What are the typical behavioral and psychological factors that contribute to weight gain?
Everything revolves around food. Every time we celebrate, every time we have a meeting it revolves around food. A lot of it is our sedentary lifestyle. Another part of the behavioral problem is that we misinterpret some of our basic needs. We may be thirsty or sleepy, yet we interpret that as being hungry. Many people use food as a coping mechanism as well. We have also become a society where we drive everywhere and we sit too much. There's resistance to walk up one flight of stairs or walk one block to a store.
What health problems might contribute to weight gain, or make it difficult to lose weight?
We now know that with obesity there is a higher chance of insulin resistance or glucose intolerance which results in patients developing type-2 diabetes. There is a higher chance of high blood pressure, sexual dysfunction, headaches, and depression. Now there is also a sense that as we get older we experience more frequent fatigue. Studies suggest that it's not necessarily our chronological age that makes us so tired or fatigued, but it could be related to obesity, not necessarily obstructive sleep apnea (OSA), just obesity. It's a vicious cycle where we sleep poorly, we are less motivated to increase physical activity, and so we gain more weight, which leads to obesity related issues including sleep apnea.
How many of your sleep apnea patients are overweight? If they are overweight, should they automatically ask their primary care doctor to screen them for sleep apnea?
The majority of our patients are obese. There seems to be a relationship between obesity and obstructive sleep apnea; however, we have to point out that not every obese patient by body mass index has obstructive sleep apnea. There are patients who have normal body mass indexes who are diagnosed with obstructive sleep apnea. Persons who are obese should undergo a general physical examination for obesity related health issues. A good test to do is to measure neck circumference. In men, if the neck circumference is 17 inches or higher there's a good chance of obstructive sleep apnea. In females, it's 16 inches or higher.
What weight loss treatment plan and advice do you recommend to your patients with sleep apnea?
It has to be tailored to the patient's current health issues, medications and lifestyle. For patients that complain of joint pain and inability to move, I recommend hydrotherapy. Exercising in the water will make it easier for them to be mobile despite their high body mass index, arthritic hips and knees. We also encourage them to join a local weight loss group. It seems people do best when they have a strong support system, a spouse or a buddy that helps them lose weight. When someone goes on their own with unrealistic expectations it doesn't seem to work. You're going to have lapses, but, overall, just keep working the plan. Another important thing to consider is general health and diet education. Many of my patients say, ‘Well I eat very little,' but what they eat is high in calories or empty calories. Being aware of your caloric intake is very important to weight loss.
Is it harder for someone with sleep apnea to lose weight?
There was speculation many years ago that sleep deprivation slows your metabolism, which, in dramatic cases, slows to the point where you couldn't lose weight. Science is showing that it's true. There is a tremendous physiological insult to your body including insulin resistance, glucose intolerance, and elevation in blood pressure. I tell my patients, that being treated for obstructive sleep apnea with CPAP (continuous positive airway pressure, the most common treatment for OSA) is not weight loss equipment. But our hope is that if we can control your sleep apnea you will get more consolidated sleep so you won't have these fluctuations in hormone levels. You will rest better, you will be more motivated to proceed with an exercise program, and you will have more energy to proceed with a weight loss program. We hope that [by using CPAP] it starts a chain reaction. Hopefully you will be more mentally and physically prepared to undergo the weight loss and that in itself will lead to more health benefits.
When do you recommend obesity surgery?
Most obesity surgery programs have a protocol where their patients have to see a psychiatrist, cardiologist and a sleep specialist. These programs are very strict on this, there is no bypassing any of the work up. If patients have sleep apnea that is another motive or indication to receive bypass surgery, and more importantly, they have to be treated and monitored after the surgery. We follow them before, during and after surgery. Patients have to be very disciplined and be followed under close medical supervision. It's usually not just one surgery. More than likely there will be subsequent surgeries to remove excessive tissue, it is a very dramatic, and intense period.
After you lose weight, will sleep apnea go away?
Weight is an important factor in obstructive sleep apnea; however, there are other important factors to apnea including some of which are purely anatomical. Someone might have a severe receded chin, prominent tonsils or a deviated nasal septum. That being said if you're only going to do one good thing in life, lose weight. It's going to help your blood pressure, your joints, and increase your vitality. There's no guarantee weight loss, in itself, is going to clear up sleep apnea, but it won't hinder it, and it has many other benefits.
Frankie Roman, MD, JD Doctors Hospital, Center for Sleep Disorders, Masillon, Ohio. Board Member, National Sleep Foundation