Obesity, Weight Loss and Obstructive Sleep Apnea

Transcription

1 Obesity, Weight Loss and Obstructive Sleep Apnea Gary D. Foster, Ph.D. Center for Obesity Research and Education Temple University School of Medicine Overview Sociocultural context Obesity: Prevalence and consequences The relationship between obesity, weight loss and obstructive sleep apnea Preliminary Sleep AHEAD Data 1

2 Making the Office Environment Receptive Have gowns available that fit larger patients Buy a scale that can weigh all of your patients Use larger blood pressure cuffs when appropriate Provide some armless chairs in the waiting room 2

3 BMI Calculation 1. Multiply weight in pounds X 703 = A 2. Divide A by height in inches = B 3. Divide B by height in inches = BMI Classification of Overweight and Obesity by BMI Prevalence of Overweight and Obesity Among US Adults Obesity Class BMI (kg/m 2 ) Underweight < 18.5 Normal Weight Overweight Obesity I II Extreme Obesity III > 40 Prevalence (%) / extreme obesity (BMI > or = 40) overweight (BMI > or = 25) obesity (BMI> or = 30) NHANES Years NHLBI Guidelines, Flegal, K et al. JAMA, 2002; Hedley, AA et al. JAMA, 2004;Ogden et al JAMA,2006 3

4 BRFSS, 1985 BRFSS, 1986 No Data <10% 10% 14% No Data <10% 10% 14% BRFSS, 1987 (*BMI 30, or ~ 30 lbs. overweight for 5 4 person) BRFSS, 1988 No Data <10% 10% 14% No Data <10% 10% 14% 4

5 BRFSS, 1989 BRFSS, 1990 No Data <10% 10% 14% No Data <10% 10% 14% BRFSS, 1991 BRFSS, 1992 No Data <10% 10% 14% 15% 19% No Data <10% 10% 14% 15% 19% 5

6 BRFSS, 1993 BRFSS, 1994 No Data <10% 10% 14% 15% 19% No Data <10% 10% 14% 15% 19% BRFSS, 1995 BRFSS, 1996 No Data <10% 10% 14% 15% 19% No Data <10% 10% 14% 15% 19% 6

7 BRFSS, 1997 BRFSS, 1998 No Data <10% 10% 14% 15% 19% 20% No Data <10% 10% 14% 15% 19% 20% BRFSS, 1999 BRFSS, 2000 No Data <10% 10% 14% 15% 19% 20% No Data <10% 10% 14% 15% 19% 20% 7

8 BRFSS, 2001 BRFSS, 2002 No Data <10% 10% 14% 15% 19% 20% 24% 25% No Data <10% 10% 14% 15% 19% 20% 24% 25% BRFSS, 2003 BRFSS, 2004 No Data <10% 10% 14% 15% 19% 20% 24% 25% No Data <10% 10% 14% 15% 19% 20% 24% 25% 8

9 BRFSS, 2005 BRFSS, 2006 No Data <10% 10% 14% 15% 19% 20% 24% 25% 29% 30% No Data <10% 10% 14% 15% 19% 20% 24% 25% 29% 30% Health Consequences of Obesity Health Benefits of Weight Loss Cardiovascular disease Type 2 diabetes Hypertension Dyslipidemia Ischemic stroke Sleep apnea Degenerative joint disease Some types of cancer Gallstones Gynecologic irregularities Weight loss of 5%-10% in obese individuals with type 2 diabetes, hypertension or dyslipidemia resulted in: Improved glycemic control Reduced blood pressure Improved lipid profile Critical guidelines. National Heart, Lung, and Blood Institute Web site. Available at Accessed July 31, Goldstein DJ. Int J Obes. 1992:16: Wing RR, et al. Arch Intern Med. 1987;147:

10 Visceral Adiposity: Higher Risk for Metabolic Syndrome Patients With High Visceral Adiposity Have Significantly Higher Risk Factors for Metabolic Syndrome Than Non-Obese Patients * * mg /d L * * µu/ml Non-Obese Low Vis. Fat High Vis. Fat 0 TG HDL-C 0 Fasting Insulin *Significantly different from non-obese patients. Significantly different from obese patients with low levels of deep abdominal fat, P<0.05. Adapted from: Després JP, et al. Arteriosclerosis. 1990;10: Vgontzas AN et al., 2003 Obesity and OSA Two-thirds of OSA participants are obese (Guilleminault C et al. Chest, 1998) One SD increase in BMI is associated with a 4-fold increase in RDI (Young T et al. NEJM, 1993) 40% of weight-loss patients have RDI>5 (Richman R et al. IJO, 1994; Vgontzas A et al. Arch Intern Med, 1994) Weight Loss and OSA Weight losses of 9% to 20% have been associated with reductions in AHI of 30% to 74% (Strobel RJ & Rosen RC. Sleep, 1996.) A 1% change in weight is associated with a 3% change in AHI 10% in weight is associated with a 26% in AHI 10% in weight is associated with a 32% in AHI (Peppard et al. JAMA 2000.) 10

11 The Sleep Heart Health Study Longitudinal cohort study of the cardiovascular consequences of OSA Sought to determine the relationship between change in weight and progression or remission of SDB 2968 male and female subjects (mean age=62 years; mean BMI=28.75) Severity of OSA measured by polysomnography, with follow-up at year 5 Mean male AHI at baseline=6.3 Mean female AHI at baseline=2.8 The Sleep Heart Health Study, Results Men were more likely to have an increase in AHI over time Male AHI increase: 3.4 ± 12.4 Female AHI increase: 2.2 ± 9.0 Newman, et al. Arch Intern Med. 2005; 165: Newman, et al. Arch Intern Med. 2005; 165: The Sleep Heart Health Study, Results Effects of Weight Loss and OSA Both men and women had a greater increase in AHI with weight gain than a decrease in AHI with weight loss OSA ultimately progressed over time, even in those who maintained a stable weight Newman, et al. Arch Intern Med. 2005; 165: %Change Weight Control n=8 Treatment n=15 %Change AHI Smith PL et al., Ann Intern Med (1985) 11

12 Weight Loss and AHI No RCT has assessed the effects of weight loss on OSA Among weight-loss treated (n=15) and control (n=8) patients, a 9% weight loss was associated with 47% reduction in AHI. Across uncontrolled studies, there was no significant relationship between weight loss and the change in AHI. Sleep AHEAD: Sleep Apnea in Look AHEAD Participants Sleep AHEAD Action for Health in Diabetes Rationale BROWN Pittsburgh Weight loss is frequently recommended for obese patients with obstructive sleep apnea (OSA), but the empirical foundation for this recommendation is not well substantiated. Weight loss in sleep apneics improves but does not eliminate sleep-disordered breathing and the degree of improvement is not correlated with weight loss. PSGRL Columbia Penn 12

13 Overnight polysomnograms were performed in the participants homes The following signals are recorded on a data acquisition system (Compumedics PS2): Electroencephalogram (C3A2, C4A1) Bilateral electrooculograms (referenced to A2 and A1 respectively) Bipolar submental electromyogram Movements of the rib cage and abdomen Nasal pressure as an index of airflow Body position Pulse oximetry Electrocardiogram Presence or absence of snoring Sleep AHEAD Participants (N = 306) Look AHEAD (not Sleep AHEAD,4 Sites) (N = 1012) p- value Gender (% female) 59.8% 60.2% 0.91 Age (years) <.0001 Race: Black/Afr. Am. Am. Ind./Nat. Am. Asian/Pac. Island Hispanic Mixed/Other White 19.0% 1% 1.6% 3.3% 2.0% 73.1% 19.5% 0.4% 0.5% 4.6% 1.9% 73.1% Years Diabetic (self-reported) Diabetes Status: % on insulin Fasting glucose (mg/dl) HbA1C (%) Body Habitus: Weight (kg) Height (cm) BMI (kg/m 2 ) Waist (cm) Sleep AHEAD Participants (N = 306) Look AHEAD (not Sleep AHEAD,4 Sites) (N = 1012) p- value % % Subject Characteristics Sleep AHEAD Total Control Intervention Weight (kg) AHI (events/hr) Age Waist (cm)

14 Sleep Disordered Breathing in Obese Patients with Type 2 Diabetes (N=306) 2.6% Undiagnosed Sleep Disordered Breathing in Obese Patients with Type 2 Diabetes (N=281) 2.8% 40.7% 21.9 % Mild Severe Severe AHI < 5 AHI < 5 AHI AHI AHI AHI AHI > 30 AHI > % Moderate 40.2% 22.8 % Mild 34.2% Moderate Undiagnosed, Unscreened Sleep Disordered Breathing in Obese Patients with Type 2 Diabetes (N=203) 42.9% Severe 3.0% 19.2 % Mild 35.0% Moderate AHI < 5 AHI AHI AHI > 30 AHI (N=67) AHI (N=108) AHI >30 (N=123) AHI a b c Gender 65.7% a 75% b 42.3% c (% female) Body Habitus: Weight (kg) BMI (kg/m 2 ) Waist (cm) a a a AHI Category a ab ab b b c Age (years)

15 AHI AHI Category AHI AHI >30 Results (N=67) (N=108) (N=123) Diabetes Status: % on insulin Fasting glucose (mg/dl) HbA1C (%) Race: Black/Afr. Am Am. Ind./Nat. Am. Asian/Pac. Island Hispanic Missing Mixed/Other White 16.4% % 0% 1.5% 3.0% 3.0% 3.0% 65.7% 13.3% % 1.0% 1.0% 4.8% 1.0% % 10.3% % 0.8% 1.6% 2.4% 0.0% 1.6% 77.0% Correlations were conducted on AHI as a continuous variable AHI was strongly related to: waist circumference (r =.349) neck circumference (r =.303) BMI (r =.263) gender (r =.227) AHI was not related to any sleep related symptoms Multiple Regression Variables that were associated with AHI were included in a multiple regression predicting AHI as a continuous variable An exploratory stepwise procedure was used while controlling for BMI Standardized beta coefficients were used to assess relative contributions Neck circumference & symptom questions did not predict AHI. Waist circumference = best predictor (p<.05; β=.28) Gender (male)= second best predictor (p<.05, β=6.79) Multiple Logistic Regression The same variables were used in a multiple logistic regression to predict severe OSA (AHI 30) when AHI was treated as a categorical variable. The only significant predictor was gender (male: OR = 3.2; 95% CI ; p <.001) There was a trend for BMI (OR = 1.07; 95% CI ; p =.07) 15

16 Mean AHI Change 14 (p=.08) * (p=.0001) n=106 n=86 n=32 n=52 treatment control Recent Findings -4 1-year 2-year Martinez-Rivera, et al., Obesity, 2008 Martinez-Rivera, et al., Obesity,

17 Martinez-Rivera, et al., Obesity, 2008 Martinez-Rivera, et al., Obesity, 2008 Summary Obesity increases the risk of OSA The role of modest weight loss is improving OSA is less clear Obese patients with T2DM appear to be at high risk for undiagnosed sleep apnea Male obese patients with T2DM are at greatest risk of severe OSA University of Pennsylvania Samuel Kuna, M.D. Tom Wadden, Ph.D. Allan Pack, M.D., Ph.D. Richard Schwab, M.D. B.J. Maschak-Carey,R.N. Beth Staley Mary Jones Parker Nida Cassim Sakhena Hin Brown University Richard Millman, M.D. Rena Wing, Ph.D. Renee Bright Marie Kearns Acknowledgements University of Pittsburgh Mark Sanders, M.D. Anne Newman, M.D., M.P.H David Kelley, M.D. Jacqueline Wesche-Thobaben Laura Waterstram Columbia University Gary Zammit, Ph.D. F. Xavier Pi Sunyer, M.D. Jennifer Pattricio 17

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