Bridging Obesity Medicine and Sleep Medicine

Recent research has elevated the management of obesity in patients with sleep disorders to a prominent position in clinical practice. Obesity has been capturing attention across social media, mainstream news, and even in cultural references such as South Park specials and Jimmy Kimmel’s 2023 Oscars commentary. This heightened focus underscores the growing importance of addressing this issue. Obesity is still considered one of the primary risk factors for obstructive sleep apnea (OSA) as well as obesity hypoventilation syndrome (OHS). Clinical data demonstrates a strong correlation between higher severity of OSA with increased body mass index (BMI) and adiposity (1). This fact raises the question: what strategies can sleep medicine providers at all levels use in clinical practice to implement preventive care rather than remedially treat moderate to severe sleep disorders? And what can we do to support patients who are struggling with obesity?

Personally, after a few years in practice as a sleep medicine physician, I recited over and over to my patients with obesity: “There are many medical conditions that can improve with weight loss, and obstructive sleep apnea is part of those health concerns” or “As part of your treatment, weight loss will help you possibly reduce the severity of your sleep apnea.” More often than not, I would get answers such as: “Doctor, I have tried everything and nothing works!” or “I have tried everything and even when I eat healthy and constantly exercise my weight remains the same.”  Those repetitive answers quickly made me displeased that I was not providing my patients with individualized, specific, and goal-oriented recommendations to help them achieve a healthier weight. Curiosity led me to pursue specific training and obtain a board certification in obesity medicine, which changed everything.

Obesity medicine defines obesity as a “chronic, relapsing, multifactorial, neurobehavioral disease, wherein an increase in body fat promotes adipose tissue dysfunction and abnormal fat mass physical forces, resulting in adverse metabolic, biomechanical, and psychosocial health consequences.” ^2-3. We target adiposity and not the number on the scale since overall weight does not always correlate with the changing distribution of adipose tissue, muscle mass and body water. The main treatment focus is to use nutrition, physical activity, behavioral modification, and medical interventions such as bariatric surgery and pharmacotherapy to improve obesity related diseases by reducing body fat and increasing muscle mass and water distribution.

There are different clinically useful parameters to identify patients with obesity. The BMI is the most widely used by insurance coverage. However, BMI does not always correlate with pathology because it does not consider muscle mass, bone density, overall body composition, and racial/sex differences. Waist circumference and body fat percentage measurements tend to have a better correlation with comorbidity and pathology, but the normal parameters vary widely depending on race. The American Association of Clinical Endocrinology (AACE) guidelines for the treatment of obesity correlate BMI with comorbidity and severity of obesity-related disorders. Under the AACE guidelines, a patient with mild to moderate obstructive sleep apnea (apnea hypopnea index (AHI) 5-29/hour) with BMI > or = 25 kg/m2 is assessed as Obesity stage 1 and severe OSA (AHI> 30 /hour) with BMI > or = 25 kg/m2 is assessed as Obesity stage 2 (4). The Edmonton Obesity Staging System (EOSS) is another staging tool that uses obesity-related clinical risk factors to determine the need for weight loss intervention. In a patient with a diagnosis of OSA as an obesity-related condition in need of intervention, a Stage 2 Obesity classification would be considered independently of the WHO classification of weight status (BMI) (5). The AACE and EOSS guidelines have shown to be more reliable assessment tools that help clinicians prioritize obesity-related complications by risk stratification leading to early identification of the need for weight management interventions. In general, a BMI > 25 kg/m2 combined with an increased waist circumference in patients with comorbid sleep disorders is the starting point to identify patients needing preventive weight management care.

After identifying the need for weight management care, the first step is to ask for permission to talk about their weight and use motivational interviewing tools. Discussing specific nutritional needs and patterns while considering long-term sustainability and small achievable goals is essential to building a well-rounded treatment plan. It’s also important to acknowledge that a long-term, sustainable nutritional plan the patient can follow is preferable to a restrictive diet for a short time, regardless of the dietary approaches used. Consider any dietary restrictions, food allergies, cultural preferences, and specific risk factors of nutritional deficiencies especially if there is a history of bariatric surgery. The expansion and exploration of new food choices rich in wholesome protein, antioxidants, and omega-3 fatty acids can reduce inflammation of the upper airway and lower the risk of sleep-breathing disorder (6).

A strategic and goal-oriented involvement in physical activity (PA) is crucial for facilitating good sleep quality and weight loss.  Participation in moderate to vigorous physical activity has been shown to reduce sleep latency, increase sleep efficiency and deep sleep staging. The most recent recommendations from the American College of Sports Medicine (ACSM) for patients with obesity is a weekly average of 150 to 300 minutes of aerobic PA at a moderate intensity and strengthening/resistance PA at least two times per week with the involvement of at least two muscle groups (7). It is important to work within any individual physical limitations or activity intolerances while providing alternatives to overcome them. Physical activity goals should be specific, realistic, and safe. Additionally, the patient’s PA goals should include a defined frequency, intensity based on their capabilities, a specific time duration, the type of activity, and tailored guidance to promote long-term enjoyment.

Promoting good eating habits can lead to enhanced sleep!

Just as sleep hygiene behavioral measures are vital for sleep medicine providers, behavioral modification is fundamental to the long-term enhancement of obesity management in patients with sleep disorders. General environmental behaviors that increase weight loss success are eating only at the table, keeping tempting foods out of sight, and avoiding the kitchen before bed to maintain a restful sleep environment. Recommending the avoidance of eating while working and instead opting for planned healthy snacks can aid in weight control. If patients dine out late at night, advise them to opt for smaller portions to prevent late-night discomfort. Also, recommending the use of smaller sized plates for dinner will support better sleep. Lastly,  engaging in regular physical activity in the early morning or early afternoon will ensure improved sleep quality and support weight loss goals.

Sleep medicine providers and clinicians are still cautiously attentive to the fresh findings of the new generation of anti-obesity medications. When assessing sleep patients for obesity, the primary step regarding pharmacology is to identify weight-promoting medications such as antidepressants, antipsychotics, anticonvulsants, beta-blockers, corticosteroids, antihistamines and review use of insulin or sulfonylureas. Also, the review of sleep-related medications and sleep aids that are weight promoting, such as gabapentin, doxepin, trazodone, diphenhydramine, and over-the-counter supplements such as valerian root could affect the patient’s weight management outcome. In most cases there are alternatives that are weight-neutral or weight-loss promoting such as melatonergic hypnotics.

Studies suggest that for every 1% decrease in total body weight (TBW) percentage there is an estimated change of 0.45 events per hour in the AHI, with a significant level of decrease in OSA comorbidity risks when 10-15% of TBW loss have been achieved (8). The advances in anti-obesity pharmacotherapy with Glucagon-like peptide 1 (GLP-1) and Glucose-dependent Insulinotropic polypeptide (GIP) agonists are making strides in sleep apnea treatment. Most recent research such as SURMOUNT OSA Phase 3 trial highly suggest that medications such as Tirzepatide can be a significant advancement for the traditional treatment of obstructive sleep apnea in patients with obesity (9). These advancements in medication offer a promising leap forward, potentially revolutionizing the management of sleep and obesity disorders.

In summary, as we deepen our understanding of supporting and treating patients with obesity in relation to sleep disorders, recognizing when to seek additional expertise is needed. Referring patients to an obesity medicine specialist is essential when standard interventions prove inadequate, especially in cases of inconsistent weight loss and regain, multiple comorbidities involving cardiovascular, pulmonary, or neurological conditions, restricted mobility due to excess weight, or significant obstacles to achieving effective weight loss. For those at risk of nutritional deficiencies due to bariatric surgery, or who require advanced, individualized care, a specialist can provide transformative support. This comprehensive, specialized approach is essential for optimizing patient outcomes by enhancing personalized sleep medicine care.

By: Rafael Sepulveda, MD D-ABOM

Source SleepWorld Magazine Sept/Oct 2024 Issue

References:

1. Sleep, Volume 47, Issue Supplement_1, May 2024, Page A372, https://doi.org/10.1093/sleep/zsae067.0866
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3. Bray G.A., Kim K.K., Wilding J.P.H., World Obesity F. Obesity: a chronic relapsing progressive disease process. A position statement of the World Obesity Federation. Obes Rev. 2017; 18:715–723.
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8. Locke BW, Gomez-Lumbreras A, Tan CJ, et al. The association of weight loss from anti-obesity medications or bariatric surgery and apnea-hypopnea index in obstructive sleep apnea. Obesity Reviews. 2024; 25(4): e13697. doi:1111/obr.13697
9. Malhotra A, Bednarik J, Chakladar S, Dunn JP, Weaver T, Grunstein R, Fietze I, Redline S, Azarbarzin A, Sands SA, Schwab RJ, Bunck MC. Tirzepatide for the treatment of obstructive sleep apnea: Rationale, design, and sample baseline characteristics of the SURMOUNT-OSA phase 3 trial. Contemp Clin Trials. 2024 Jun; 141:107516. doi: 10.1016/j.cct.2024.107516. [/vc_column_text][/vc_column][/vc_row]