SLEEP APNEA – Symptoms, hazards to health, and treatment with lifestyle modification
Obesity and obstructive sleep apnea (OSA) tend to co-exist. Obstructive sleep apnea causes people to stop breathing for short periods repeatedly (sometimes hundreds of times a night) and is a substantial health problem. In the USA, almost 1 in 5 adults have sleep apnea, and these patients with OSA are at higher risk for developing diabetes, heart disease, obesity, sudden death and car accidents.
Every day, thousands of patients are seen in primary care offices for routine disease management visits for hypertension, diabetes, heart disease and obesity. To determine how these patients are doing, careful attention is given to the patients’ laboratories and physical findings. These indicators include the patients’ blood pressure readings, their current Hb A1c levels, changes in cholesterol ratios and elevations in BMI.
The most important measurement in OSA is called the respiratory disturbance index or RDI, and an abnormally high RDI is linked to adverse outcomes and progression to one or more of the major chronic diseases listed above. It has been established that sufferers of sleep apnea have a 60% increased risk of developing heart failure, a 200% higher likelihood of developing a stroke, a 300% chance of having resistant hypertension and a dramatic 400% increased risk of developing atrial fibrillation. Taken together, all cause cardiovascular mortality that is nearly twice as high for patients suffering from untreated moderate to severe sleep apnea. Additionally, the hypoxia (low oxygen) associated with each apneic episode is associated with the death of brain cells, especially those responsible for short term memory.
One of the most common signs of obstructive sleep apnea is loud and chronic (ongoing) snoring. Pauses may occur in the snoring. Choking or gasping may follow the pauses. The snoring usually is loudest when you sleep on your back; it might be less noisy when you turn on your side. You might not snore every night. Over time, however, the snoring can happen more often and get louder.
Because you’re asleep when the snoring or gasping happens, you likely won’t know that you’re having problems breathing or be able to judge how severe the problem is. A family member or bed partner often will notice these problems before you do.
Not everyone who snores has sleep apnea.
Another common sign of sleep apnea is fighting sleepiness during the day, at work, or while driving. You may find yourself rapidly falling asleep during the quiet moments of the day when you’re not active. Even if you don’t have daytime sleepiness, talk with your doctor if you have problems breathing during sleep.
Other Signs and Symptoms
Others signs and symptoms of sleep apnea include:
- Morning headaches
- Memory or learning problems and not being able to concentrate
- Feeling irritable, depressed, or having mood swings or personality changes
- Waking up frequently to urinate
- Dry mouth or sore throat when you wake up
In children, sleep apnea can cause hyperactivity, poor school performance, and angry or hostile behavior. Children who have sleep apnea also may breathe through their mouths instead of their noses during the day.
Clearly, OSA is a significant health problem, yet up to 90% of patients with OSA remain undiagnosed today. This is unfortunate because patients treated for OSA show lower rates of complications from associated diseases. While CPAP (continuous positive airway pressure), delivered by mask or nasal prongs, has been the therapy of choice for many of patients diagnosed with OSA, less aggressive therapies that do not require long term use also remain options. These include ENT or oral surgery, referral to a dentist for an oral appliance fitting, or lifestyle changes. New research from a multidisciplinary team at the Perelman School of Medicine at the University of Pennsylvania now reveals that the single most important factor in improving cardiovascular health in obese OSA patients is weight reduction. (NEJM, June, 2014).
Obesity is a major risk factor for sleep apnea. In 2009, researchers from Sweden’s Karolinska Institute showed that overweight and obese men who lost weight had big improvements in their sleep apnea symptoms. These patients lost an average of 24 pounds and were three times as likely to experience remission in sleep apnea as those that did not lose weight. A similar study published in 2011 (British Medical Journal, Online first, June 1, 2011) also showed that weight loss was an effective treatment for patients that were overweight or obese. They showed a 58% reduction in sleep apnea symptoms, and events declined by an average of 21/hour with a 40 pound weight reduction in men that were 60 or more pounds overweight. Indeed, it does not take a lot of weight gain to push a patient from snoring into sleep apnea, but it also does not take a lot of weight loss to improve symptoms. Dramatic changes in sleep apnea symptoms are usually seen in patients losing 10-15% of their body weight as fat.
Obesity and OSA tend to coexist and are associated with inflammatory changes in the body leading to insulin resistance, coronary disease and high blood pressure. One way of measuring these inflammatory changes is by looking at serum levels of cardio-reactive protein or CRP. A study published in June, 2014 in the New England Journal of Medicine showed significant reductions in CRP, insulin resistance, blood pressure and triglycerides in patients treated with weight loss. In stark contrast, they did not observe a significant effect of CPAP on CRP, insulin resistance, cholesterol or blood pressure, even in those with strict adherence to the therapy. The author concludes that “these data argue against an independent causal relationship between these cardiovascular risk factors and suggests in this population that CPAP is not an effective therapy to reduce the burden of these particular risk factors. These findings also indicate that weight loss therapy should be a central component of strategies to improve the cardiovascular risk factors in these obese patients with OSA.”
One of the problems with treating weight loss alone is that each apneic episode is associated with a huge stress response with released stress hormones that causes weight gain. For all intents and purposes, each time a patient stops breathing it is equivalent to being strangled. When this happens 50 to 100 times a night, the high serum levels of cortisol seen causes significant weight gain from the mobilization of sugars in preparation for a “fight or flight” response. For this reason, it is very difficult for patients with OSA to lose weight without the assistance of CPAP. The studies cited above suggest that once the weight is lost, there is a 50-60% probability of the OSA resolving and therefore there is less need for CPAP. Losing as little as 10% of body weight can potentially make a huge impact on your quality of sleep, your ability to cope the next day, your energy levels, and overall quality of life, not to mention improving the outcomes or preventing the onset of numerous chronic and potentially fatal diseases.
OSA can now be reliably diagnosed using Home Sleep Testing. This is one of many services we now provide here at The Institute for Lifestyle, Preventive and Family Medicine. We are constantly learning new techniques to improve what we do to ensure the health and wellbeing of our patients. Please ask us more about testing for OSA if you or a loved one has any of the symptoms of sleep apnea and especially if you are having difficulty losing weight.