If you’re overlooking complementary therapies, you’re not alone. Providers who offer their patients LIs will boast better care and earn a competitive advantage. An expert offers his prescription for what works and what doesn’t.
By Emerson M. Wickwire, PhD
For many patients, obstructive sleep apnea (OSA) is a lifestyle disease. And for the vast majority of patients, OSA involves a lifestyle component. Seventy percent or more of patients with OSA are obese. Mood disorders, anxiety, and other behavioral issues are common and can impact treatment outcomes. Behavioral choices, such as drinking alcohol, smoking cigarettes, and not getting enough sleep, can all worsen OSA. By any measure, the most common treatment for OSA, PAP therapy, requires substantial lifestyle changes.
For other sleep disorders, particularly chronic insomnia, the importance of lifestyle interventions (LIs) is well documented. Indeed, the availability of interventions such as cognitive-behavioral treatment (CBT), which can be considered a LI, will continue to increase as behavioral sleep medicine training, telemedicine, and online interventions continue to expand. Yet, in spite of the lifestyle factors associated with OSA and the increasing availability of LIs in other areas of sleep medicine, LIs are conspicuously absent in most OSA treatment plans.
As sleep medicine enters its second wave, an increased focus on comprehensive care and chronic disease management will pave the way for inclusion of LIs into routine patient care. To benefit the most from this trend, sleep disorder specialists should embrace appropriate evidence-based recommendations, expand their clinical skill sets, and, where feasible, expand the clinical service offerings in their centers. Adopting these changes is likely to result in improved patient care, differentiation in the marketplace, and profitable program development.
Benefits to You and the Patient
Many patients prefer LIs. They are noninvasive and low risk, and treat disease by making lasting changes in behavior, cognition, exercise, nutrition, and other areas. Although no data exist for OSA, two studies have found patients to prefer behavioral intervention to pharmacotherapy for insomnia. NIH’s National Center for Complementary and Alternative Medicine (NCCAM) reported in 2002 that 1.6 million US adult insomniacs attempted some form of complementary and alternative medicine as a remedy. Of course, sleep medicine is and should remain a medical subspecialty. Nonetheless, a lot of individuals seem to prefer LIs, when available.
But the majority of sleep medicine specialists don’t have training in LIs. Even though the American Academy of Sleep Medicine (AASM) practice parameters frequently refer to behavioral recommendations or lifestyle factors, training in LIs is not required in medical school curricula or during sleep medicine fellowships. Most sleep specialists simply don’t possess the requisite expertise or interest to administer LIs effectively—the extent of LIs in most sleep centers is a recommendation along the lines of “weight loss should be encouraged, if clinically indicated.” So providers who expand their skill sets to include LIs will be able to provide better care to their patients and gain a competitive marketplace advantage. Equally important, providers well versed in LIs will be able to respond to their patients’ queries and advise against LIs as stand-alone treatments when indicated.
So much has been written regarding the changing face and uncertain future of sleep medicine. Advancing technologies such as home sleep testing (HST) and auto-titrating positive airway pressure (APAP), changes in reimbursement for sleep services, and developing practice models render the future uncertain. Incorporation of LIs can expand the reach of sleep medicine, help ensure more untreated patients receive the health care they need, and increase the sustainability of sleep medicine services.
Of course, LIs are not appropriate for all patients. And in the case of OSA, evidence doesn’t support LIs as stand-alone interventions in most cases. But in light of the importance of lifestyle factors in OSA and the shift toward a chronic disease management perspective, lifestyle can’t be ignored any longer.
Case Study: Weight Gain and OSA
It’s well documented that weight, body mass index (BMI), and fat distribution all relate to OSA. More than 40% of obese individuals have OSA. Increased central adiposity and fat deposits around the pharynx impair pulmonary function and alter upper airway anatomy, respectively. Weight gain also impacts the apnea–hypopnea index (AHI). Peppard et al conducted a longitudinal study of 690 adults in the Wisconsin Sleep Cohort and found that weight gain worsens OSA, and weight loss improves OSA.(1)
An increase in body weight of 10% was associated with a 32% increase in AHI as well as a sixfold increase in risk for developing moderate to severe OSA. Conversely, a 10% reduction in body weight was associated with an average 26% decrease in AHI.
And this relationship is bidirectional. Not only can weight gain impact OSA, but OSA can increase weight gain through both biological and psychological/behavioral pathways. For example, OSA reduces exercise capacity, energy metabolism, and endocrine function. All three physiologic changes are well-documented causes of weight gain. From a behavioral perspective, OSA can lower patient motivation to remain active and it can impair cognitive function, which may impair judgment about lifestyle choices and lower physical activity due to sleepiness.
So it seems logical to treat OSA and weight gain concurrently. Here’s how this paradigm shift might impact OSA treatment.
Nonsurgical Weight Loss Lowers AHI
Multiple studies have evaluated the relationship between nonsurgical weight loss and OSA severity. Barvaux et al reviewed 10 such interventions and found AHI to be reduced in nine studies by 30% to 100%.(2) (In one outlier study, weight loss intervention was not successful, and the AHI was reduced by only 3.3%.)
More recently, 72 overweight or obese patients (BMI range 28-40) with mild OSA were randomized to either a 1-year LI (consisting of an initial 12-week period of caloric restriction and supervised lifestyle and behavior modification) or to an active control including routine lifestyle counseling.(3) At both 3 and 12 months, the intervention reduced body weight (-10.7 kg) and waist circumference, as well as AHI and nocturnal oxygenation, relative to the control. In addition, the intervention was associated with improvements in quality of life. These authors argue convincingly that LIs can be considered first-line strategies for patients with mild OSA.
Similarly, Foster et al evaluated 264 OSA patients with comorbid type 2 diabetes mellitus.(4) Participants were obese (mean BMI=36.7) and had moderate sleep apnea (mean AHI=23.2). Participants were randomized to a 4-month behavioral weight loss program tailored for patients with obesity and type 2 diabetes mellitus or to three group sessions targeting diabetes support and education. After 12 months, participants in the treatment condition had lost more weight (10.8 kg vs 0.6 kg, p<.001) and experienced a greater reduction in AHI (-9.7 events/hour, p<.001) relative to the control. In addition, the prevalence of severe OSA in the intervention group was half that of the control group. Relative to control, the intervention group had more than three times as many participants in total remission of their OSA (AHI <5).
In a study examining the effects of diet alone, Johansson et al randomized 63 obese men aged 30 to 65 years to 7 weeks of a liquid, very low energy diet, followed by 2 weeks of gradual return to normal food.(5) The other group was a wait list control. Relative to the control, dieting participants had significantly greater weight loss (20 kg). Further, OSA was eliminated (AHI <5) in five of 30 participants (17%) randomized to diet, and AHI was reduced to <15 in=”” an=”” additional=”” 15=”” 50=”” conversely=”” moderate=”” or=”” severe=”” osa=”” ahi=””>15) persisted in all but one participant in the control group.
In the past several years, a small but growing number of studies have found similar improvements in OSA following LIs including dietary changes and exercise. Although OSA often persists, patients report improved daytime function and better sleep quality. LIs can complement and even improve traditional approaches to sleep medicine.
LIs + PAP = Greater Weight Loss
In a recent quantitative review, three studies (n=261) were found to evaluate the additive effects of diet and PAP.(6) Relative to diet alone, diet and PAP together resulted in significantly greater weight loss (-2.64 kg). These results highlight the shared mechanisms between weight gain and OSA and suggest the complementary nature of lifestyle and traditional sleep medicine interventions.
Tighten and Tone…The Airway?
In addition to questions about weight and OSA, many patients present with questions about alternative treatments to OSA, including LIs designed to increase patency of the upper airway through oropharyngeal exercises, playing a musical instrument, or singing. Familiarity with the research will improve your ability to respond to queries in an evidence-based fashion.
In the first study to examine oral exercise, Guimares and colleagues randomized 31 adults with moderate OSA to either a 3-month oral exercise intervention or to a sham control group.7 Results indicated a 39% reduction in AHI as well as improved nocturnal oxygen saturations. Although moderate OSA persisted, participants also reported improvements in snoring, sleepiness, and sleep quality. In an uncontrolled study of 15 patients with mild to moderate OSA, Younis et al found oropharyngeal exercises reduced AHI, arousals, snoring, and O2 desaturations (all p’s < .001).8 However, OSA persisted in all but two participants. At this time, oropharyngeal exercises can’t be recommended as an effective
treatment for OSA.
The “Didgeridoo Cure” (It Doesn’t Exist)
One of the most common inquiries I receive is whether the didgeridoo will “cure” sleep apnea. This Australian wind instrument requires ongoing, prolonged exhalations. Puhan et al conducted a randomized study of 25 nonobese participants using a wait list control.9 The intervention consisted of thorough instruction followed by 4 months of daily didgeridoo playing. Relative to the control, participants in the active treatment experienced less snoring (p<.01), reduced AHI (mean reduction=6.2; p<.05), and a 3-point reduction in daytime sleepiness as measured by the Epworth Sleepiness Scale (p=.03). However, OSA persisted in all patients, and no improvements in self-reported sleep quality or quality of life were observed. In spite of its notoriety as a PAP alternative, playing the didgeridoo can’t be recommended as a viable treatment for OSA.
Sing Me the Blues (Singing Offers Minimal Impact)
Other investigators have hypothesized that singing would increase airway patency and muscle tone, thereby reducing AHI. Ojay and Ernst conducted a nonrandomized study (n=20) and found that 3 months of daily singing practice reduced snoring.10 Similarly, Pai et al found that singers snored less than nonsingers, but no differences were observed in daytime sleepiness.(11)
Following similar logic, Wardrop et al administered the Berlin Questionnaire to 1,111 orchestra musicians and found no differences in OSA risk between wind and brass musicians and those who played other instruments.(12) However, Ward et al conducted a nationwide Internet survey and found that playing a double-reed instrument was associated with lower OSA risk than playing other kinds of instruments (p<.05), and the self-reported number of hours spent playing also predicted lower OSA risk (p=.02).13 Patients should be strongly advised against attempting singing or playing a musical instrument as a treatment for OSA.
Your Action Plan
LIs involving nonsurgical weight loss appear promising in OSA patients, and they may be especially effective when combined with traditional treatment approaches. Clearly, however, for patients with moderate to severe or symptomatic OSA, traditional treatment should not be delayed. In these patients, LIs should be viewed as adjunctive to traditional therapies.
In terms of clinical recommendations, if you do nothing else as a result of reading this article, make this one change: Be more specific when talking to patients about lifestyle changes. Instead of simply advising, “Weight loss is encouraged,” instruct your patients to increase their exercise (you can brainstorm possible activities), eat more fruits and vegetables and fewer sugars and fats, and track their triggers for eating. Also have them start an exercise log or food diary, and follow up regularly. Get to know the lifestyle or obesity specialists in your community and provide appropriate referrals.
If you are at a sleep health center, know that comprehensive centers will increasingly incorporate lifestyle interventions into OSA management plans. Some will do so reluctantly, while leaders have already begun this transition. I recently advised a leading internationally renowned medical center regarding the incorporation of LIs and behavioral intervention into a sleep and cardiovascular disease management program. Target lifestyle behaviors included PAP adherence, sleep hygiene, exercise, and nutrition. This center sought to leverage technology and employ multidisciplinary group psychoeducation and intervention sessions to treat the whole patient, encourage lifestyle change, and ensure financial sustainability. Although this center and its leadership can be considered cutting edge, others will soon follow suit. For your own center, clearly define organizational goals and then work backwards from where you want to be in 1, 3, and 5 years. In defining your vision, study industry leaders but beware of benchmarking (benchmarks represent current, not future, best practices). In a future article, we will explore in more detail practical strategies to provide and market related service offerings to maximize patient care and measurable outcomes.
Emerson M. Wickwire, PhD, is Sleep Medicine Program Director at The Howard County Center for Lung and Sleep Medicine in Columbia, Md, and Assistant Professor at Johns Hopkins School of Medicine. A recognized expert in the nondrug treatments of sleep disorders, Dr Wickwire has particular expertise in lifestyle intervention as well as leveraging technology to improve patient care. He currently serves on the education committees for the American Academy of Sleep Medicine as well as the National Sleep Foundation. He can be reached at [email protected].
References
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10. Ojay A, Ernst E. Can singing exercises reduce snoring? A pilot study. Complement Ther Med. 2000;8(3):151-6.
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13. Ward CP, York KM, McCoy JG. Risk of obstructive sleep apnea lower in double reed wind musicians. J Clin Sleep Med. 2012;8(3):251-5.
