11. • Obstructive sleep apnea (OSA)—also referred to
as obstructive sleep apnea-hypopnea (OSAH)—is
a sleep disorder that involves cessation or
significant decrease in airflow in the presence of
breathing effort.
• There are cases where breathing stops for more
than 60 seconds during sleep
WHAT IS OSA?
12. • OSA is the most common type of sleep-disordered
breathing (SDB) and is characterized by recurrent
episodes of upper airway collapse during sleep.
• These episodes are associated with recurrent
oxyhemoglobin desaturations and arousals from
sleep.
15. WHAT IS OSA?
• Episodes of complete or partial collapse of airway
are translated to # of apnea and hypopnea
events (AHI).
– Apnea = Cessation of airflow > 10 seconds
– Hypopnea = Decreased airflow > 10 seconds
associated with:
• Arousal
• Oxyhemoglobin desaturation
16.
17. Measures of Sleep Apnea Frequency
• Apnea Index
– # apneas per hour of sleep
• Apnea / Hypopnea Index (AHI)
– # apneas + hypopneas per hour
of sleep
19. OSA
• Obstructive Sleep Apnea
– Cessation of airflow for 10 seconds
– Usually associated with 4% oxygen desaturation
• Obstructive Sleep hypopnea
– Decrease of 30–50% in airflow for 10 seconds
– May be associated with 4% oxygen desaturation
OSA syndrome
AHI ≥ 5
+
Symptom
20. Suggestion of sleep apnea
Snoring
Witnessed apnea, gasping
Obesity (esp. neck circumference)
Hypertension
Excessive daytime sleepness
Family history
Previous tonsillectomy
Non-restorative sleep
AHI ≥ 5+
OSA
syndrome
22. • OSA associated with excessive daytime
sleepiness (EDS) is commonly called obstructive
sleep apnea syndrome (OSAS)—also referred to
as obstructive sleep apnea-hypopnea syndrome
(OSAHS).
• Despite being a common disease, OSAS is under
recognized by most primary care physicians in the
United States; an estimated 80% of Americans
with OSAS are not diagnosed.
23. Why does OSA occur?
• Upper airway tone is decreased during sleep,
especially in REM
• Collapse/obstruction of the upper airway during
sleep causes obstruction & apnea
-
-
-
-
-
Nares /hard palate
Pharynx
Larynx / trachea
24. Most of apneic episodes occur within the pharynx, due to
the deformation of soft tissue (tongue, soft-palate).
30. OSA Increases Co-Morbid Health Risks
• OSA is an independent risk factor for HTN & Type II DM
Obesity
Depression
40%
Diabetes
50%
CHF
50%
50%
Stroke
50%
Hypertension
35%
Wolk et al 2003 Javaheri et al 1999,
Somers et al 2007
Einhorn ADA 2005
Sjostrom et al 2004Sandberg et al 2008Smith et al 2002,
Schroder et al 2005
• Left undiagnosed, OSA increases risk of stroke by 2X, risk of fatal
cardiovascular events by 5X, and risk of serious vehicular accidents
%DiseaseCo-morbiditywithOSA
= With OSA
Sources: Yaggi et al, NEJM 2005; Young et al, Sleep 2008; Teran-Santos, NEJM 1999
31. Sleep Apnea is:
• Common
• Dangerous
• Easily recognized
• Treatable
32. • Identification of at-risk individuals for this
potentially serious condition continues to pose a
challenge.
• Underrecognition of presenting symptoms by
physcians, and by patients, may be one
contributing factor for improper identification and
management of OSA.
33. Prevalence in Middle Aged Adults
% Men % Women
AHI ≥ 5
AHI ≥ 5 + daytime somnolence
24 9
4 2
AHI = Apnea Hypopnea Index
Symptomatic OSA (OSA with EDS)present in 4% of
middle aged men and 2% of women
34. Prevalence of Sleep Apnea
Sleep apnea is a common disorder.
0
5
10
15
20
25
AHI > 5 SAS Asthma
Male
Female
U.S. Pop
30-60 year olds
Percent of
Population
Adapted from Young T et al. N Engl J Med 1993;328.
35. OSA is a Largely Undiagnosed
Epidemic
• 18 million suffer (prevalence similar to Diabetes)
• 85% have not been diagnosed
Diabetes and OSA Prevalence is Similar
Diabetes OSA
Undiagnosed
Diagnosed
Millions of
Americans
(Adults)
10
20
Young 2002, 1997
36. Sleep apnea can effect anyone at anytime. From
children to star athletes, no one is immune to the
condition which is why it is all too important to be
tested for sleep disorders if you display any of the
common symptoms, such as snoring and daytime
sleepiness that never goes away.
While anyone can suffer from sleep apnea, certain
groups of people are more prone to suffering from
the condition
38. Sleep Apnea Risk Factors
Obesity
Increasing age
Male gender
Post-menopausal state
Family history
Alcohol or sedative use / sleeping pills
Smoking
Associated conditions e.g. Endocrinal
abnormalities
Craniofacial/Upper Airway Soft Tissue Anatomic
Abnormalities
39. • Although obesity is the most common cause of
OSA, sleep apnea also occurs in non-obese
patients with craniofacial features e.g
1. Narrowing of the hard palate,
2. Small jaw (or Micrognathia)
3. Long or large tongue (or macroglossia)
4. Mandible displaced backward (or retrognathism)
5. Large tonsils and adenoids (especially in children),
6. people with Down Syndrome
7. Nasal abnormalities, including septal deviation and
allergic rhinitis.
44. Obesity Epidemic
• World epidemic encompasses 1.7 billion people
• Highest in the U.S.
• Approximately 2/3 of Americans are
overweight, and almost half are obese
• BMI subgroups of >35 and >40 are
experiencing most rapid growth
48. Measuring weight
• Calibrated weighing
scales.
• Empty pockets.
• Remove shoes
• Keeping patient’s
dignity – remove
heavy items of
clothing.
• Ensure scales are
calibrated regularly.
49. STADIOMETER – measures height
• Remove shoes
• Stand upright
• Ears level with eye line
• Feet back against wall
50.
51.
52.
53.
54. Body mass index (BMI)
• Body mass index (BMI) is a measure of body fat based
on height and weight that applies to both adult men and
women.
BMI Categories
Underweight = <18.5
Normal weight = 18.5-24.9
Overweight = 25-29.9
Obesity = 30 or greater
Severe Obesity = 30.0 – 34.9
Morbid Obesity = >40
55. • Being 100 pounds over “ideal weight”
(your ideal body weight will be calculated during your first visit
with your surgeon)
• Using the Body Mass Index (BMI)
Morbid Obesity is defined as a person:
-BMI of 40 or higher
OR
-BMI of 35 or higher with co-morbidities related to
morbid obesity
What is Morbid Obesity?
56.
57. Obesity Trends* Among U.S. Adults
BRFSS, 1985
Source: Mokdad A H, et al. J Am Med Assoc 1999;282:16, 2001;286:10.
These maps show obesity as a percentage of the total adult population. This data comes from
CDC.
58. Obesity Trends* Among U.S. Adults
BRFSS, 1986
Source: Mokdad A H, et al. J Am Med Assoc 1999;282:16, 2001;286:10.
59. Obesity Trends* Among U.S. Adults
BRFSS, 1987
Source: Mokdad A H, et al. J Am Med Assoc 1999;282:16, 2001;286:10.
60. Obesity Trends* Among U.S. Adults
BRFSS, 1988
Source: Mokdad A H, et al. J Am Med Assoc 1999;282:16, 2001;286:10.
61. Obesity Trends* Among U.S. Adults
BRFSS, 1989
Source: Mokdad A H, et al. J Am Med Assoc 1999;282:16, 2001;286:10.
62. Obesity Trends* Among U.S. Adults
BRFSS, 1990
Source: Mokdad A H, et al. J Am Med Assoc 1999;282:16, 2001;286:10.
63. Obesity Trends* Among U.S. Adults
BRFSS, 1991
Source: Mokdad A H, et al. J Am Med Assoc 1999;282:16, 2001;286:10.
64. Obesity Trends* Among U.S. Adults
BRFSS, 1992
Source: Mokdad A H, et al. J Am Med Assoc 1999;282:16, 2001;286:10.
65. Obesity Trends* Among U.S. Adults
BRFSS, 1993
Source: Mokdad A H, et al. J Am Med Assoc 1999;282:16, 2001;286:10.
66. Obesity Trends* Among U.S. Adults
BRFSS, 1994
Source: Mokdad A H, et al. J Am Med Assoc 1999;282:16, 2001;286:10.
67. Obesity Trends* Among U.S. Adults
BRFSS, 1995
Source: Mokdad A H, et al. J Am Med Assoc 1999;282:16, 2001;286:10.
68. Obesity Trends* Among U.S. Adults
BRFSS, 1996
Source: Mokdad A H, et al. J Am Med Assoc 1999;282:16, 2001;286:10.
69. Obesity Trends* Among U.S. Adults
BRFSS, 1997
Source: Mokdad A H, et al. J Am Med Assoc 1999;282:16, 2001;286:10.
No
Data <10% 10%-14% 15%-19% 20%-24% 25%
70. Obesity Trends* Among U.S. Adults
BRFSS, 1998
Source: Mokdad A H, et al. J Am Med Assoc 1999;282:16, 2001;286:10.
No
Data <10% 10%-14% 15%-19% 20%-24% 25%
71. Obesity Trends* Among U.S. Adults
BRFSS, 1999
Source: Mokdad A H, et al. J Am Med Assoc 1999;282:16, 2001;286:10.
No
Data <10% 10%-14% 15%-19% 20%-24% 25%
72. Obesity Trends* Among U.S. Adults
BRFSS, 2000
Source: Mokdad A H, et al. J Am Med Assoc 1999;282:16, 2001;286:10.
No
Data <10% 10%-14% 15%-19% 20%-24% 25%
73. Obesity Trends* Among U.S. Adults
BRFSS, 2001
Source: Mokdad A H, et al. J Am Med Assoc 1999;282:16, 2001;286:10.
No
Data <10% 10%-14% 15%-19% 20%-24% 25%
74. Source: Behavioral Risk Factor Surveillance System,
CDC
Source: Mokdad A H, et al. J Am Med Assoc 1999;282:16, 2001;286:10.
Obesity Trends* Among U.S. Adults
BRFSS, 2002
No
Data <10% 10%-14% 15%-19% 20%-24% 25%
75. Obesity* Trends Among U.S. Adults
BRFSS, 2003
Source: Mokdad A H, et al. J Am Med Assoc 1999;282:16, 2001;286:10.
No
Data <10% 10%-14% 15%-19% 20%-24% 25%
76. Source: Behavioral Risk Factor Surveillance System, CDC.
19961991
2003
Obesity Trends* Among U.S. Adults
BRFSS, 1991, 1996, 2003
No
Data
<10% 10%-14% 15%-19% 20%-24% 25%
(*BMI 30, or about 30 lbs overweight for 5’4” person)
77.
78. 1999
Obesity Trends Among U.S. Adults
BRFSS, 1990, 1999, 2009
2009
1990
No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%
79. The Obesity Epidemic
Obesity rate has doubled in adults in the past two
decades.
Obesity rate has tripled in adolescents in the past
two decades.
The Epidemic within the Epidemic
Morbid obesity rate has quadrupled in the past
two decades.
Sturn R. Arch Intern Med. 2003;163:2146-2148.
1999 National Health and Nutrition Examination Survey, CDC National Center for
Health Statistics
81. The Problem
Prevalence of obesity in U.S. increased from
12% to 21% between 1991 and 2001 = 15
million people
Obesity is the 2nd most common cause of death
from a modifiable behavioral risk factor
111,909 excess deaths annually
Mokdad AH et al. JAMA. 2003;289:76-79
Flegal KM et al. JAMA 2005;293:1861-1919
82. Pulmonary disease
abnormal function
obstructive sleep apnea
hypoventilation syndrome
Nonalcoholic fatty liver
disease
steatosis
steatohepatitis
cirrhosis
Coronary heart disease
Diabetes
Dyslipidemia
Hypertension
Gynecologic abnormalities
abnormal menses
infertility
polycystic ovarian syndrome
Osteoarthritis
Skin
Gall bladder disease
Cancer
breast, uterus, cervix
colon, esophagus, pancreas
kidney, prostate
Phlebitis
venous stasis
Gout
Medical Complications of Obesity
Idiopathic intracranial
hypertension
Stroke
Cataracts
Severe pancreatitis
85. Diabetes
Gall bladder disease
Hypertension
Dyslipidemia
Insulin resistance
Breathlessness
Sleep apnea
Greatly increased
(relative risk >>3)
Coronary heart disease
Osteoarthritis (knees)
Hyperuricemia and
gout
Cancer (breast cancer in
postmenopausal women,
endometrial cancer, colon
cancer)
Reproductive hormone
abnormalities
Polycystic ovary
syndrome
Impaired fertility
Low back pain
Increased anesthetic risk
Fetal defects arising
from maternal obesity
Moderately increased
(relative risk 2-3)
Slightly increased
(relative risk 1-2)
Relative risk of health problems
associated with obesity
86. 2/3 of overweight patients have comorbid
conditions such as diabetes, hpyerlipidemia,
hypertensive, CAD, sleep apnea, etc.
Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in
Adults. National Institutes of Health, National Heart, Lung, and Blood Institute. September 1998.
87. The more overweight one is , the more likely it
is that you will have one or more chronic health
conditions
Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in
Adults. National Institutes of Health, National Heart, Lung, and Blood Institute. September 1998.
88. Obesity is more costly than
chronic smoking and drinking
Sturn R., The Effects of Obesity, Smoking and Problem Drinking On Chronic
Medical Problems and Health Care Cost, Health Affairs, 21 (2), 2002, 245-253
89.
90. Obesity
• Lowers life-expectancy
• Associated with various diseases
– Type 2 diabetes
– Cardiovascular disease (CVD)
– Sleep apnoea
– Some cancers
– Osteoarthritis
91. Obesity as a Risk Factor For OSA
Structural Factors
• Airway obstruction occurs when the nasopharynx
and oropharynx are occluded by posterior
movement of the tongue and palate against the
posterior pharyngeal wall
• Narrower airways are more easily collapsible and
prone to airway occlusion
92. Obesity as a Risk Factor For OSA
Structural Factors
• Obese people have extrinsic narrowing of the
area surrounding collapsible region of the pharynx
and regional soft tissue enlargement
• Increased fat deposits posteriolateral to
oropharyngeal airspace at level of soft palate,, and
in submental area
93. OBESITY
• Strongest risk factor for OSA
– Present in > 60% of patients referred for
a diagnostic sleep evaluation
– Wisconsin Sleep Cohort Study
• A one standard deviation difference in BMI
was associated with a 4-fold increase in
disease prevalence
94. Obesity
• Alters upper airway mechanics during sleep
1. Increased parapharyngeal fat deposition:
neck circumference: > 17” males
> 16” females
With subsequent:
Excessive fat deposition in the neck would
tend to narrow the pharyngeal cross-sectional
area smaller upper airway
increase the collapsibility of the pharyngeal
airway
95. Risk Factor: Obesity
Davies RJ et al. Eur Respir J 1990;3.
0
10
20
30
40
50
60
70
80
70 80 90 100 110 120 130 140
>4%Arterialsaturationdipah-1
% Predicted normal neck circumference
After passing a threshold neck circumference, the severity of
apnea increases linearly with increasing neck size.
96.
97. Obesity
2. Changes in neural compensatory mechanisms
that maintain airway patency:
diminished protective reflexes which
otherwise would increase upper airway dilator
muscle activity to maintain airway patency
98. Obesity
3. Waist circumference
Fat deposition around the abdomen produces
reduced lung volumes (functional residual
capacity) which can lead to loss of caudal
traction on the upper airway
low lung volumes are associated with
diminished oxygen stores
99.
100.
101. Body Fat Distribution
• An excess deposition of adipose tissue focused on
the trunk is Upper Body Obesity or Andriod
Obesity. Upper body obesity, more specifically,
visceral body fat distribution is related to disease
etiologies.
• An excess of deposition on the limbs or buttox is
Lower Body Obesity or Gynoid Obesity.
102.
103.
104.
105.
106. Obesity as a Risk Factor For OSA
Apple shape is riskier than Pear shape
107.
108. Hip to Waist Ratio
• Central Obesity defined by an increased waist-to-
hip ratio
• Excess fat in the abdominal region poses a
greater health risk than excess fat in the hips and
thighs and is associated with a higher risk of high
blood pressure, diabetes, early onset of heart
disease, and certain types of cancers
109.
110. • A high waist hip ratio (> 0.85 for women; > 1.0 for
men) indicates an apple-shaped or barrel-shaped
figure, with a non-existing waistline and a higher
risk for heart disease.
• (Waist circumference for a woman should not
exceed 88 cm and for a man not 102 cm.)
Hip to Waist Ratio
111. • A healthy waist hip ratio for men is considered to
be below 0.9 Borderline cases are between 0.9
and 1 but above 1 is considered to be unhealthy.
• A healthy waist hip ratio for women is considered
to be below 0.8. Borderline cases are between 0.8
and 0.85 but above 0.85 is considered to be
unhealthy.
Hip to Waist Ratio
112.
113. • WHO STEPS states that abdominal obesity is
defined as a waist–hip ratio above 0.90 for males
and above 0.85 for females, or a body mass index
(BMI) above 30
• The National Institute of Diabetes, Digestive and
Kidney Diseases (NIDDK) states that women with
waist–hip ratios of more than 0.8, and men with
more than 1.0, are at increased health risk
because of their fat distribution
115. ● In general, men deposit adipose on the trunk
where as women on the limbs.
● Male Gender androgenic patterns of body fat
distribution favor fat deposition in the neck area
● Premenopausal women distribute more on the
limbs, but redistribute to abdominal fat after
menopause.
Adipose deposits can be sex specific.
116. Obesity as a Risk Factor For OSA
• Fat accumulation in the central, android (apple
shape), and upper body correlate with metabolic
syndrome, atherosclerosis, and OSA
• Waist circumference more important than BMI,
weight, or total fat content
• Increased waist circumference predicts OSA even
in non-obese (Grunstein 1993)
117. • Obesity is the most powerful risk factor for
obstructive sleep apnea (OSA) - especially central
type
• Scientists discovered that people who are
overweight (BMI of 25 to 29) and obese (BMI of 30
and above) have the higher risk for OSA.
118. • Excessive upper body fat distribution (truncal
obesity) is one of the major contributing factors in
the development of OSA; 70% of OSA patients are
obese
• The studies have demonstrated that obesity
increases the rate of progression of sleep apnea,
and weight gain further accelerates disease
progression.
119. • With every 10% weight gain, the apnea hyponea
index (AHI) increases with almost 32%.
• However, losing 10% of weight will decrease the
AHI with 26%.
• Obesity is essentially the only reversible risk factor
for obstructive sleep apnea (OSA)
120. Obesity and OSA
• About 70% of those with OSA are obese (Malhotra et
al 2002)
• Prevalence of OSA in obese men and women is
about 40% (Young et al 2002)
• Higher BMI associated with higher prevalence
– BMI>30: 26% with AHI>15 , 60% with AHI>5
– BMI>40: 33% with AHI>15 , 98% with AHI>5
(Valencia-flores 2000)
121. Obesity and OSA
• Total body weight, BMI, and fat distribution all
correlate with odds of having OSA
– Every 10 kg increase in weight increases risk by
2X
– Every increase in BMI by 6 increases risk by 4X
– Every increase in waist or hip circumference by
13 to 15 cm increases risk by 4X (Young et al
1993)
122. • Obesity - More than 60% of sleep apnea patients
are overweight, so it should ring a bell to anyone
who has body fat. However, it is not the excess of
the weight that triggers sleep apnea, but the neck
size that counts.
Here are the facts:
– Men with a neck circumference of 17 inches or larger,
– Women with a neck circumference of 16 inches or
larger,
– People with double chins
– People with a lot of fat at the waist
are more likely to have their airway collapse while
they sleep.
125. Leptin
• Leptin is an appetite suppressant
• Obese and pts with OSA (independently) have high
leptin due to leptin resistance rather than as a result of
leptin deficiency
• Sleep deprivation/disordered sleep causes decreased
leptin making you feel more hungry (Patel et al 2004)
• Treatment of OSA with CPAP decreases leptin (after 2
months) and ghrelin levels (after 2 days) (Harsch et al
2003)
• ?? Treating OSA could lead to decreased appetite
126. Ghrelin
• Ghrelin is an appetite stimulant
• Ghrelin levels increase after weight loss
• Ghrelin levels higher in OSA pts
• Treatment of OSA may reduce ghrelin levels
leading to decreased appetite
127. Gale SM et al. J Nutr 2004; 134:295-8
LACK OF SLEEP
less
more
128. Can Obesity be a consequence of
OSA?
• OSA reduces physical activity and exercise
performance
• OSA reduces energy metabolism
• OSA reduces motivation (from underlying
comorbidities like depression: several studies
have found correlation between OSA and
depression)
136. Ministry of Health & population, Egypt
Community based survey study On Non-communicable
diseases and their Risk Factors, Egypt, 2005- 2006
137. The prevalence of diabetes mellitus in Egypt as a results of
STEP wise survey is 15.8 % with higher elevation in females
18 % than in males 13.6 %
138.
139. The percentage of mild hypertension (SBP ≥ 140 and/or DBP ≥ 90
mmHg ) in Egypt is 26.7% with irrelevant differences between
males and females
140. The percentage of severe hypertension in Egypt
(SBP ≥ 170 and/or DBP ≥ 100 mmHg) is 6.9 %
141.
142.
143. Dietary weight loss can improve OSA
• Reduces upper airway collapse by modifying
anatomy and function
– 13% weight loss decreased nasopharyngeal
airway collapsibility in obese patients with OSA
after diet. All had decrease in AHI.
– Improved pharyngeal and glottic fxn and
significant decrease in AHI after 26 kg weight
loss in obese patients with OSA
144. Dietary weight loss can improve OSA
• Impact of weight loss is greater in those with
severe OSA (AHI>30) and those higher in BMI
– In obese patients, even minimal weight loss can
be beneficial
– Thought to be related to preferential loss of
visceral fat first as oppose to subcutaneous fat
which has metabolic advantages
145. Treatment of OSA and its effect on
weight
• Weight loss may be helped by CPAP in obese with
OSA in compliant vs. noncompliant (use >4 hrs)
(Loube 1997)
• 6 mo. of CPAP could reduce intra-abdominal
visceral fat and serum leptin even in absence of
weight loss (Chin, 1999)
• 2 mo. of CPAP assoc. with reduced serum leptin in
absence of weight change (Harsch 2003)
146. Non-operative Treatment of Obesity
How does it add up?
• Diet
• Exercise
• Behavioral therapy
• + Drug therapy
.
• ??????
147.
148. How to manage your weight
• Reducing caloric intake is the most common form,
but difficult long term
• Reducing calorie intake is most important: portion
of fat vs. protein vs. carbs doesn’t matter in
regards to weight loss, satiety, hunger, and
satisfaction (Sacks et al. 2009)
• Diet + exercise is most effective method of weight
loss recommended by most doctors
149. How to manage your weight
• Diet alone may be just as good as diet and
exercise
– Metanalysis of 25 yrs of weight loss research on diet
alone, exercise alone, vs. diet + exercise
– Concluded: 15-week diet or diet plus exercise
program, produces a weight loss of about 24 lbs, with
a 15 and 19 lb maintained loss after one year,
respectively. (Miller 1997)
• Many studies suggest diet + exercise provides
about a 20% greater weight loss initially than diet
alone
• Exercise alone probably doesn’t work that well
(Caudwell 2009)
151. Weight Loss
Should be prescribed for all obese patients
Can be curative but has low success rate
Other treatment is required until optimal weight
loss is achieved
152. Because of the high correlation between sleep
apnea and obesity, particularly increased upper
body mass, all patients who are obese should be
encouraged to lose weight.
Exercise and fitness should be recommended to
all patients, both to improve sleep apnea and
reduce cardiovascular disease risk.
Weight loss can be very effective and, in some
cases, even curative.
153. The problem that frequently occurs is that weight
loss, while effective, is difficult to achieve and to
maintain.
In patients with significant sleep apnea, other
forms of treatment should not be delayed until
proper weight loss is achieved since they may
continue to experience the complications of sleep
apnea during the period of attempted weight loss.
155. Weight Loss and Sleep Apnea
-4
-20 to <-
10%
-10 to <-
5%
-5% to
<+5
+5 to
+10%
+10% to
+20
-3
-2
-1
0
1
2
3
4
5
6
Change in Body WeightAdapted from Peppard PE et al.
JAMA 2000;284.
Mean Change in
AHI, Events/hr
156. Even a modest degree of weight loss can have a
significant impact on apnea severity
The frequency of apneas drops significantly with
weight loss, often into the normal range, and the
drops in oxyhemoglobin saturation accompanying
the apneas are less severe
Weight control can be an effective method for
managing sleep apnea.
157.
158. • Obesity : BMI, neck circumference, waist-to-
hip ratio
• The most common risk factor is the presence
of obesity, specifically measures of central
obesity.
• Upper body fat distribution is one of the major
contributing factors to the development of
sleep apnea..
Conclusions
159. Conclusions
• OSA may lead to weight gain and weight gain leads
to OSA
• Losing weight can improve OSA/lessens symptoms.
• Unclear if treating OSA leads to weight loss
although some studies show this is the case/weight
loss is easier in patients who are treated by nasal
CPAP
• Diet and exercise as well as diet alone are good
weight loss techniques
161. Patient Selection
• Age 18 - 55
AND
• BMI ≥ 40 kg/m2 OR
• BMI 35 - 40 kg/m2 with
– High risk health problems OR
– Obesity-induced physical
problems
NIH Consensus Development Conference
162. Weight-loss surgery
There are many types of weight-loss surgery, known
collectively as bariatric surgery.
Bariatric surgery is currently the only modality that
provides a significant, sustained weight loss for the
patient who is morbidly obese, with resultant
improvement in obesity-related comorbidities
Gastric bypass is one of the most common types of
bariatric surgery in the United States. Many surgeons
prefer gastric bypass surgery because it generally has
fewer complications than do other weight-loss
surgeries.
163.
164. • The U.S. National Institutes of Health
recommends bariatric surgery for obese people
with a body mass index (BMI) of at least 40, and
for people with BMI 35 and serious coexisting
medical conditions
165. • A medical guideline by the American College of
Physicians concluded:
" Bariatric Surgery should be considered as a
treatment option for patients with a BMI of 40 kg/m2
or greater who instituted but failed an adequate
exercise and diet program (with or without
adjunctive drug therapy) and
For patients who present with obesity-related
comorbid conditions, such as hypertension, diabetes
mellitus, hyperlipidemia, and obstructive sleep
apnea
166. Who Qualifies for Weight-Loss Surgery?
Normal Weight
(BMI 18.5 to 24.9)
Overweight
(BMI 25 to 29.9)
Obese
(BMI 30 to 34.9)
Severely Obese
(BMI 35 to 39.9 )
Morbidly Obese
(BMI 40 or more)
BMI 18.5-24.9 BMI 25-29.9 BMI 30-34.9 BMI 35-39.9 BMI>40
167. Gastric bypass and other weight-loss surgeries are
typically done only after you've tried to lose weight
by improving your diet and exercise habits.
Still, all forms of weight-loss surgery, including
gastric bypass, are major procedures that can pose
serious risks and side effects
keep in mind that bariatric surgery is expensive
168. Regarding bariatric surgery for weight loss, OSA is
prevalent in at least 45% of these patients
Surgically induced weight loss significantly improves
obesity-related OSA and sleep quality parameters.
Although many such morbidly obese patients who
undergo bariatric surgery can expect reduction of
AHI and CPAP pressure needed to maintain patent
airway, most surgical patients with preoperative OSA
will continue to need CPAP after surgery
169. Weight loss is an important long-range goal.
Patients who are obese should be informed that
obesity strongly correlates with OSA, particularly
with heavy upper body mass.
Weight loss can be very effective and, in some
cases, even curative, but its rate of success is low.
Nonetheless, a 10% weight loss is associated with a
26% decrease in AHI.
In patients with significant OSA, other treatments
should not be delayed until proper weight loss is
achieved, since OSA complications may continue
during the weight loss period.
170. Weight loss is strongly encouraged for all patients
Increasing body weight will worsen OSAS.
The patient needs to be aware that weight loss is
not the sole treatment for moderate-to-severe
OSAS, but is an adjunctive treatment that needs to
occur in conjunction with other forms of treatment
171.
172. • OSAS is strongly associated with obesity but is
also increasingly identified in the less obese, in
whom a particular craniofacial structure is an
important contributory factor.
• The prevalence of OSAS is likely to be increasing
in parallel with the epidemic of obesity currently
occurring in many countries
173. • Great eaters and great sleepers
are incapable of doing anything
that is great.
William Shakespeare
“Henry IV”
174. To sleep, or not to sleep, that
is the question!
