The act of sleeping comprises about one-third of our life. It is not just about time, but also the fact that sleeping affects nearly everything that we need to do. Quality of sleep affects quality of life. Obstructive sleep apnea (OSA) is a most common sleep-related breathing disorder, and snoring is the most important symptom. A 30–50% of snorers suffer from OSA, which can further lead to its comorbidities such as arterial hypertension, myocardial infarction, cerebral stroke, depression and anxiety disorders, or impotency disorders. Total body weight, body mass index (BMI), and fat distribution all correlate with odds of having OSA. Obesity causes deposition of adipose in and around the throat, which might lead to snoring and manifest into OSA if left untreated. Every 10 kg increase in weight increases risk by two times. An increase in BMI by six increases risk by four times. In obese patients, even minimal weight loss can be beneficial since it is related to preferential loss of visceral fat first as opposed to subcutaneous fat which has metabolic advantages. Therefore, one of the major modifiable risk factors for developing OSA is obesity. Lifestyle changes in the form of dietary modifications, imparting right knowledge about required nutrition for body, and implementation of the same monitored in a way that can manifest into a permanent behavioral change can go a long way in preventing and curing sleep-related breathing disorders and improving the quality of life of the patient as well as the bed partner.
Punjabi NM, Sorkin JD, Katzel LI, et al. Sleep-disordered breathing and insulin resistance in middle-aged and overweight men. Am J Respir Crit Care Med 2002;165(5):677–682. DOI: 10.1164/ajrccm.165.5.2104087.
Schwab RJ, Gupta KB, Gefter WB, et al. Upper airway and soft tissue anatomy in normal subjects and patients with sleep-disordered breathing. Significance of the lateral pharyngeal walls. Am J Respir Crit Care Med 1995;152(5 Pt 1):1673–1689. DOI: 10.1164/ajrccm.152.5.7582313.
Soriano-Co M, Vanhecke TE, Franklin BA, et al. Increased central adiposity in morbidly obese patients with obstructive sleep apnoea. Intern Med J 2011;41(7):560–566. DOI: 10.1111/j.1445-5994.2010.02283.x.
Opp MR. Cytokines and sleep. Sleep Med Rev 2005;9(5):355–364. DOI: 10.1016/j.smrv.2005.01.002.
Kimoff RJ, Hamid Q, Divangahi M, et al. Increased upper airway cytokines and oxidative stress in severe obstructive sleep apnoea. Eur Respir J 2011;38(1):89–97. DOI: 10.1183/09031936.00048610.
O'Donnell CP, Schaub CD, Haines AS, et al. Leptin prevents respiratory depression in obesity. Am J Respir Crit Care Med 1999;159(5 Pt 1): 1477–1484. DOI: 10.1164/ajrccm.159.5.9809025.
Epstein LJ, Kristo D, Strollo PJ Jr, et al. Clinical guideline for the evaluation, management and long-term care of obstructive sleep apnea in adults. J Clin Sleep Med 2009, Jun 15;5(3):263–276.
Tuomilehto HP, Seppä JM, Partinen MM, et al. Lifestyle intervention with weight reduction: first-line treatment in mild obstructive sleep apnea. Am J Respir Crit Care Med 2009;179(4):320–327. DOI: 10.1164/rccm.200805-669OC.
Johansson K, Hemmingsson E. Longer term effects of very low energy diet on obstructive sleep apnoea in cohort derived from randomised controlled trial: prospective observational follow-up study. BMJ 2011;1(342):d3017. DOI: 10.1136/bmj.d3017.
Tuomilehto H, Gylling H, Peltonen M, et al. Sustained improvement in mild obstructive sleep apnea after a diet- and physical activity-based lifestyle intervention: postinterventional follow-up. Am J Clin Nutr 2010;92(4):688–696. DOI: 10.3945/ajcn.2010.29485.
Tuomilehto H, Seppä J, Uusitupa M. Obesity and obstructive sleep apnea—clinical significance of weight loss. Sleep Med Rev 2013;17(5):321–329. DOI: 10.1016/j.smrv.2012.08.002.
Kuna ST, Reboussin DM, Borradaile KE, et al. Long-term effect of weight loss on obstructive sleep apnea severity in obese patients with type 2 diabetes. Sleep AHEAD Research Group of the Look AHEAD Research Group. Sleep 2013;36(5):641A–649A. DOI: 10.5665/sleep.2618.
Sharma SK, Kumpawat S, Banga A, et al. Prevalence and risk factors of obstructive sleep apnea syndrome in a population of Delhi, India. Chest 2006;130(1):149–156. DOI: 10.1378/chest.130.1.149.
Bixler EO, Vgontzas AN, Ten Have T, et al. Effects of age on sleep apnea in men: I. Prevalence and severity. Am J Respir Crit Care Med 1998;157(1):144–148. DOI: 10.1164/ajrccm.157.1. 9706079.
Young T, Shahar E, Nieto FJ, et al. Predictors of sleep-disordered breathing in community-dwelling adults: the Sleep Heart Health Study. Sleep Heart Health Study Research Group. Arch Intern Med 2002;162(8):893–900. DOI: 10.1001/archinte.162.8.893.
Young T, Peppard PE, Gottlieb DJ, et al. Epidemiology of obstructive sleep apnea a population health perspective. Am J Respir Crit Care Med 2002;165(9):1217–1239.
Gami AS, Caples SM, Somers VK, et al. Obesity and obstructive sleep apnea. Endocrinol Metab Clin North Am 2003;32(4):869–894. DOI: 10.1016/S0889-8529(03)00069-0.
Vgontzas AN, Papanicolaou DA, Bixler EO, et al. Sleep apnea and daytime sleepiness and fatigue: relation to visceral obesity, insulin resistance, and hypercytokinemia. J Clin Endocrinol Metab 2000;85(3):1151–1158. DOI: 10.1210/jcem.85.3.6484.
Peppard PE, Young T, Palta M, et al. Longitudinal study of moderate weight change and sleep-disordered breathing. JAMA 2000;284(23):3015–3021. DOI: 10.1001/jama.284.23.3015.
Levers-Landis C, Redline S. Pediatric sleep apnea: implications of the epidemic of childhood overweight. Am J Respir Crit Care Med 2007;175(5):436–441. DOI: 10.1164/rccm.200606-790PP.
Redline S, Storfer-Isser A, Rosen CL, et al. Association between metabolic syndrome and sleep-disordered breathing in adolescents. Am J Respir Crit Care Med 2007;176(4):401–408. DOI: 10.1164/rccm.200703-375OC.
Schwab RJ, Pasirstein M, Pierson R, et al. Identification of upper airway anatomic risk factors for obstructive sleep apnea with volumetric magnetic resonance imaging. Am J Respir Crit Care Med 2003; 168(5):522–530. DOI: 10.1164/rccm.200208-866OC.
Naimark A, Cherniack RM. Compliance of the respiratory system and its components in health and obesity. J Appl Physiol 1960 May;15:377–382. DOI: 10.1152/jappl.1960.15.3.377.
Patel SR, Larkin EK, Redline S. Shared genetic basis for obstructive sleep apnea and adiposity measures. Int J Obes (Lond) 2008;32(5): 795–800. DOI: 10.1038/sj.ijo.0803803.
Popko K, Gorska E, Wasik M, et al. Frequency of distribution of leptin receptor gene polymorphism in obstructive sleep apnea patients. J Physiol Pharmacol 2007 Nov;58(Suppl 5(2)):551–561.
Sahni N, Bansal S. Food Perceptions of Obstructive Sleep Apnea Patients. Online J Health Allied Scs 2018;17(2):3, available at URL: https://www.ojhas.org/issue66/2018-2-3.html.
Vgontzas AN, Tan TL, Bixler EO, et al. Sleep apnea and sleep disruption in obese patients. Arch Intern Med 1994;154(15):1705–1711. DOI: 10.1001/archinte.1994.00420150073007.
Pillar G, Shehadeh N. Abdominal fat and sleep apnea: the chicken or the egg? Diabetes Care 2008;31(Suppl 2):S303–S309. DOI: 10.2337/dc08-s272.
Smith PL, Gold AR, Meyers DA, et al. Weight loss in mildly to moderately obese patients with obstructive sleep apnea. Ann Intern Med 1985;103(6(Pt 1)):850–855. DOI: 10.7326/0003-4819-103-6-850.
Noseda A, Kempenaers C, Kerkhofs M, et al. Sleep apnea after 1 year domiciliary nasal-continuous positive airway pressure and attempted weight reduction. Potential for weaning from continuous positive airway pressure. Chest 1996;109(1):138–143. DOI: 10.1378/chest.109.1.138.
Newman AB, Foster G, Givelber R, et al. Progression and regression of sleep-disordered breathing with changes in weight: the Sleep Heart Health Study. Arch Intern Med 2005;165(20):2408–2413. DOI: 10.1001/archinte.165.20.2408.
Dixon JB, Schachter LM, O'Brien PE, et al. Polysomnography before and after weight loss in obese patients with severe sleep apnea. Int J Obes (Lond) 2005;29(9):1048–1054. DOI: 10.1038/sj.ijo.0802960.
Sahlman J, Pukkila M, Seppä J, et al. Evolution of mild obstructive sleep apnoea after different treatments. Laryngoscope 2007;117(6):1107. DOI: 10.1097/MLG.0b013e3180514d08.
Berger G, Berger R, Oksenberg A, et al. Progression of snoring and obstructive sleep apnoea: the role of increasing weight and time. Eur Respir J 2009;33(2):338–345. DOI: 10.1183/09031936.00075408.
Suratt PM, McTier RF, Findley LJ, et al. Effect of very-low-calorie diets with weight loss on obstructive sleep apnea. Am J Clin Nutr 1992;56(1):182S–184S. DOI: 10.1093/ajcn/56.1.182S.
Braver HM, Block AJ, Perri MG, et al. Treatment for snoring: combined weight loss, sleeping on side, and nasal spray. Chest 1995;107(5): 1283–1288. DOI: 10.1378/chest.107.5.1283.
Barnes M, Goldsworthy UR, Cary BA, et al. A diet and exercise program to improve clinical outcomes in patients with obstructive sleep apnoea–a feasibility study. J Clin Sleep Med 2009;5(05):409–415.
Jebb S. Carbohydrates and obesity: From evidence to policy in the UK. Proc Nutr Soc 2015;74(3):215–220. DOI: 10.1017/S0029665114001645.
Simin L, Manson JE. Dietary carbohydrates, physical inactivity, obesity, and the ‘metabolic syndrome’ as predictors of coronary heart disease. Curr Opin Lipidol 2001;12(4):395–404. DOI: 10.1097/00041433-200108000-00005.
Denzer CM, Young JC. The effect of resistance exercise on the thermic effect of food. International Journal of Sport Nutrition and Exercise Metabolism. 2003;13(3):396–402.
Lau DC, Douketis JD, Morrison KM, et al. 2006 Canadian clinical practice guidelines on the management and prevention of obesity in adults and children summary. CMAJ (Practice Guideline, Review) 2007;176(8):S1–S13. DOI: 10.1503/cmaj.061409.
McClernon FJ, Yancy WS Jr, Eberstein JA, et al. The effects of a low-carbohydrate ketogenic diet and a low-fat diet on mood, hunger, and other self-reported symptoms. Obesity (Silver Spring) 2007;15(1): 182–187. DOI: 10.1038/oby.2007.516.
Billings ME, Krishnan V, Su G, et al. Clinical Practice Guideline Summary for Clinicians: The Role of Weight Management in the Treatment of Adult Obstructive Sleep Apnea. Ann Am Thorac Soc 2019;16(4): 405–408. DOI: 10.1513/AnnalsATS.201810-708CME.
Habdank K, Paul T. A randomized controlled trial evaluating the effectiveness of a weight loss strategy in overweight and obese patients with obstructive sleep apnea (OSA). Sleep Med 2006;7(Suppl 2):S73–S74. DOI: 10.1016/j.sleep.2006.07.176.
Wu T, Gao X, Chen M, et al. Long-term effectiveness of diet-plus-exercise interventions vs. diet-only interventions for weight loss: a meta-analysis. Obes Rev 2009;10(3):313–323. DOI: 10.1111/j.1467-789X.2008.00547.x.
Johns DJ, Hartmann-Boyce J, Jebb SA, et al. Behavioural Weight Management Review Group. Diet or exercise interventions vs combined behavioral weight management programs: a systematic review and meta-analysis of direct comparisons. J Acad Nutr Diet 2014;114(10):1557–1568. DOI: 10.1016/j.jand.2014.07.005.
Winslow DH, Bowden CH, DiDonato KP, et al. A randomized, double-blind, placebo-controlled study of an oral, extended-release formulation of phentermine/topiramate for the treatment of obstructive sleep apnea in obese adults. Sleep 2012;35(11):1529–1539. DOI: 10.5665/sleep.2204.
Blackman A, Foster GD, Zammit G, et al. Effect of liraglutide 3.0 mg in individuals with obesity and moderate or severe obstructive sleep apnea: the SCALE Sleep Apnea randomized clinical trial. Int J Obes 2016;40(8):1310–1319. DOI: 10.1038/ijo.2016.52.
Rössner S, Sjöström L, Noack R, et al. European Orlistat Obesity Study Group. Weight loss, weight maintenance, and improved cardiovascular risk factors after 2 years treatment with orlistat for obesity. Obes Res 2000;8(1):49–61. DOI: 10.1038/oby.2000.8.
Dixon JB, Schachter LM, O'Brien PE, et al. Surgical vs conventional therapy for weight loss treatment of obstructive sleep apnea: a randomized controlled trial. JAMA 2012;308(11):1142–1149. DOI: 10.1001/2012.jama.11580.
Feigel-Guiller B, Drui D, Dimet J, et al. Laparoscopic gastric banding in obese patients with sleep apnea: a 3-year controlled study and follow-up after 10 years. Obes Surg 2015;25(10):1886–1892. DOI: 10.1007/s11695-015-1627-5.
Balshem H, Helfand M, Schünemann HJ, et al. GRADE guidelines: 3. Rating the quality of evidence. J Clin Epidemiol 2011;64(4):401–406. DOI: 10.1016/j.jclinepi.2010.07.015.
GRADEpro GDT: GRADEpro Guideline Development Tool [software]. McMaster University; 2015 (developed by Evidence Prime, Inc.).
Schünemann HJ, Jaeschke R. ATS Documents Development and Implementation Committee. An official ATS statement: grading the quality of evidence and strength of recommendations in ATS guidelines and recommendations. Am J Respir Crit Care Med 2006;174(5):605–614. DOI: 10.1164/rccm.200602-197ST.
Qaseem A, Holty JE, Owens DK, et al. Management of obstructive sleep apnea in adults: a clinical practice guideline from the American College of Physicians. Ann Intern Med 2013;159(7):471–483.
Fleetham J, Ayas N, Bradley D, et al. CTS Sleep Disordered Breathing Committee. Canadian Thoracic Society guidelines: diagnosis and treatment of sleep disordered breathing in adults. Can Respir J 2006;13(7):387–392. DOI: 10.1155/2006/627096.
Morgenthaler TI, Kapen S, Lee-Chiong T, et al. Standards of Practice Committee; American Academy of Sleep Medicine. Practice parameters for the medical therapy of obstructive sleep apnea. Sleep 2006;29(8):1031–1035. DOI: 10.1093/sleep/29.8.1031.
Phelan S, Nallari M, Darroch FE, et al. What do physicians recommend to their overweight and obese patients? J Am Board Fam Med 2009;22(2):115–122. DOI: 10.3122/jabfm.2009.02.080081.
Aveyard P, Lewis A. Screening and brief intervention for obesity in primary care: a parallel, two-arm, randomised trial. Lancet 2016;388:2492–2500. DOI: 10.1016/S0140-6736(16)31893-1.
Rose SA, Poynter PS, Anderson JW, et al. Physician weight loss advice and patient weight loss behavior change: a literature review and meta-analysis of survey data. Int J Obes 2013;37(1):118–128. DOI: 10.1038/ijo.2012.24.