In recent years, there has been a focus on the art of medicine; this aspect of care assumes that the science of medicine has been well implemented. The art comes from innovation in how concepts are approached and negotiated with the patient to enact an understanding of both health and disease, as well as participation in self-care. Sleep is an area in which the art of medicine is critical. Titration and trouble-shooting problems with pressure, humidity, etc are relatively formulaic. The brushstrokes in the art of sleep medicine come in the form of crafting patient acceptance of disease and creating an approach to better health that is effective, efficient, and realistic for the patient.
The case of a morbidly obese, 55-year-old African-American male, whose main complaint is that his energy level has been progressively decreasing, demonstrates how the scientific and artistic approach to sleep medicine is needed in bariatric case management.
The patient’s medical history includes current hypertension and diabetes mellitus. He weighs 278 pounds and is 5 feet 9 inches tall (BMI = 41). Bedtime is at 10 pm, and he wakes by alarm, typically at 6 am. The patient also wakes with nocturia two or three times per night. On weekends, he phase extends and takes a refreshing 1-hour nap in a recliner. He snores loudly and awakens from his own snoring occasionally. His wife has witnessed him choking for air. His Epworth sleepiness score was 14.
On physical exam, the patient has a thick neck and crowded airway marked by Mallampati IV, a low arched soft palate, and a large uvula. Attended sleep laboratory split night polysomnography revealed the following data:
Diagnostic half: AI = 5, AHI = 25, SAI = 10, RDI = 35, SaO2 nadir = 65%, and Mean HR = 52.
Titration half: AI = 0, AHI = 2, SAI = 1, RDI = 3, SaO2 nadir = 93%, and Mean HR = 48 with optimum CPAP pressure of 18 cm H2O.*
*Apnea Index (AI), Apnea Hypopnea Index (AHI), Snore Arousal Index (SAI),
Respiratory Disturbance Index (RDI), Heart Rate (HR)
Our case patient is aware that he is obese and has some education on healthy diet and the importance of exercise. He complains of lack of energy, and time and money are impediments to proper exercise and diet. The patient believes that his health and the quality of his life are in peril if he does not lose weight. He investigated diets and asked his wife to not buy potato chips anymore. Though he joined a gym, he went only twice in a month. Despite being morbidly obese, our patient joined a body-building gym; realistically, he should have received a tailored plan that focuses more on moderate aerobic exercise.
Our patient’s medical conditions, central obesity, hypertension, and diabetes mellitus, indicated that he is suffering from metabolic syndrome. We established our management plan based on educating the patient about OSA and obesity and the available treatment options, monitoring efficacy and compliance, and establishing support.
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We explained to the patient in simple language that there is a consequential relation between level of energy, obesity, high blood sugar, OSA, lifestyle, concentration and memory, and quality of life. The patient understood that, with optimal treatment of OSA, he would feel rested and refreshed and have better blood pressure control. The patient understood that his adherence to the management plan is the key to success. He was told that his conditions are chronic and need a long-term plan.
In order to address his conditions, the patient was trained on CPAP and received a diet and exercise plan. A recent study showed that various diets are modestly effective and, thus, diets can be individualized according to personal preferences and metabolic needs.1 To come up with a personalized diet, we sent our patient to a registered dietician who worked with him to identify what he can and cannot give up in his diet, healthy replacement foods, and possibly needed supplements. An exercise plan that can be routinely implemented and that taps into his access and resources to exercise was also critical. Exercise has been shown to not only significantly decrease weight but has been found to profoundly impact fatigue as well. Patients should be instructed to check with insurance companies as services like massages and gym memberships are, occasionally, partially covered.
Considering that obesity is a chronic medical condition, close follow-up is an important element of success. On the follow-up visit, CPAP compliance data confirmed that the patient had been using the machine every night. The patient did not have any complaint about the mask or machine.
Despite CPAP compliance, the program of diet and exercise did not lead to significant weight loss. Studies of pharmacological and behavioral interventions for obesity indicate a high attrition rate. Further, after an initial rapid weight loss within the first 6 months, a maintenance phase of partial rebound and a plateau is usually seen.1 With weight regain, patients may become disappointed and stressed and go back to prior habits and, thus, have more significant weight gain. With the diet and exercise plan, our patient lost 12 pounds in 6 months. Our patient had an increase of 4 pounds from his lowest weight during the ensuing 6 months.
As the patient’s weight was still high, we referred the patient for evaluation by a bariatric surgeon. The patient underwent lapband surgery as an outpatient. During the subsequent 6 months, the patient lost 40 pounds and his final weight at this time was 230 pounds. The patient also reported that his CPAP pressure was too high. He underwent a repeat CPAP titration with optimum pressure of 12 cm H2O. In repeated follow-up, he was encouraged to keep the new lifestyle that included regular exercise to increase his energy expenditure and decreased intake of calories by following the new eating habits.
Key to facilitating a patient’s ability to understand OSA/bariatric risk factors and implement management strategies is that they feel supported in doing so, and believe that it is necessary if they are to obtain a better quality of life. These key elements must be met for change and long-term benefit. Even in patients who are precontemplative, introduction of the importance of change is beneficial. In those who have reached a contemplative stage (motivated to initiate change), introduction of a plan is possible.
Obesity is a main risk factor for OSA. Management of obesity is complex and multidisciplinary. As with any chronic condition, patient education and involvement in management, close follow-up, and a strong support system are fundamental for successful outcomes.
Amir Sharafkhaneh, MD, PhD, is assistant professor of medicine at Baylor College of Medicine, and director, Sleep Fellowship Program, Michael E. DeBakey VA Medical Center, Houston. Hossein Sharafkhaneh, MD, is a sleep research specialist at Michael E. DeBakey VA Medical Center. Mary Wilcox Rose, PsyD, CBSM, is assistant professor of medicine at Baylor College of Medicine, director of Psycho-Oncology in the Breast Center, and on staff with the Pulmonary, Critical Care, and Sleep Medicine Section, Department of Medicine, at Baylor College of Medicine. The authors can be reached at [email protected].
- Shai I, Schwarzfuchs D, Henkin Y, et al. Weight loss with a low-carbohydrate, Mediterranean, or low-fat diet. N Engl J Med. 2008;359:229-241.