Continuous positive airway pressure was previously defined as the primary treatment of OSA, as well as related issues like mask fits. Weight management has been continuously unaddressed in guidelines and literature.
Overweight and obesity—common yet reversible risks for obstructive sleep apnea (OSA)—are now being targeted by new guidelines released by the American Thoracic Society for management of the sleep condition.
In a study supporting the guidelines, weight-loss interventions, particularly comprehensive lifestyle interventions, have been found to correlate with improvements in OSA severity, cardiometabolic comorbidities, and quality of life, investigator David W. Hudgel, MD, told MD Magazine®. In fact, most patients with OSA are already overweight or obese.
“I observed a few patients referred to comprehensive weight loss programs who lost significant weigh—such that their OSA also improved, as well as cardiovascular co-morbidities,” Hudgel said. “Also, it seemed that weight management of OSA was not being presented to OSA patients as a therapeutic option, wasn't being discussed at national meetings, but [are] known to be effective.”
Previously, continuous positive airway pressure (CPAP) was defined as the primary treatment of OSA, as well as related issues like mask fits. Weight management was continuously unaddressed.
To confront this issue, Hudgel assembled a 20-member, international panel of sleep, pulmonary, weight management specialists, behavioral science experts, and patients to critically review literature and develop updated therapeutic recommendations. Together, the panel reviewed studies, which they rated in strength by using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system.
Hudgel emphasized to MD Mag that the team followed “rigorous methods” put in place for guideline development. Recommendations were derived based on the strength, extent, and quality of literature supporting them.
While reductions in OSA severity, reverses in common comorbidities, and improvements in quality of life were found to correlate with behavioral, pharmacological, and surgical treatments, given the methodological limitations in the studies evaluated, the panel turned to a comprehensive lifestyle intervention.
In the intervention, the panel called for 3 main criteria: a reduced calorie diet, increased physical activity or exercise, and behavioral guidance. This intervention criteria were prescribed for overweight or obese OSA patients with a body mass index (BMI) ≥ 25 kg/m2.
An evaluation for anti-obesity pharmacotherapy was recommended for OSA patients with a BMI ≥27 kg/m2 who have not improved despite participating in a comprehensive program.
A suggested referral for bariatric surgery evaluation was also recommended for OSA patients with a BMI ≥ 35 kg/m2 that was not improved despite participating in a comprehensive weight loss lifestyle intervention program.
No contraindications to pharmacotherapy, like active cardiovascular disease, are a contingency for these recommendations. Active cardiovascular disease was defined as “myocardial infarction or cerebrovascular accident within the past 6 months, uncontrolled hypertension, life-threatening arrhythmias or decompensated congestive heart failure.”
Additionally, the panel found that the effect of gastric banding was the main therapy investigated by the only available well-controlled trials of bariatric surgery in OSA patients. Compared to lifestyle interventions that result in weight loss, gastric banding was not found to be more effective in reducing OSA severity.
Prevention of type 2 diabetes, improved glycemic control in those with type 2 diabetes, lower blood pressure, and improved quality of life were also found to be associated with weight loss by the panel, showing the benefits of weight management beyond OSA.
Hudgel anticipated that these guidelines will eventually become the standard of care for OSA patients combating overweight or obesity.
“With weight loss, OSA severity will improve, allowing for lower CPAP pressure or no CPAP at all, and improved cardiovascular co-morbidities, such as hypertension and myocardial risks, as well as improved quality of life,” Hudgel said.