ATS publishes new guideline on role of weight management in sleep apnea treatment

A new guideline focused on the role of weight management in treating adult obstructive sleep apnea (OSA) has been published online by the American Thoracic Society in the Sept. 15 American Journal of Respiratory and Critical Care Medicine.

OSA is a common disease that occurs when the upper airway becomes blocked repeatedly during sleep, reducing or stopping airflow. Being overweight or obese is a strong risk factor for OSA, and weight loss can often reduce the severity of OSA.

"This guideline expands the content of previous clinical practice guidelines addressing the care of OSA patients who are overweight or obese by offering specific recommendations for weight loss and discussing the evidence for each recommendation," said David W. Hudgel, MD, panel chair and a specialist and investigator in sleep-disordered breathing. "In addition to these scientifically derived recommendations, the guideline reviews and discusses successful methods for practitioners to discuss weight issues and ways to interact with patients who are overweight or obese."

The 20-member guideline panel - which included sleep, pulmonary, weight management and behavioral experts, as well as three patients - reviewed scores of studies and rated the strength of study findings, along with the certainty of the panel's recommendations, using the GRADE (Grading of Recommendations, Assessment, Development and Evaluation) system.

For patients with OSA who are overweight or obese (body mass index - BMI ? 25 kg/m2 ) the panel:

• Recommended participation in a comprehensive lifestyle intervention program that includes a reduced calorie diet, exercise/increased physical activity and behavioral counseling (strong recommendation, very low certainty in the estimated effects).
• Suggested that in the absence of a comprehensive program, participation in a diet and exercise program is recommended, together or individually (conditional recommendation, very low certainty in the estimated effects).

For patients with OSA who have a BMI ?27 kg/m2 and whose weight has not improved despite participating in a comprehensive program--and who have no contraindications to pharmacotherapy such as active cardiovascular disease--the panel:

• Suggested an evaluation for anti-obesity pharmacotherapy (conditional recommendation, very low certainty in the estimated effects).

The panel defined active cardiovascular diseases as "myocardial infarction or cerebrovascular accident within the past six months, uncontrolled hypertension, life-threatening arrhythmias or decompensated congestive heart failure."

For patients with OSA who have a BMI ? 35 kg/m2 and whose weight has not improved despite participating in a comprehensive weight loss lifestyle intervention program--and who have no contraindications--the panel:

• Suggested referral for bariatric surgery evaluation (conditional recommendation, very low certainty in the estimated effects). The panel found that the only available well-controlled trials of bariatric surgery in patients with OSA examined the effect of gastric banding. Gastric banding was not found to be more effective in reducing OSA severity than lifestyle interventions that result in weight loss.

  The panel also noted that weight loss, either through lifestyle changes or bariatric surgery, has benefits beyond reducing OSA severity. Among those benefits are prevention of type 2 diabetes, improved glycemic control in those with type 2 diabetes, lower blood pressure and improved quality of life.

  In formulating its recommendations, the panel reviewed studies that found patients are often unaware that they are overweight or obese and that clinicians are often reluctant to give patients a diagnosis of obesity. Even when the need for weight loss is discussed, the panel said, an effective weight loss program is often not initiated.

  "This guideline demonstrates that weight loss provides a distinct benefit to OSA patients, but many patients may not know about how to achieve these benefits because their health care provider has not had an in-depth discussion about proven methods to achieve weight loss with them," said panel co-chair Sanjay R. Patel, MD, professor of medicine and medical director of the sleep laboratory at the University of Pittsburgh Medical Center.

  "Overweight or obese patients with OSA who are encouraged to participate in a comprehensive weight-loss program that includes calorie reduction, increased physical activity, behavioral counseling and close follow-up, will most likely be grateful to their health care provider for discussing the issue and recommending effective strategies for weight management."\