TABLE VIII.D. 2.
Evidence for the role of weight loss in the management of obstructive sleep apnea (OSA)
| Study | Year | LOE | Study design | Study groups | Clinical endpoint | Conclusion |
|---|---|---|---|---|---|---|
| López-Padrós et al.1412 | 2020 | 2b | RCT | 1. Intensive weight loss program with low (600–800 kcal/day) calorie diet for 15 days followed by a 1200 kcal/day diet during the remainder of the initial 12 weeks, and a 1200–1800 kcal/day Mediterranean diet for the last 36 weeks (n = 22) 2. Control group (n = 20) |
AHI (PSG) | In obese patients with severe OSA (AHI > 30), an intensive weight loss program is superior to control in reducing weight and OSA severity. Diet group: MD in weight at 3 months: −10.5 kg 12 months: −8.2 kg MD in AHI at 3 months: −23.7 12 months: −19.4 Control group: MD in weight at 3 months: −2.3 kg at 12 months: −0.1 kg MD in AHI at 3 months: −9 at 12 months: −13.5 |
| Hudgel et al.1415 | 2018 | 2a | SR with meta-analysis | 4 RCTs that examined the impact of weight loss on OSA | AHI | MD in weight was −11.6 kg; MD in BMI was −4.1 kg/m2
AHI MD −8.5 ESS MD −2.4 points For patients with OSA who are overweight or obese, suggest a reduced-calorie diet (with or without exercise/increased physical activity) rather than no diet (conditional recommendation, very low certainty in the estimated effect). |
| Fernandes et al.1407 | 2015 | 2b | RCT | 800 Cal diet group (n = 11) Control group (n = 10) Age (20–55) |
pAHI (with WatchPAT) | Weight loss superior to control in improving OSA severity. Mean differences below.Diet group:Change in weight: −5.57 kgChange in pAHI: −7.22 Control group:Change in weight: 0.43 kgChange in pAHI: 0.13 (p = 0.04) |
| Make-Nunes et al.1409 | 2015 | 2b | RCT | Hypocaloric diet (decrease of 500 kcal/day) and exercise training group (n = 16) Control group (n = 8) | AHI (PSG) | Hypocaloric diet and exercise training superior to control in improving OSA severity. Mean differences below. Hypocaloric diet and exercise training group Change in weight: −5 kg Change in AHI: −16 Control group: Change in weight: 1 kg Change in AHI: 11 Change in body weight was associated with change in AHI. |
| Ng et al.1410 | 2015 | 2b | RCT | Dietician led lifestyle modification program (diet) group (n = 61) Control group: usual care (n = 43) |
AHI | In patients with moderate to severe OSA, lifestyle modification was superior to usual care in reducing the severity of OSA. Dietician led lifestyle modification program (diet) group: Change in BMI: −1.8 kg/m2 Percent change in AHI: −16.9% Control group: Change in BMI: −0.6 kg/m2 Percent change in AHI + 0.6% |
| Desplan et al.1406 | 2014 | 2b | RCT | Inpatient rehabilitation program group including individualized exercise training, education activities sessions, and dietary management (n = 11) Control group: one-month education activity sessions (n = 11) |
AHI, ODI (PSG) | In patients with moderate to severe OSA, intervention was superior to control in reducing AHI and ODI. Inpatient rehabilitation program: Change in BMI: −0.8kg/m2 Change in AHI: −12.6 Change in ODI: −5.5 Control group: Change in BMI: 0 kg/m2 Change in AHI: 5.6 Change in ODI: 5.2 Change in arousals: 6.7 |
| Papandreou et al.1414 | 2012 | 2b | RCT | Mediterranean diet, CPAP, and lifestyle intervention (n = 20) Prudent diet, CPAP, and lifestyle intervention (n = 20) |
AHI (PSG) | In patient with moderate to severe OSA (AHI > 15) and BMI ≥ 30 kg/m2, Mediterranean diet was only superior to control in reducing AHI during REM sleep. Otherwise, there were no significant differences in other sleep parameters between the two groups. Changes in weight and BMI did not reach statistical significance between the two groups. |
| Foster et al.122 | 2009 | 2a | RCT | Intervention group: diet, exercise, and training (n = 125) Control group: three group sessions for diabetes management (n = 139) |
AHI, ODI (unattended overnight PSG) | Intervention superior to control in reducing AHI reported as adjusted mean differences. Diet and exercise group: Change in weight: 10.8 kg Change in BMI: −3.8kg/m2 Change in AHI: −5.4 Change in ODI: −5.5 Control group: Change in weight: 0.6 kg Change in BMI: 0.2 kg/m2 Change in AHI: 4.2 Change in ODI: 1.2 |
| Johansson et al.1408 | 2009 | 2b | RCT | Intervention group: Very low calorie (2.3 MJ/day) liquid diet (n = 30) Control group: usual diet (n = 33) |
pAHI, ODI (WatchPAT) | Very low calorie diet superior to usual diet in reducing pAHI. Low energy diet improved OSA in obese men, with the greatest effect in patients with severe disease. Mean differences below. Intervention group: Change in weight: −18.7 kg Change in BMI: −5.7 kg/m2 Change in pAHI: −25 Change in ODI: −19 Control group: Change in weight: 1.1 kg Change in BMI: 0.3 kg/m2 Change in pAHI: −2 Change in ODI: −1 |
| Tuomilehto et al.1411 | 2009 | 2b | RCT | Intervention: very low calorie diet program 600–800 kcal/day (with supervised lifestyle modification (n = 35) Control: routine lifestyle counseling (n = 37) |
AHI, mean SaO2 | Intervention superior to control in reducing AHI in mild OSA, and improving mean oxygen saturation, together with weight loss. Mean differences below. Diet group: Change in weight: −10.7 kg Change in BMI: −3.5 kg/m2 Change in AHI: −4.0 Change in mean SaO2: 0.8 Control group: Change in weight: −2.4 kg Change in BMI −0.8 kg/m2 Change in AHI: 0.3 Change in mean SaO2: −0.3 |
| Nerfeldt et al.1413 | 2008 | 2b | RCT | Intervention: weight reduction program consisting of a low-calorie diet and group meetings (n = 6) Control: expectancy followed by crossover after 8 weeks (n = 5) |
AHI, ODI (Micro Digi trapper-type 3) | Intervention was superior to control in reducing ODI in males with BMI ≥30. Mean differences below. Diet group: Change in weight: −18.5 kg Change in BMI: −4.8 kg/m2 Change in ODI: −50 Control group: Change in weight: −13 kg Change in BMI: −3.7 kg/m2 Change in ODI: −1 |
| Pharmacotherapy | ||||||
| Blackman et al.1417 | 2016 | 1b | RCT | Liraglutide 3 mg with diet (500 kcal/day) and exercise (n = 180) Placebo with diet (500 kcal/day) and exercise (n = 179) |
AHI (PSG) | Intervention was superior to placebo in reducing AHI in patients with obesity (BMI ≥30 kg/m2) and mild–moderate OSA (AHI ≥ 15). Mean differences below. Liraglutide group: Change in weight: −6.7 kg ± 0.5 Change in BMI: −2.2 ± 0.2 kg/m2 Change in AHI: −12.2 ± 1.8 Placebo group: Change in weight: −1.9 kg ± 0.4 Change in BMI: −0.6 ± 0.1 kg/m2 Change in AHI: −6.0 ± 2.0 Significant treatment difference in AHI, weight, SBP, and HbA1c between groups. |
| Winslow et al.1418 | 2012 | 2b | RCT | Phentermine 15 mg plus extended-release topiramate 92 mg (n = 22) Placebo (n = 23) |
AHI (PSG) | Treatment was superior to placebo in reducing AHI. Mean differences below. Phentermine and topiramate group: Change in weight: −11.0 ± 1.24 kg Change in AHI: −31.5 ± 4.2 Placebo group: Change in weight: −4.5 ± 1.21 kg Change in AHI: −16.6 ± 4.5 |
Abbreviations: AHI, apnea hypopnea index; CWLP, comprehensive weight loss program; EDS, excessive daytime sleepiness; ESS, Epworth sleepiness score; MD, mean difference; N, number; ODI, oxygen desaturation index; OSA, obstructive sleep apnea; pAHI, PAT AHI; PAT, peripheral arterial tonometry; RCT, randomized controlled trial; SaO2, oxygen saturation; SBP, systolic blood pressure; SR, systematic review.