Diet and exercise in the management of obstructive sleep apnoea and cardiovascular disease risk

Devon A Dobrosielski, Christopher Papandreou, Susheel P Patil, Jordi Salas-Salvadó, Devon A Dobrosielski, Christopher Papandreou, Susheel P Patil, Jordi Salas-Salvadó

Abstract

Obstructive sleep apnoea (OSA) is associated with increased cardiovascular disease (CVD) morbidity and mortality. It is accepted that OSA and obesity commonly coexist. The American Academy of Sleep Medicine recommends dietary-induced weight loss and exercise as lifestyle treatment options for OSA. However, most clinical trials upon which this recommendation is based have focused on establishing the effectiveness of calorie-restricted, often low-fat diets for improving OSA severity, whereas less attention has been given to the means through which weight loss is achieved (e.g. altered dietary quality) or whether diet or exercise mediates the associations between reduced weight, improved OSA severity and the CVD substrate. The current evidence suggests that the benefits of a low-carbohydrate or Mediterranean diet in overweight and obese individuals go beyond the recognised benefits of weight reduction. In addition, exercise has an independent protective effect on vascular health, which may counter the increased oxidative stress, inflammation and sympathetic activation that occur in OSA patients. This review aims to expand our understanding of the effects of diet and exercise on OSA and associated CVD complications, and sets the stage for continued research designed to explore optimal lifestyle strategies for reducing the CVD burden in OSA patients.

Conflict of interest statement

Conflict of interest: Disclosures can be found alongside this article at err.ersjournals.com

Copyright ©ERS 2017.

Figures

FIGURE 1
FIGURE 1
Estimated mean±se changes in a) body weight and b) apnoea–hypopnea index (AHI) from baseline at years 1, 2 and 4 in obese patients with diabetes given diabetes support and education or a lifestyle intervention comprising dietary-induced weight loss and promotion of physical activity. Reproduced and modified from [12] with permission.
FIGURE 2
FIGURE 2
Schematic diagram indicating the possible mechanisms linking obesity/central obesity with obstructive sleep apnoea (OSA) development. CNS: central nervous system.
FIGURE 3
FIGURE 3
Schematic diagram indicating the possible mechanisms through which the Mediterranean diet may improve the severity of obstructive sleep apnoea (OSA), independent of weight loss.
FIGURE 4
FIGURE 4
Exercise confers cardioprotection through improved vascular function. Obstructive sleep apnoea is characterised by oxyhaemoglobin desaturations and sympathetic activation, which result in cardiovascular morbidity and mortality. The thin arrows imply that exercise may not confer cardioprotection in the presence of disturbed sleep. NO: nitric oxide bioavailability.

References

    1. Patil SP, Schneider H, Schwartz AR, et al. . Adult obstructive sleep apnea: pathophysiology and diagnosis. Chest 2007; 132: 325–337.
    1. Young T, Peppard PE, Gottlieb DJ. Epidemiology of obstructive sleep apnea: a population health perspective. Am J Respir Crit Care Med 2002; 165: 1217–1239.
    1. Punjabi NM, Caffo BS, Goodwin JL, et al. . Sleep-disordered breathing and mortality: a prospective cohort study. PLoS Med 2009; 6: e1000132.
    1. Soriano-Co M, Vanhecke TE, Franklin BA, et al. . Increased central adiposity in morbidly obese patients with obstructive sleep apnoea. Intern Med J 2011; 41: 560–566.
    1. Peppard PE, Young T, Palta M, et al. . Longitudinal study of moderate weight change and sleep-disordered breathing. JAMA 2000; 284: 3015–3021.
    1. Schwartz AR, Gold AR, Schubert N, et al. . Effect of weight loss on upper airway collapsibility in obstructive sleep apnea. Am Rev Respir Dis 1991; 144: 494–498.
    1. Epstein LJ, Kristo D, Strollo PJ Jr, et al. . Clinical guideline for the evaluation, management and long-term care of obstructive sleep apnea in adults. J Clin Sleep Med 2009; 5: 263–276.
    1. Tuomilehto HP, Seppä JM, Partinen MM, et al. . Lifestyle intervention with weight reduction: first-line treatment in mild obstructive sleep apnea. Am J Respir Crit Care Med 2009; 179: 320–327.
    1. Foster GD, Borradaile KE, Sanders MH, et al. . A randomized study on the effect of weight loss on obstructive sleep apnea among obese patients with type 2 diabetes: the Sleep AHEAD study. Arch Intern Med 2009; 169: 1619–1626.
    1. Johansson K, Neovius M, Lagerros YT, et al. . Effect of a very low energy diet on moderate and severe obstructive sleep apnoea in obese men: a randomised controlled trial. BMJ 2009; 339: b4609.
    1. Johansson K, Hemmingsson E, Harlid R, et al. . Longer term effects of very low energy diet on obstructive sleep apnoea in cohort derived from randomised controlled trial: prospective observational follow-up study. BMJ 2011; 342: d3017.
    1. Kuna ST, Reboussin DM, Borradaile KE, et al. . Long-term effect of weight loss on obstructive sleep apnea severity in obese patients with type 2 diabetes. Sleep 2013; 36: 641–649.
    1. Tuomilehto H, Gylling H, Peltonen M, et al. . Sustained improvement in mild obstructive sleep apnea after a diet- and physical activity-based lifestyle intervention: postinterventional follow-up. Am J Clin Nutr 2010; 92: 688–696.
    1. Tuomilehto H, Seppä J, Uusitupa M. Obesity and obstructive sleep apnea – clinical significance of weight loss. Sleep Med Rev 2013; 17: 321–329.
    1. Araghi MH, Chen YF, Jagielski A, et al. . Effectiveness of lifestyle interventions on obstructive sleep apnea (OSA): systematic review and meta-analysis. Sleep 2013; 36: 1553–1562.
    1. Gardner CD, Kiazand A, Alhassan S, et al. . Comparison of the Atkins, Zone, Ornish, and LEARN diets for change in weight and related risk factors among overweight premenopausal women: the A TO Z Weight Loss Study: a randomized trial. JAMA 2007; 297: 969–977.
    1. Papandreou C, Schiza SE, Bouloukaki I, et al. . Effect of Mediterranean diet versus prudent diet combined with physical activity on OSAS: a randomised trial. Eur Respir J 2012; 39: 1398–1404.
    1. Borel AL, Leblanc X, Alméras N, et al. . Sleep apnoea attenuates the effects of a lifestyle intervention programme in men with visceral obesity. Thorax 2012; 67: 735–741.
    1. Ryan DH, Espeland MA, Foster GD, et al. . Look AHEAD (Action for Health in Diabetes): design and methods for a clinical trial of weight loss for the prevention of cardiovascular disease in type 2 diabetes. Control Clin Trials 2003; 24: 610–628.
    1. Ludwig DS, Friedman MI. Increasing adiposity: consequence or cause of overeating? JAMA 2014; 311: 2167–2168.
    1. Kline CE, Crowley EP, Ewing GB, et al. . The effect of exercise training on obstructive sleep apnea and sleep quality: a randomized controlled trial. Sleep 2011; 34: 1631–1640.
    1. Mora S, Cook N, Buring JE, et al. . Physical activity and reduced risk of cardiovascular events: potential mediating mechanisms. Circulation 2007; 116: 2110–2118.
    1. Bassetti CL, Milanova M, Gugger M. Sleep-disordered breathing and acute ischemic stroke: diagnosis, risk factors, treatment, evolution, and long-term clinical outcome. Stroke 2006; 37: 967–972.
    1. Peppard PE, Young T, Palta M, et al. . Prospective study of the association between sleep-disordered breathing and hypertension. N Engl J Med 2000; 342: 1378–1384.
    1. Marin JM, Carrizo SJ, Vicente E, et al. . Long-term cardiovascular outcomes in men with obstructive sleep apnoea-hypopnoea with or without treatment with continuous positive airway pressure: an observational study. Lancet 2005; 365: 1046–1053.
    1. Dempsey JA, Veasey SC, Morgan BJ, et al. . Pathophysiology of sleep apnea. Physiol Rev 2010; 90: 47–112.
    1. Somers VK, Mark AL, Zavala DC, et al. . Contrasting effects of hypoxia and hypercapnia on ventilation and sympathetic activity in humans. J Appl Physiol 1989; 67: 2101–2106.
    1. Somers VK, Dyken ME, Clary MP, et al. . Sympathetic neural mechanisms in obstructive sleep apnea. J Clin Invest 1995; 96: 1897–1904.
    1. Ip MSM, Lam B, Chan LY, et al. . Circulating nitric oxide is suppressed in obstructive sleep apnea and is reversed by nasal continuous positive airway pressure. Am J Respir Crit Care Med 2000; 162: 2166–2171.
    1. Jelic S, Padeletti M, Kawut SM, et al. . Inflammation, oxidative stress, and repair capacity of the vascular endothelium in obstructive sleep apnea. Circulation 2008; 117: 2270–2278.
    1. Punjabi NM, Sorkin JD, Katzel LI, et al. . Sleep-disordered breathing and insulin resistance in middle-aged and overweight men. Am J Respir Crit Care Med 2002; 165: 677–682.
    1. Patil SP, Schneider H, Marx JJ, et al. . Neuromechanical control of upper airway patency during sleep. J Appl Physiol 2007; 102: 547–556.
    1. Schwab RJ, Gupta KB, Gefter WB, et al. . Upper airway and soft tissue anatomy in normal subjects and patients with sleep-disordered breathing. Significance of the lateral pharyngeal walls. Am J Respir Crit Care Med 1995; 152: 1673–1689.
    1. Schwartz AR, Patil SP, Laffan AM, et al. . Obesity and obstructive sleep apnea: pathogenic mechanisms and therapeutic approaches. Proc Am Thorac Soc 2008; 5: 185–192.
    1. Opp MR. Cytokines and sleep. Sleep Med Rev 2005; 9: 355–364.
    1. Kimoff RJ, Hamid Q, Divangahi M, et al. . Increased upper airway cytokines and oxidative stress in severe obstructive sleep apnoea. Eur Respir J 2011; 38: 89–97.
    1. Friedman JM. The function of leptin in nutrition, weight, and physiology. Nutr Rev 2002; 60: S1–S14.
    1. Breslow MJ, Min-Lee K, Brown DR, et al. . Effect of leptin deficiency on metabolic rate in ob/ob mice. Am J Physiol 1999; 276: E443–E449.
    1. O'Donnell CP, Schaub CD, Haines AS, et al. . Leptin prevents respiratory depression in obesity. Am J Respir Crit Care Med 1999; 159: 1477–1484.
    1. Schwartz AR, Patil SP, Squier S, et al. . Obesity and upper airway control during sleep. J Appl Physiol 2010; 108: 430–435.
    1. Smith PL, Gold AR, Meyers DA, et al. . Weight loss in mildly to moderately obese patients with obstructive sleep apnea. Ann Intern Med 1985; 103: 850–855.
    1. Guyenet SJ, Schwartz MW. Clinical review: regulation of food intake, energy balance, and body fat mass: implications for the pathogenesis and treatment of obesity. J Clin Endocrinol Metab 2012; 97: 745–755.
    1. Keys A. Atherosclerosis: a problem in newer public health. J Mt Sinai Hosp NY 1953; 20: 118–139.
    1. Anderson KM, Castelli WP, Levy D. Cholesterol and mortality. 30 years of follow-up from the Framingham study. JAMA 1987; 257: 2176–2180.
    1. Howard BV, Van Horn L, Hsia J, et al. . Low-fat dietary pattern and risk of cardiovascular disease: the Women's Health Initiative Randomized Controlled Dietary Modification Trial. JAMA 2006; 295: 655–666.
    1. Wing RR, Bolin P, Brancati FL, et al. . Cardiovascular effects of intensive lifestyle intervention in type 2 diabetes. N Engl J Med 2013; 369: 145–154.
    1. Forsythe CE, Phinney SD, Fernandez ML, et al. . Comparison of low fat and low carbohydrate diets on circulating fatty acid composition and markers of inflammation. Lipids 2008; 43: 65–77.
    1. US Department of Health and Human Services and US Department of Agriculture . 2015–2020 Dietary Guidelines for Americans. Date last accessed: May 30, 2017. Date last updated: December 2015.
    1. Nordmann AJ, Nordmann A, Briel M, et al. . Effects of low-carbohydrate vs low-fat diets on weight loss and cardiovascular risk factors: a meta-analysis of randomized controlled trials. Arch Intern Med 2006; 166: 285–293.
    1. 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.
    1. Santos FL, Esteves SS, da Costa Pereira A, et al. . Systematic review and meta-analysis of clinical trials of the effects of low carbohydrate diets on cardiovascular risk factors. Obes Rev 2012; 13: 1048–1066.
    1. Hashimoto Y, Fukuda T, Oyabu C, et al. . Impact of low-carbohydrate diet on body composition: meta-analysis of randomized controlled studies. Obes Rev 2016; 17: 499–509.
    1. Sumithran P, Prendergast LA, Delbridge E, et al. . Ketosis and appetite-mediating nutrients and hormones after weight loss. Eur J Clin Nutr 2013; 67: 759–764.
    1. Morton GJ, Cummings DE, Baskin DG, et al. . Central nervous system control of food intake and body weight. Nature 2006; 443: 289–295.
    1. Feinman RD, Pogozelski WK, Astrup A, et al. . Dietary carbohydrate restriction as the first approach in diabetes management: critical review and evidence base. Nutrition 2015; 31: 1–13.
    1. Rogers A, Ravenell J, Donat M, et al. . Predictors of obstructive sleep apnea risk among blacks with metabolic syndrome. J Obes Overweight 2015; 1: 1184.
    1. Fine EJ, Feinman RD. Insulin, carbohydrate restriction, metabolic syndrome and cancer. Expert Rev Endocrinol Metab 2015; 10: 15–24.
    1. Gannon MC, Hoover H, Nuttall FQ. Further decrease in glycated hemoglobin following ingestion of a LoBAG30 diet for 10 weeks compared to 5 weeks in people with untreated type 2 diabetes. Nutr Metab 2010; 7: 64.
    1. Westman EC, Yancy WS Jr, Mavropoulos JC, et al. . The effect of a low-carbohydrate, ketogenic diet versus a low-glycemic index diet on glycemic control in type 2 diabetes mellitus. Nutr Metab 2008; 5: 36.
    1. Dashti HM, Mathew TC, Khadada M, et al. . Beneficial effects of ketogenic diet in obese diabetic subjects. Mol Cell Biochem 2007; 302: 249–256.
    1. Volek JS, Phinney SD, Forsythe CE, et al. . Carbohydrate restriction has a more favorable impact on the metabolic syndrome than a low fat diet. Lipids 2009; 44: 297–309.
    1. Volek JS, Ballard KD, Silvestre R, et al. . Effects of dietary carbohydrate restriction versus low-fat diet on flow-mediated dilation. Metabolism 2009; 58: 1769–1777.
    1. Foster GD, Sanders MH, Millman R, et al. . Obstructive sleep apnea among obese patients with type 2 diabetes. Diabetes Care 2009; 32: 1017–1019.
    1. Trichopoulou A, Costacou T, Bamia C, et al. . Adherence to a Mediterranean diet and survival in a Greek population. N Engl J Med 2003; 348: 2599–2608.
    1. Estruch R, Martínez-González MA, Corella D, et al. . Effect of a high-fat Mediterranean diet on bodyweight and waist circumference: a prespecified secondary outcomes analysis of the PREDIMED randomised controlled trial. Lancet Diabetes Endocrinol 2016; 4: 666–676.
    1. Paniagua JA, Gallego de la Sacristana A, Romero I, et al. . Monounsaturated fat-rich diet prevents central body fat distribution and decreases postprandial adiponectin expression induced by a carbohydrate-rich diet in insulin-resistant subjects. Diabetes Care 2007; 30: 1717–1723.
    1. Jacobs DR Jr, Steffen LM. Nutrients, foods, and dietary patterns as exposures in research: a framework for food synergy. Am J Clin Nutr 2003; 78: 508S–513S.
    1. Estruch R, Ros E, Salas-Salvadό J, et al. . Primary prevention of cardiovascular disease with a Mediterranean diet. N Engl J Med 2013; 368: 1279–1290.
    1. Spiegel K, Tasali E, Penev P, et al. . Brief communication: sleep curtailment in healthy young men is associated with decreased leptin levels, elevated ghrelin levels, and increased hunger and appetite. Ann Intern Med 2004; 141: 846–850.
    1. Rayner DV, Trayhurn P. Regulation of leptin production: sympathetic nervous system interactions. J Mol Med 2001; 79: 8–20.
    1. van der Lely AJ, Tschöp M, Heiman ML, et al. . Biological, physiological, pathophysiological, and pharmacological aspects of ghrelin. Endocr Rev 2004; 25: 426–457.
    1. St-Onge MP. The role of sleep duration in the regulation of energy balance: effects on energy intakes and expenditure. J Clin Sleep Med 2013; 9: 73–80.
    1. Punjabi NM, Polotsky VY. Disorders of glucose metabolism in sleep apnea. J Appl Physiol 2005; 99: 1998–2007.
    1. Stamatakis KA, Punjabi NM. Effects of sleep fragmentation on glucose metabolism in normal subjects. Chest 2010; 137: 95–101.
    1. Nonogaki K. New insights into sympathetic regulation of glucose and fat metabolism. Diabetologia 2000; 43: 533–549.
    1. Andrews RC, Walker BR. Glucocorticoids and insulin resistance: old hormones, new targets. Clin Sci 1999; 96: 513–523.
    1. Broussard JL, Chapotot F, Abraham V, et al. . Sleep restriction increases free fatty acids in healthy men. Diabetologia 2015; 58: 791–798.
    1. Volek JS, Fernandez ML, Feinman RD, et al. . Dietary carbohydrate restriction induces a unique metabolic state positively affecting atherogenic dyslipidemia, fatty acid partitioning, and metabolic syndrome. Prog Lipid Res 2008; 47: 307–318.
    1. Kajaste S, Brander PE, Telakivi T, et al. . A cognitive-behavioral weight reduction program in the treatment of obstructive sleep apnea syndrome with or without initial nasal CPAP: a randomized study. Sleep Med 2004; 5: 125–131.
    1. Quan SF, Budhiraja R, Clarke DP, et al. . Impact of treatment with continuous positive airway pressure (CPAP) on weight in obstructive sleep apnea. J Clin Sleep Med 2013; 9: 989–993.
    1. Batool-Anwar S, Goodwin JL, Drescher AA, et al. . Impact of CPAP on activity patterns and diet in patients with obstructive sleep apnea (OSA). J Clin Sleep Med 2014; 10: 465–472.
    1. Després JP, Poirier P. Diabetes: looking back at Look AHEAD – giving lifestyle a chance. Nat Rev Cardiol 2013; 10: 184–186.
    1. Peppard PE, Young T. Exercise and sleep-disordered breathing: an association independent of body habitus. Sleep 2004; 27: 480–484.
    1. Quan SF, O'Connor GT, Quan JS, et al. . Association of physical activity with sleep-disordered breathing. Sleep Breath 2007; 11: 149–157.
    1. Awad KM, Malhotra A, Barnet JH, et al. . Exercise is associated with a reduced incidence of sleep-disordered breathing. Am J Med 2012; 125: 485–490.
    1. Redolfi S, Bettinzoli M, Venturoli N, et al. . Attenuation of obstructive sleep apnea and overnight rostral fluid shift by physical activity. Am J Respir Crit Care Med 2015; 191: 856–858.
    1. Mendelson M, Lyons OD, Yadollahi A, et al. . Effects of exercise training on sleep apnoea in patients with coronary artery disease: a randomised trial. Eur Respir J 2016; 48: 142–150.
    1. Ross R, Dagnone D, Jones PJ, et al. . Reduction in obesity and related comorbid conditions after diet-induced weight loss or exercise-induced weight loss in men. A randomized, controlled trial. Ann Intern Med 2000; 133: 92–103.
    1. Giannopoulou I, Ploutz-Snyder LL, Carhart R, et al. . Exercise is required for visceral fat loss in postmenopausal women with type 2 diabetes. J Clin Endocrinol Metab 2005; 90: 1511–1518.
    1. Stewart KJ, Bacher AC, Turner KL, et al. . Effect of exercise on blood pressure in older persons: a randomized controlled trial. Arch Intern Med 2005; 165: 756–762.
    1. Myers J, Kaykha A, George S, et al. . Fitness versus physical activity patterns in predicting mortality in men. Am J Med 2004; 117: 912–918.
    1. Myers J, Prakash M, Froelicher V, et al. . Exercise capacity and mortality among men referred for exercise testing. N Engl J Med 2002; 346: 793–801.
    1. Erikssen G, Liestøl K, Bjørnholt J, et al. . Changes in physical fitness and changes in mortality. Lancet 1998; 352: 759–762.
    1. Dobrosielski DA, Patil S, Schwartz AR, et al. . Effects of exercise and weight loss in older adults with obstructive sleep apnea. Med Sci Sports Exerc 2015; 47: 20–26.
    1. Kline CE, Reboussin DM, Foster GD, et al. . The effect of changes in cardiorespiratory fitness and weight on obstructive sleep apnea severity in overweight adults with type 2 diabetes. Sleep 2016; 39: 317–325.
    1. Green DJ. Exercise training as vascular medicine: direct impacts on the vasculature in humans. Exerc Sport Sci Rev 2009; 37: 196–202.
    1. Green DJ, O'Driscoll G, Joyner MJ, et al. . Exercise and cardiovascular risk reduction: time to update the rationale for exercise? J Appl Physiol 2008; 105: 766–768.
    1. Hambrecht R, Adams V, Erbs S, et al. . Regular physical activity improves endothelial function in patients with coronary artery disease by increasing phosphorylation of endothelial nitric oxide synthase. Circulation 2003; 107: 3152–3158.
    1. Montero D, Roberts CK, Vinet A. Effect of aerobic exercise training on arterial stiffness in obese populations: a systematic review and meta-analysis. Sports Med 2014; 44: 833–843.
    1. Garber CE, Blissmer B, Deschenes MR, et al. . American College of Sports Medicine position stand. Quantity and quality of exercise for developing and maintaining cardiorespiratory, musculoskeletal, and neuromotor fitness in apparently healthy adults: guidance for prescribing exercise. Med Sci Sports Exerc 2011; 43: 1334–1359.
    1. Ueno LM, Drager LF, Rodrigues AC, et al. . Effects of exercise training in patients with chronic heart failure and sleep apnea. Sleep 2009; 32: 637–647.

Source: PubMed

Patrocinadores y Colaboradores

Condiciones médicas

Intervenciones de drogas

3
Suscribir