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Dose-response relationship between weight loss and improvements in obstructive sleep apnea severity after a diet/lifestyle interventions: secondary analyses of the "MIMOSA" randomized clinical trial.
Georgoulis, M, Yiannakouris, N, Kechribari, I, Lamprou, K, Perraki, E, Vagiakis, E, Kontogianni, MD
Journal of clinical sleep medicine : JCSM : official publication of the American Academy of Sleep Medicine. 2022;18(5):1251-1261
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Obstructive sleep apnoea (OSA) represents one of the most common and serious sleep-related breathing disorders. Excess body weight has emerged as the strongest modifiable predictor of the onset and severity of OSA. The aim of this study was to explore the dose-response relationship between the degree of weight loss and improvements in OSA severity. This study is a secondary analysis of the Mediterranean diet/lifestyle Intervention for the Management of Obstructive Sleep Apnea (MIMOSA) study, which was designed as a single-centre, single-blind, parallel, randomised, controlled clinical trial. Results show that respiratory events and oximetry indices improved only in patients who lost weight and improvements were proportional to the degree of weight loss. Authors conclude that their findings indicate a dose-response relationship between the degree of weight loss and improvement in OSA severity and symptoms. However, further research is needed to gather more data on the optimal degree of weight loss and appropriate weight-loss interventions for managing the wide spectrum of OSA severity to guide clinical practice.
Expert Review
Conflicts of interest:
None
Take Home Message:
Important from a public health perspective:
- This study has confirmed that even a small degree of weight loss can have a beneficial effect on respiratory events and oxygen desaturation in moderate-to-severe OSA, but clinicians should preferably aim at a ≥ 5% weight loss, and ideally a ≥ 10% weight loss, to achieve clinically meaningful reductions in OSA severity.
Evidence Category:
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X
A: Meta-analyses, position-stands, randomized-controlled trials (RCTs)
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B: Systematic reviews including RCTs of limited number
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C: Non-randomized trials, observational studies, narrative reviews
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D: Case-reports, evidence-based clinical findings
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E: Opinion piece, other
Summary Review:
Introduction
OSA represents one of the most common and serious sleep-related breathing disorders, with a high worldwide prevalence of almost 1 billion people. OSA has numerous well-established cardiometabolic consequences.
The authors highlight that weight loss is essential for obstructive sleep apnea (OSA) management. However, the optimal degree of weight loss for improving OSA severity or eliminating sleep-disordered breathing has not been extensively studied. The aim of this study was to explore the dose-response relationship between the degree of weight loss and improvements in OSA severity.
Methods
This is a secondary analysis of the Mediterranean diet/lifestyle Intervention for the Management of Obstructive Sleep Apnea (MIMOSA) study. This study was designed as a single-center, single-blind, parallel, randomised, controlled clinical trial to evaluate the effectiveness of a weight-loss Mediterranean dietary/lifestyle intervention on managing OSA.
This 6-month long clinical trial included 180 adult, overweight/obese moderate-to-severe OSA patients (45 patients per study group plus a 29% dropout rate). All patients were prescribed the standard of care continuous positive airway pressure (CPAP) therapy and were randomised to 3 arms: standard care; Mediterranean diet; Mediterranean lifestyle
Based on percent change in weight at 6 months, participants were categorised into a weight-stable/gain (WS/GG) group or one of 3 weight-loss groups (WLG): < 5%WLG; 5%–10%WLG; ≥ 10%WLG. Polysomnographic data and OSA symptoms were also evaluated preintervention and postintervention.
Results
Results confirm a dose-response relationship between the degree of weight loss achieved through a dietary/lifestyle intervention and improvements in OSA severity.
- Respiratory events and oximetry indices improved only in patients who lost weight. Improvements were proportional to the degree of weight loss.
- Median percent change in apnea-hypopnea index (AHI) was −11.7%, − 37.9%, and − 49.3% in the < 5%WLG, 5%–10%WLG, and ≥ 10%WLG, respectively (P < .001).
- Compared to the WS/GG, the age-, sex-, baseline-, and CPAP use–adjusted relative risk (95% confidence interval) of severe OSA (AHI ≥ 30 events/h) was 0.45 (0.23–0.87) in the 5%–10%WLG and 0.32 (0.17–0.64) in the ≥ 10%WLG; the risk was also lower in the ≥ 10%WLG vs the < 5%WLG (0.42 [0.22–0.82]).
- Insomnia and daytime sleepiness also improved more in participants exhibiting ≥ 5% weight loss.
- The dose-response relationship between weight loss and improvement in OSA severity was evident regardless of self-reported CPAP use.
Conclusions
The authors conclude that even a < 5% weight loss was sufficient for improvements in respiratory events and oximetry indices, but the prevalence of severe OSA reduced only after a ≥ 5% weight loss, and patients achieving a ≥ 10% weight loss exhibited the greatest benefits compared to weight-stable/gain patients.
Clinical practice applications:
These findings might be useful for Nutritional Therapists and Clinical Practitioners:
- Clinicians should aim for a ≥ 5% weight loss, and ideally a ≥ 10% weight loss, to achieve clinically meaningful reductions in OSA severity.
- Improvements after weight loss were significant even though a healthy body weight was not achieved.
Considerations for future research:
- The study sample consisted of predominantly male, overweight, otherwise healthy patients with moderate-to-severe OSA. Therefore, findings cannot be generalised to the whole OSA population and further research is required with broader, diverse, study samples.
- 6 months is a short duration period, therefore longer trials are required.
- Self-reported CPAP use by participants is a limitation of this study. Further robust analysis methods should be considered for future trials.
- Participants were advised to abstain from CPAP therapy for 2 days prior to the follow-up PSG but this was not evaluated or confirmed in this study and should be in future research.
Abstract
STUDY OBJECTIVES Lifestyle-induced weight loss is a complementary therapeutic approach for obstructive sleep apnea (OSA). We aimed at identifying the dose-response relationship between weight loss and OSA severity improvement. METHODS This is a secondary analysis of a 6-month clinical trial in 180 adult, overweight/obese moderate-to-severe OSA patients. Participants were randomized to a standard care, a Mediterranean diet, or a Mediterranean lifestyle arm. All patients were prescribed with continuous positive airway pressure (CPAP), while intervention arms additionally participated in a weight-loss dietary/lifestyle intervention. Based on percent change in weight at 6 months, participants were categorized into a weight-stable/gain (WS/GG) group or 3 weight-loss groups (WLG): < 5%WLG, 5%-10%WLG, and ≥ 10%WLG. Polysomnographic data and OSA symptoms were evaluated preintervention and postintervention. RESULTS Respiratory events and oximetry indices improved only in patients who lost weight and improvements were proportional to the degree of weight loss. Median percent change in apnea-hypopnea index (AHI) was -11.7%, - 37.9%, and - 49.3% in the < 5%WLG, 5%-10%WLG, and ≥ 10%WLG, respectively (P < .001). Compared to the WS/GG, the age-, sex-, baseline-, and CPAP use-adjusted relative risk (95% confidence interval) of severe OSA (AHI ≥ 30 events/h) was 0.45 (0.23-0.87) in the 5%-10%WLG and 0.32 (0.17-0.64) in the ≥ 10%WLG; the risk was also lower in the ≥ 10%WLG vs the < 5%WLG (0.42 [0.22-0.82]). Insomnia and daytime sleepiness also improved more in participants exhibiting ≥ 5% weight loss. CONCLUSIONS Even a < 5% weight loss can reduce respiratory events, but a ≥ 5% and ideally ≥ 10% weight loss is necessary for reducing the prevalence of severe OSA. CLINICAL TRIAL REGISTRATION Registry: ClinicalTrials.gov; Name: Mediterranean Diet/Lifestyle Intervention in Obstructive Sleep Apnea; URL: https://clinicaltrials.gov/ct2/show/NCT02515357; Identifier: NCT02515357. CITATION Georgoulis M, Yiannakouris N, Kechribari I, et al. Dose-response relationship between weight loss and improvements in obstructive sleep apnea severity after a diet/lifestyle intervention: secondary analyses of the "MIMOSA" randomized clinical trial. J Clin Sleep Med. 2022;18(5):1251-1261.
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Development and Effects of College-Based Lifestyle Modification Program for Menstrual Health of Young Adult Women with Irregular Menses: A Randomized Controlled Trial.
Park, YJ, Shin, H, Jeon, S, Cho, I, Park, HJ
International journal of environmental research and public health. 2020;18(1)
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Irregular menstruation is characterized by abnormal uterine bleeding, unpredictable menstrual volume, and irregularity of menstruation. A regular menstrual cycle demonstrates a normal sex hormone profile and functioning of reproductive organs, whereas irregularity may suggest a dysfunctional sex hormone profile or disorder of reproductive organs. This study is a randomised controlled trial intended to develop a College-based Lifestyle Modification Programme (LMP) to improve the menstrual health of young adult women who experienced irregular menstruation less than ten times a year, and its effects on their health. The study has two arms: intervention and control group. Female participants (n=46) were randomly assigned 1:1 to one of the two groups. Results show that the College-based LMP had positive effects on the alleviation of depression and anxiety, and improvement of sleep duration. Whereas there were no significant differences for certain variables (menstrual cycle index, sex hormone binding globulin, testosterone, free androgen index), overall premenstrual syndrome, menstrual volume, body composition parameters, and nutrient intake. Authors conclude that their findings demonstrated the importance of lifestyle modifications, which could provide ordinary young adult women with healthy menstruation. However, further studies with the use of supplements are required to address the limitations of the current study.
Abstract
Purpose: This study was conducted to develop the 'College-based Lifestyle Modification Program' (College-based LMP) for young adult women with irregular menstruation and examine its effects after intervention. Methods: The College-based LMP consisted of small group education, individual physical exercise counseling/training, individual diet counseling, and feedback and support. Participants were comprised of 38 females who reported less than 10 irregular menstruations in a year and were randomly assigned to the experimental and control groups. The primary outcome variables consisted of menstrual cycle index (MCI), sex hormone binding globulin (SHBG), and androgenic profile (testosterone-T, free androgen index-FAI), while the outcome variables included premenstrual symptoms (PMS), menstrual volume, body composition parameters, glycemic parameters (fasting blood sugar-FBS, insulin, HOMA-IR), sleep duration, perceived stress, and nutrient intake.. Results: There were no significant differences in primary outcome variables (MCI, SHBG, T, and FAI). In the variables, there were no significant differences except for the partial domain of PMS (symptoms of depression and anxiety) and sleep duration. Conclusions: The study was significant in that it demonstrated the importance of lifestyle, which could provide ordinary young adult women with healthy menstruation. The College-based LMP needs to be elaborated with further studies.
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Association between sleep duration and musculoskeletal pain: The Korea National Health and Nutrition Examination Survey 2010-2015.
Chun, MY, Cho, BJ, Yoo, SH, Oh, B, Kang, JS, Yeon, C
Medicine. 2018;97(50):e13656
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Musculoskeletal pain is highly prevalent in old age and can be disabling to sufferers, resulting in significant economic burden and a detrimental impact on quality of life. The aim of the study was to investigate the association between self-reported sleep duration and musculoskeletal pain in Korean adult population. The study showed that extreme sleep duration is prevalent in musculoskeletal pain subjects and it is more prevalent in subjects with multi-site joint pain. Thus, both longer and shorter sleep durations were linked with a higher prevalence of musculoskeletal pain. Authors conclude that specific assessment and treatment of sleep disturbance should be included as an important part of pain management in patients with musculoskeletal pain.
Abstract
Both extremely long and short sleep durations have been associated with increased risk of numerous health problems. This study examined the association between self-reported sleep duration and reporting of musculoskeletal pain in the adult Korean population.This study included data from 17,108 adults aged ≥50 years, obtained from the Korea National Health and Nutrition Examination Survey 2010-2012 and 2013-2015. Self-reported daily hours slept and the presence of musculoskeletal pain in knee joint, hip joint, or low back were examined. Patients were stratified into 5 groups by their sleep duration: ≤5, 6, 7, 8, or ≥9 h. Multivariate logistic regression analysis was performed, adjusting for covariates including age, sex, marital status, smoking, alcohol use, family income level, education, physical exercise, body mass index (BMI), and stress level.A U-shaped relationship was observed between the length of sleep duration and the presence of musculoskeletal pain. After adjusting for covariates, sleep duration of ≤5 h or ≥9 h was significantly associated with musculoskeletal pain experienced for more than 30 days over a 3-month period. We also found that the presence of multi-site musculoskeletal pain was significantly higher among those who slept for ≤5 h or ≥9 h than in those who slept for 7 h.These findings suggest that either short or long sleep duration is associated with musculoskeletal pain among Korean adults.
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Melatonin Supplementation Lowers Oxidative Stress and Regulates Adipokines in Obese Patients on a Calorie-Restricted Diet.
Szewczyk-Golec, K, Rajewski, P, Gackowski, M, Mila-Kierzenkowska, C, Wesołowski, R, Sutkowy, P, Pawłowska, M, Woźniak, A
Oxidative medicine and cellular longevity. 2017;2017:8494107
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Obesity is one of the major global health problems. Melatonin is a hormone which regulates wakefulness, functions as an antioxidant and plays a role in the immune system. Previous research suggests that melatonin deficiency is associated with obesity. The aim of this study was to estimate the effect of melatonin on oxidative stress and levels of cell signalling proteins released by fat cells (adipokines) in obese patients on a calorie-restricted diet. Thirty obese patients were supplemented with a daily dose of 10 mg of melatonin or placebo for 30 days with a calorie-restricted diet. Blood levels of melatonin, adipokines and markers of oxidative stress were measured at baseline and after supplementation. Significant body weight reduction (7%) was observed only in the melatonin group. After melatonin supplementation, the adiponectin and omentin-1 levels and glutathione peroxidase activities statistically increased, whereas the malondialdehyde concentrations were reduced. In the placebo group, a significant rise in 4-hydroxynonenal and a drop in the melatonin concentrations were found. The results show evidence of increased oxidative stress accompanying calorie restriction. The authors concluded that melatonin supplementation facilitated body weight reduction, improved the antioxidant defence, and regulated adipokine secretion. The findings suggest that melatonin should be considered in the management of obesity.
Abstract
Obesity is one of the major global health problems. Melatonin deficiency has been demonstrated to correlate with obesity. The aim of the study was to estimate the effect of melatonin on oxidative stress and adipokine levels in obese patients on a calorie-restricted diet. Thirty obese patients were supplemented with a daily dose of 10 mg of melatonin (n = 15) or placebo (n = 15) for 30 days with a calorie-restricted diet. Serum levels of melatonin, 4-hydroxynonenal (HNE), adiponectin, omentin-1, leptin, and resistin, as well as erythrocytic malondialdehyde (MDA) concentration and Zn/Cu-superoxide dismutase, catalase, and glutathione peroxidase (GPx) activities, were measured at baseline and after supplementation. Significant body weight reduction was observed only in the melatonin group. After melatonin supplementation, the adiponectin and omentin-1 levels and GPx activities statistically increased, whereas the MDA concentrations were reduced. In the placebo group, a significant rise in the HNE and a drop in the melatonin concentrations were found. The results show evidence of increased oxidative stress accompanying calorie restriction. Melatonin supplementation facilitated body weight reduction, improved the antioxidant defense, and regulated adipokine secretion. The findings strongly suggest that melatonin should be considered in obesity management. This trial is registered with CTRI/2017/07/009093.