Elsevier

Sleep Medicine

Volume 5, Issue 2, March 2004, Pages 125-131
Sleep Medicine

Original article
A cognitive-behavioral weight reduction program in the treatment of obstructive sleep apnea syndrome with or without initial nasal CPAP: a randomized study

https://doi.org/10.1016/j.sleep.2003.07.007Get rights and content

Abstract

Background and purpose: To evaluate (a) whether an active weight reduction strategy based on the cognitive-behavioral approach and an initial very-low-calorie diet might lead to short- and long-term weight loss and alleviation of OSAS; and (b) whether the results of this intervention could be enhanced by combining it with nasal continuous positive airway pressure (CPAP) treatment during the first 6 months.

Patients and methods: Thirty-one obese male symptomatic sleep apnea patients underwent a 2-year weight reduction program with total follow-up of 36 months from baseline. The mean age (±SD) was 49.1±7.9 years, body mass index 43.8±5.4, and oxygen desaturation index (ODI4) 51.3±31.1. The patients were randomized to CPAP (17 patients) and non-CPAP groups (14 patients).

Results: The mean weight loss was 19.1±10.2 kg (14% of the original weight) for the whole group at 6 months, 18.3±13.2 (13%) at 12 months and 12.6±14.7 kg (9%) at 24 months. Excellent or good treatment results, as defined in terms of an ODI4 (average number of oxygen desaturation events p/h>4% from baseline) reduction of at least 50% from the baseline, were seen in 61% of patients at 6 months and were still observable in 42% of patients at 24 months. The correlations between changes in weight and in ODI4 were 0.59 (P<0.01) at 6 months, 0.68 (P<0.01) and 0.75 (P<0.01) at 24 months. Adding CPAP treatment to the weight reduction therapy for the first 6 months did not result in greater weight loss or diminution of desaturation indices (without CPAP) at any time point. One year after the termination of the program the mean weight loss was 6.6±12.9 kg, and 42% of patients still showed at least 5% weight loss as compared with their original weight.

Conclusion: Satisfactory weight loss associated with improvement of OSAS could be achieved by means of a cognitive-behavioral weight loss program. Adding CPAP in the initial phase of the weight reduction program did not result in significantly greater weight loss.

Introduction

Obesity is one of the main risk factors for obstructive sleep apnea syndrome (OSAS) [1]. Alterations in the structure and function of the upper airway and in pulmonary function, an imbalance between mass loading and central ventilatory drive, and obesity-induced hypoxemia are among the suggested mechanisms linking obesity to sleep apnea [2]. Weight loss has been shown to reduce apnea and hypopnea and to alleviate sleep apnea symptoms [3], [4], [5], [6], [7], [8]. Published results on long-term maintenance after weight reduction are varied and the reductions are mostly modest [9].

It has been shown that even a slight weight loss of 5–10% can produce beneficial effects with regard to hypertension, glucose metabolism and dyslipidemias [10]. This amount of weight loss is nowadays regarded as a minimum goal in the management of obesity. Some recent studies show that a substantial number of patients may be able to achieve and maintain this goal by means of intensive weight reduction programs based on cognitive-behavioral therapy and active dietary intervention. In studies conducted by Wadden and Frey [11] and Pekkarinen and Mustajoki [12], more than half of the patients showed a 5% weight loss and 25–35% of patients a 10% weight loss 3–5 years after the termination of the weight reduction program.

Nasal continuous positive airway pressure (CPAP) is the current standard treatment for OSAS [13], [14], [15]. It has been shown to effectively eliminate apneas and hypopneas, to reduce subjective symptoms of OSAS, and to improve cognitive function and quality of life [16], [17], [18], [19]. However, as effectiveness continues only while the treatment is being used, OSAS patients should continue the treatment for a long time. There is some evidence showing that obese OSAS patients have been successfully weaned from CPAP therapy after a marked weight loss [20], [21].

The present study was designed to explore (1) whether an active weight reduction strategy based on the cognitive-behavioral approach and an initial very-low-calorie diet (VLCD) could lead to short- and long-term weight loss and alleviation of sleep apnea; and (2) whether the results of this intervention could be enhanced by combining it with CPAP treatment during the first 6 months. The hypothesis was that using nasal CPAP treatment in the beginning of the weight reduction program would improve vigilance and daytime activity and increase motivation to lose weight. This would in turn lead to better dietary control, which could support lifestyle changes and weight reduction. A 2-year weight reduction program based on individualized cognitive-behavioral therapy and dietary counseling, with an initial 6-week period of VLCD was used for all patients. Because we wanted to investigate the effect of an initial CPAP, patients were chosen at random for nasal CPAP during the first 6 months of the weight loss program.

Section snippets

Patients

Thirty-three obese male sleep apnea patients aged between 30 and 60 years were included in the study. All patients received cognitive behavioral therapy (CBT) for weight loss and initial VLCD. In this study the CPAP group (N=18) consisted of patients treated with CPAP during the first 6 months of CBT. The non-CPAP group (N=15) consisted of patients treated with CBT and VLCD only. All patients gave their written informed consent. The study was approved by the local ethics committee.

Inclusion and exclusion criteria

Patients were

Results

Thirty-three patients who entered the study were randomly assigned initial CPAP treatment (N=18) or not (N=15). However, one patient in each group refused to start the weight reduction program after randomization, leaving 17 patients in the CPAP group and 14 patients in the non-CPAP group. The baseline characteristics of these 31 patients are shown in Table 1. The differences between the CPAP and non-CPAP groups were not significant. After the 12-month follow-up, two patients were admitted to

Discussion

The present study shows that for obese sleep apnea patients an active weight reduction program based on individualized CBT and initial VLCD did result in significant weight loss in most patients and that this was associated with alleviation of sleep apnea and an improvement in emotional well-being. The greatest weight loss and alleviation of sleep apnea (ODI4) was seen at 6 months, after which the patients started to gain weight. After 2 years, however, more than one-third of the patients still

Acknowledgements

This study was supported by the Miina Sillanpää Foundation.

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