By Austin Ulrich, PharmD, BCACP
Consultant Pharmacist, Ulrich Medical Writing LLC, Greensboro, NC
SYNOPSIS: Obesity is a primary cause of obstructive sleep apnea (OSA), and improvements in weight and other lifestyle factors can yield benefits for OSA and related comorbidities.
SOURCE: Carneiro-Barrera A, Amaro-Gahete FJ, Guillén-Riquelme A, et al. Effect of an interdisciplinary weight loss and lifestyle intervention on obstructive sleep apnea severity: The INTERAPNEA randomized clinical trial. JAMA Netw Open 2022;5:e228212.
Globally, obstructive sleep apnea (OSA) places a substantial health burden on society, with approximately 936 million adults affected.1 As a result of pathologic effects from an intermittently occluded airway, OSA is responsible for increased risk for several comorbidities, including cardiovascular disease, hypertension, dyslipidemia, and diabetes. Risk factors for OSA include male sex, advancing age, and higher body mass index (BMI); obesity is considered the leading cause of OSA.1,2 Use of continuous positive airway pressure (CPAP) is the treatment of choice and should be offered as an option to all patients with OSA.3 Behavioral therapies, such as weight loss, exercise, and positional therapy, also are recognized as effective treatments. However, concentrated approaches incorporating widespread implementation of lifestyle changes to treat OSA are lacking.4
To evaluate the effectiveness of an interdisciplinary weight loss and lifestyle intervention on OSA and its comorbidities, Carneiro-Barrera et al conducted the Interdisciplinary Weight Loss and Lifestyle Intervention for OSA (INTERAPNEA) randomized, clinical trial. In this open-label trial, the authors enrolled men age 18-65 years with moderate to severe OSA, based on apnea-hypopnea index (AHI) scores ≥ 15 events/hour of sleep and BMI ≥ 25 kg/m2. Participants were recruited from an outpatient sleep unit of a hospital in Spain and were randomized to the standard of care (i.e., CPAP) alone or an eight-week weight loss and lifestyle intervention plus standard of care. The intervention included five components: nutritional behavior change, moderate aerobic exercise, smoking cessation, alcohol avoidance, and sleep hygiene, covered in weekly group-based sessions of 60-90 minutes. Participants assigned to standard of care alone received one-time advice on weight loss and lifestyle changes in a 30-minute session.
A total of 89 men were enrolled, with 49 in the control group and 40 in the intervention group. Baseline characteristics of the study population included average age of 54.1 years, mean AHI score of 41.3 events/hour, and mean BMI of 34.4 kg/m2. The primary endpoint was change in AHI at the end of the intervention period and at six months after intervention. Participants in the intervention group recorded a 51% reduction in AHI score at the intervention endpoint (41.6 events/hour at baseline vs. 20.4 events/hour at intervention endpoint; 95% CI, -25.4 to -16.9 events/hour). They also experienced a 57% reduction in AHI score six months after intervention (17.8 events/hour; 95% CI, -28.3 to -19.3 events/hour). In contrast, there were no significant differences in AHI scores in the control group at the intervention endpoint and six months after intervention. The intervention group demonstrated an AHI score 23.6 events/hour lower than the control group at intervention end and 23 events/hour lower at six months after intervention (P < 0.001). Additionally, 29.4% of participants in the intervention group experienced complete remission of OSA, and 61.8% no longer required CPAP at six months after intervention. The intervention group also experienced greater reductions in weight (-6.9 kg vs. -1.2 kg), BMI, neck circumference, chest circumference, waist circumference, fat mass, visceral adipose tissue, and cardiometabolic risk than the control group. Overall, participants in the intervention group experienced substantial reductions in body weight (-7%), fat mass (-19%), and visceral adipose tissue (-26%).
The authors concluded that in Spanish men with moderate to severe OSA treated with CPAP, clinically meaningful and sustainable improvements in OSA and related outcomes resulted from an eight-week interdisciplinary weight loss and lifestyle intervention.
COMMENTARY
In this study, significant and durable benefits for OSA, weight loss, and related comorbidities were observed with a structured weight loss and lifestyle intervention. Despite the well-documented effectiveness of weight loss to improve OSA, few investigators have fully explored structured weight loss interventions in combination with lifestyle modification that includes alcohol avoidance and smoking cessation, as in the INTERAPNEA trial.4 Limitations to this study are related primarily to generalizability; the trial only included Spanish men, so results may not be applicable to other populations. The authors included only men because of the higher incidence and prevalence of OSA, difference in OSA phenotype between men and women, and effectiveness of weight loss interventions in men.5 However, there remains a need for identification and management of OSA in women.5
Although patients with OSA often are referred to a sleep specialist, primary care practitioners (PCPs) frequently encounter sleep apnea and its complications in routine practice.6 PCPs play a key role in referring patients based on suspicion of sleep apnea and also can be involved in longitudinal management of OSA. Based on the significant benefits of weight loss and lifestyle interventions observed in the INTERAPNEA trial, PCPs can help emphasize lifestyle change as part of managing OSA. The benefits of these interventions also can prove valuable for other chronic conditions often managed solely in primary care.
REFERENCES
- Benjafield AV, Ayas NT, Eastwood PR, et al. Estimation of the global prevalence and burden of obstructive sleep apnoea: A literature-based analysis. Lancet Respir Med 2019;7:687-698.
- Senaratna CV, Perret JL, Lodge CJ, et al. Prevalence of obstructive sleep apnea in the general population: A systematic review. Sleep Med Rev 2017;34:70-81.
- Epstein LJ, Kristo D, Strollo PJ Jr, et al. Clinical guideline for the evaluation, management and long-term care of obstructive sleep apnea in adults. J Clin Sleep Med 2009;5:263-276.
- Carneiro-Barrera A, Díaz-Román A, Guillén-Riquelme A, Buela-Casal G. Weight loss and lifestyle interventions for obstructive sleep apnoea in adults: Systematic review and meta-analysis. Obes Rev 2019;20:750-762.
- Wimms A, Woehrle H, Ketheeswaran S, et al. Obstructive sleep apnea in women: Specific issues and interventions. Biomed Res Int 2016;2016:1764837.
- Pendharkar SR, Blades K, Kelly JE, et al. Perspectives on primary care management of obstructive sleep apnea: A qualitative study of patients and health care providers. J Clin Sleep Med 2021;17:89-98.
Obesity is a primary cause of obstructive sleep apnea (OSA), and improvements in weight and other lifestyle factors can yield benefits for OSA and related comorbidities.
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