9], and body mass index 38.0 [SD, 6.7]), 567 (92.8%) completed the trial, and 505 (82.7%) were receiving treatment at trial end. At week 68, the estimated mean body weight change from baseline was -16.0% for semaglutide vs -5.7% for placebo (difference, -10.3 percentage points [95% CI, -12.0 to -8.6]; P < .001). More participants treated with semaglutide vs placebo lost at least 5% of baseline body weight (86.6% vs 47.6%, respectively; P < .001). A higher proportion of participants in the semaglutide vs placebo group achieved weight losses of at least 10% or 15% (75.3% vs 27.0% and 55.8% vs 13.2%, respectively; P < .001). Gastrointestinal adverse events were more frequent with semaglutide (82.8%) vs placebo (63.2%). Treatment was discontinued owing to these events in 3.4% of semaglutide participants vs 0% of placebo participants.

CONCLUSIONS AND RELEVANCE

Among adults with overweight or obesity, once-weekly subcutaneous semaglutide compared with placebo, used as an adjunct to intensive behavioral therapy and initial low-calorie diet, resulted in significantly greater weight loss during 68 weeks. Further research is needed to assess the durability of these findings.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03611582.

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.

Alternative Procedure to Individual Nasal Pressure Titration for Sleep Apnea

In the treatment of obstructive sleep apnea (OSA), the current standard of "CPAP titration" in the laboratory or at home is a resource demanding and costly approach that, in developed economies, markedly augments healthcare costs and in low resource economies precludes access to care altogether. Here, we discuss that current guidelines for titration of CPAP could be obviated by taking a different route that in many ways is similar to the institution of treatment in many other medical conditions. To this effect, we present novel population based data from 16,780 patients, showing that after individualized and labor-intensive and expensive CPAP titration, 86.4% of OSA patients are treated with nasal pressure settings within the range of 9 ± 2 cmH₂O, and review the literature to justify the potential adoption of a standard therapeutic CPAP setting as the initial intervention which would be subsequently followed by any necessary adjustments in only a minority of patients who would not derive the necessary benefit from such standardized intervention. Assuming an 80-85% success rate as derived from our analyses, our personal view if extensively adopted could radically reduce healthcare costs and enable markedly improve access to diagnostics.