Lifestyle Interventions in Obstructive Sleep Apnea:
Forward-Thinking Strategies to Treat the Whole Patient

For many patients, OSA is a lifestyle disease. And for the vast majority of patients, OSA involves a lifestyle component. For example, seventy percent or more of OSA patients are obese. Mood disorders, anxiety, and other behavioral issues are common and can impact treatment outcomes. Behavioral choices such as drinking alcohol, smoking cigarettes, and not getting enough sleep can all worsen OSA severity. By any measure, the most common treatment for OSA, PAP therapy, requires substantial lifestyle change.

Among other sleep disorders, particularly chronic insomnia, the importance of lifestyle interventions is well documented. Indeed, the availability of interventions such as cognitive-behavioral treatment (CBT, which can be considered a lifestyle intervention) will continue to increase as behavioral sleep medicine training, telemedicine, and online interventions continue to expand. Yet in spite of the lifestyle factors associated with OSA and the increasing availability of lifestyle interventions (LIs) in other areas of sleep medicine, LIs remain conspicuously absent in most OSA treatment plans.

As sleep medicine enters its second wave, an increased focus on comprehensive care and chronic disease management will pave the way for inclusion of LIs into routine patient care. To benefit maximally from this trend, sleep disorder specialists should embrace appropriate evidence-based recommendations, expand their clinical skill sets, and where feasible, expand the clinical service offerings in their centers. Adopting these changes are likely to result in improved patient care, differentiation in the marketplace, and profitable program development. 

Lifestyle interventions can benefit patients, providers, and the field at large

Many patients prefer LIs. LIs are non-invasive, low risk, and seek to treat disease by making lasting change in the areas of behavior, cognition, exercise, and nutrition, among others. Although no data exist for OSA, two studies have found patients to prefer behavioral intervention to pharmacotherapy for insomnia, and NIH’s National Center for Complimentary and Alternative Medicine (NCCAM) reported in 2002 that 1.6 million U.S. adults attempted some form of complimentary and alternative medicine (CAM) as a remedy for their insomnia. Of course, sleep medicine is and should remain a medical subspecialty. Nonetheless, a substantial number of individuals appear to prefer lifestyle interventions when available.

Second, the vast majority of sleep medicine specialists have no training in LIs. Even though the AASM practice parameters frequently refer to behavioral recommendations or lifestyle factors for the management of sleep disorders, training in LIs are required neither in medical school curricula nor during sleep medicine fellowship. Most sleep specialists simply do not possess the requisite expertise or interest to administer LIs effectively, and the extent of LI in most sleep centers is a recommendation along the lines of “weight loss should be encouraged, if clinically indicated.” As a result, providers who expand their skill sets to include LIs will be able to provide better care to their patients as well as experience a competitive marketplace advantage. Equally important, providers well versed in LIs will be able to respond to their patients’ queries and advise against LIs as stand-alone treatments when indicated.

Finally, much has been written regarding the changing face and uncertain future of sleep medicine. Advancing technologies such as HST and APAP, changes in reimbursement for sleep services, and developing practice models render our future uncertain. Incorporation of LIs can expand the reach of sleep medicine, help ensure more untreated patients receive the sleep health care they need, and increase the sustainability of sleep medicine services.

Of course, LIs are not appropriate for all patients. Further, in the case of OSA, evidence does not support LIs as stand-alone interventions in the majority of cases. Nonetheless, in light of the importance of lifestyle factors in OSA, and the shift toward a chronic disease management perspective, lifestyle can no longer be ignored as a contributing factor to OSA and important target for treatment.

Lifestyle case study: Weight gain and OSA

It is well documented that weight, BMI, and fat distribution all related to OSA. Over 40% of obese individuals have OSA. Increased central adiposity and fat deposits around the pharynx impair pulmonary function and alter upper airway anatomy, respectively. Weight gain also impacts AHI. Peppard et al (2000) conducted a longitudinal study of 690 adults participants in the Wisconsin Sleep Cohort and found that an increase in body weight of 10% was associated with a 32% increase in AHI as well as a six-fold increase in risk for developing moderate to severe OSA. Conversely, a 10% reduction in body weight was associated with an average 26% decrease in AHI. In short, weight gain worsens OSA, and weight loss improves OSA.

Not surprisingly, this realtionship is bidirectional. Not only can weight gain impact OSA, but OSA can increase weight gain through both biological and psychological/behavioral pathways. For example, OSA reduces exercise capacity, reduces energy metabolism, and impairs endocrine function. All three of these physiologic changes are well-documented causes of weight gain. And from a behavioral or lifestyle perspective, OSA can lower patient motivation to remain active, impair cognitive function—which may reduce awareness and judgment regarding lifestyle choices, and reduce physical activity due to sleepiness.

In light of the bidirectional relationship between OSA and weight gain, it seems logical to treat both conditions concurrently. Let’s briefly explore how this paradigm shift might impact on OSA treatment.

Non-surgical weight loss lowers AHI

Multiple studies have evaluated the relationship between non-surgical weight loss and OSA severity. Barveaux et al (2000) reviewed ten such interventions and found AHI to be reduced in nine studies by 30% to 100%. (In one outlier study, weight loss intervention was not successful, and the AHI was reduced by only 3.3%.)

More recently, 72 overweight or obese patients (BMI range 28-40) with mild OSA were randomized to either a 1-year lifestyle intervention that consisted of an initial, 12-week period of caloric restriction and supervised lifestyle and behavior modification, or to active control including routine lifestyle counseling (Tuomilehto et al, 2009). At both 3 and 12-months, the intervention reduced body weight (-10.7kg) and waist circumference, as well as AHI and nocturnal oxygenation, relative to control. Further, the intervention was associated with improvements in quality of life. These authors argue convincingly that lifestyle interventions can be considered first-line intervention for patients with mild OSA.

Similarly, Foster et al (2009) evaluated 264 OSA patients with comorbid type 2 diabetes mellitus. Participants were obese (mean BMI=36.7) and had moderate sleep apnea (mean AHI=23.2). Participants were randomized to a 4-month behavioral weight loss program tailored for patients suffering obesity and T2DM, or 3 group sessions targeting diabetes support and education. After 12 months, participants in the treatment condition had lost more weight (10.8kg vs. 0.6kg, p<.001) and also experienced a greater reduction in AHI (-9.7 events/hour, p<.001) relative to control. Further, the prevalence of severe OSA in the intervention group was half that of the control group, and relative to control, and more than three times as many participants in the intervention had total remission of their OSA (AHI<5).

In a study examining the effects of diet alone, Johnasson et al (2009) randomized sixty-three obese men aged 30-65 years to seven weeks of a liquid, very low energy diet followed by two weeks of gradual return to normal food, or to a wait list control. Relative to control, diet resulted in significantly greater weight loss (20kg). Further, OSA was eliminated (AHI<5) in 5 of 30 participants (17%) randomized to diet, and AHI was reduced to <15 in an additional 15 (50%). Conversely, moderate or severe OSA (AHI>15) persisted in all but one participant in the control group.

In the past several years, a small but growing number of studies have found similar improvements in OSA following LIs including dietary changes and exercise. Although OSA often persists, patients report improved daytime function and improved sleep quality. Of practical significance, LIs can complement and even improve traditional approaches to sleep medicine.

1+1=3… or, Lifestyle Interventions and PAP provide additive benefit

In a recent quantitative review, three studies (n=261) were found to evaluate the additive effects of diet and PAP. Relative to diet alone, diet + PAP resulted in significantly greater weight loss (-2.64kg). These results highlight the shared mechanisms between weight gain and OSA and suggest the complimentary nature of lifestyle and traditional sleep medicine interventions.

But I read it on Google, she said

In addition to questions about weight and OSA, many patients present with questions about alternative treatments to OSA, including LIs designed to increase patency of the upper airway through oropharyngeal exercises, playing a musical instrument, or singing. Familiarity with the research in question will improve your ability to respond to patient queries in an evidence-based fashion.

Tighten and tone the airway?

In the first study to examine oral exercise, Guimares and colleagues (2009) randomized 31 adults with moderate OSA to either a 3-month oral exercise intervention or sham control. Results indicated a 39% reduction in AHI as well as improved nocturnal oxygen saturations. Although moderate OSA persisted, participants also reported improvements in snoring, sleepiness, and sleep quality. In an uncontrolled study of 15 patients with mild-moderate OSA, Baz et al (2011) found oropharnygeal exercises reduced AHI, arousals, snoring, and O2 desaturations (all p’s < .001). However, OSA persisted in all but 2 participants. At this time, oropharyngeal exercises cannot be recommended as an effective treatment for OSA.

The digeridoo does not cure sleep apnea!

One of the most common inquiries I receive from patients and non-sleep providers oriented toward complimentary, alternative, or lifestyle approaches is whether the digeridoo will “cure” sleep apnea. The digeridoo is an Australian instrument requiring ongoing, prolonged exhalations. Puhan et al (2005) conducted a randomized study of 25 non-obese participants using a wait list control. The intervention consisted of thorough instruction followed by 4 months of daily digeridoo playing. Relative to control, participants in the active treatment experienced less snoring (p<.01), reduced AHI (mean reduction=6.2; p<.05), and 3-point reduction in daytime sleepiness as measured by the Epworth Sleepiness Scale (p=.03). However, OSA persisted in all patients, and no improvements in self-reported sleep quality or quality of life were observed. In spite of its notoriety as a PAP alternative, the digeridoo cannot be recommended as a viable treatment for OSA.

Sing me the blues: Minimal impact of singing and instrument type on OSA

Other investigators have similarly hypothesized that singing would increase airway patency and muscle tone, thereby reducing AHI. Two studies have evaluated singing versus non-singing. Ojay and Ernst (2000) conducted a non-randomized study (n=20) and found that 3 months of daily snoring practice reduced snoring. Similarly, Pai et al (2008) found that singers snored less than non-singers, but no differences were observed in daytime sleepiness.

Following similar logic, Wardrop et al (2011) administered the Berlin Questionnaire to 1,111 orchestra musicians, and found no differences in OSA risk between wind and brass musicians and those who played other instruments. However, Ward et al (2012) conducted a nationwide internet survey and found that playing a double-reed instrument was associated with lower OSA risk than playing other kinds of instruments (p<.05), and the self-reported number of hours spent playing also predicted lower OSA risk (p=.02). Patients should be strongly advised against attempting singing or playing a musical instrument as a treatment for OSA.

Action plan for the sleep health professional

LIs involving non-surgical weight loss appear promising in OSA patients, and they may be especially effective when combined with traditional treatment approaches to OSA such as PAP. Clearly, however, for patients with moderate to severe or symptomatic OSA, traditional treatment should not be delayed. LIs should be viewed as adjunctive to traditional therapies.

In terms of clinical recommendations, if you do nothing else as a result of reading this article, be more specific when talking to patients about lifestyle change. And track results. For example, the three clinical cornerstones of any weight loss program are caloric restriction, increased energy expenditure, and behavior modification or CBT to modify the stimulus and reinforcement values of food. Therefore, instead of simply advising your patients, “weight loss is encouraged,” instruct your patients to increase their exercise (you can brainstorm possible activities), to eat more fruits and vegetables and fewer sugars and fats, and track their triggers for eating. Also recommend an exercise log or food diary, and follow-up regularly. Get to know the lifestyle or obesity specialists in your community, and provide appropriate referrals.

Action plan for hospitals and sleep health centers

The fact is that comprehensive sleep centers will increasingly incorporate lifestyle interventions into OSA management plans. Some will do so reluctantly, while leaders have already begun this transition. For example, I recently advised a leading, internationally renowned medical center regarding the incorporation of LIs and behavioral intervention into a sleep and cardiovascular disease management program. Target lifestyle behaviors included PAP adherence, sleep hygiene, exercise, and nutrition. This center sought to leverage technology and employ multidisciplinary group psychoeducation and intervention sessions to treat the whole patient, encourage lifestyle change, and ensure financial sustainability. Although this center and their leadership can be considered cutting edge, others will soon follow suit. For your own center, clearly define organizational goals and then work backwards from where you want to be in 1, 3, and 5 years. And in your defining your vision, study industry leaders but beware of benchmarking—benchmarks represent current, not future, best practices.

References

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