Interdisciplinary Weight Loss and Lifestyle Intervention for Obstructive Sleep Apnoea in Adults: Rationale, Design and Methodology of the INTERAPNEA Study

Almudena Carneiro-Barrera, Francisco J Amaro-Gahete, Amparo Díaz-Román, Alejandro Guillén-Riquelme, Lucas Jurado-Fasoli, Germán Sáez-Roca, Carlos Martín-Carrasco, Jonatan R Ruiz, Gualberto Buela-Casal, Almudena Carneiro-Barrera, Francisco J Amaro-Gahete, Amparo Díaz-Román, Alejandro Guillén-Riquelme, Lucas Jurado-Fasoli, Germán Sáez-Roca, Carlos Martín-Carrasco, Jonatan R Ruiz, Gualberto Buela-Casal

Abstract

Obesity is a major risk factor for obstructive sleep apnoea (OSA), the most common sleep-disordered breathing related to neurocognitive and metabolic syndromes, type II diabetes, and cardiovascular diseases. Although strongly recommended for this condition, there are no studies on the effectiveness of an interdisciplinary weight loss and lifestyle intervention including nutrition, exercise, sleep hygiene, and smoking and alcohol cessation. INTERAPNEA is a randomised controlled trial with a two-arm parallel design aimed at determining the effects of an interdisciplinary tailored weight loss and lifestyle intervention on OSA outcomes. The study will include 84 males aged 18-65 with a body mass index of ≥25 kg/m2 and severe to moderate OSA randomly assigned to usual care (i.e., continuous positive airway pressure), or interdisciplinary weight loss and lifestyle intervention combined with usual care. Outcomes will be measured at baseline, intervention end-point, and six-month post-intervention, including apnoea-hypopnoea index (primary outcome), other neurophysical and cardiorespiratory polysomnographic outcomes, sleep quality, daily functioning and mood, body weight and composition, physical fitness, blood biomarkers, health-related quality of life, and cost-effectiveness. INTERAPNEA may serve to establish a cost-effective treatment not only for the improvement of OSA and its vast and severe comorbidities, but also for a potential remission of this condition.

Keywords: alcohol; apnoea-hypopnoea index; exercise; interdisciplinary lifestyle intervention; nutrition; obesity; obstructive sleep apnoea; sleep hygiene; smoking; weight loss.

Conflict of interest statement

The authors declare no conflict of interest.

Figures

Figure 1
Figure 1
Flow diagram of the INTERAPNEA study participants.

References

    1. Carneiro-Barrera A., Díaz-Román A., Guillén-Riquelme A., Buela-Casal G. Weight loss and lifestyle interventions for obstructive sleep apnoea in adults: Systematic review and meta-analysis. Obes. Rev. 2019;20:750–762. doi: 10.1111/obr.12824.
    1. Jordan A.S., McSharry D.G., Malhotra A. Adult obstructive sleep apnoea. Lancet. 2014;383:736–747. doi: 10.1016/S0140-6736(13)60734-5.
    1. Fu Y., Xia Y., Yi H., Xu H., Guan J., Yin S. Meta-analysis of all-cause and cardiovascular mortality in obstructive sleep apnea with or without continuous positive airway pressure treatment. Sleep Breath. 2017;21:181–189. doi: 10.1007/s11325-016-1393-1.
    1. Hoyos C.M., Drager L.F., Patel S.R. OSA and cardiometabolic risk: What’s the bottom line? Respirology. 2017;22:420–429. doi: 10.1111/resp.12984.
    1. Blackwell T., Yaffe K., Laffan A., Redline S., Ancoli-Israel S., Ensrud K.E., Song Y., Stone K.L. Associations between sleep-disordered breathing, nocturnal hypoxemia, and subsequent cognitive decline in older community-dwelling men: The Osteoporotic Fractures in Men Sleep Study. J. Am. Geriatr. Soc. 2015;63:453–461. doi: 10.1111/jgs.13321.
    1. Guglielmi O., Gómez A.I.S., Jurado-Gámez B., Buela-Casal G. Obstructive sleep apnea syndrome effects on quality of life and daytime sleepiness. Univ. Psychol. 2013;12:601–611. doi: 10.11144/Javeriana.UPSY12-2.esah.
    1. Tregear S., Reston J., Schoelles K., Phillips B. Obstructive sleep apnea and risk of motor vehicle crash: Systematic review and meta-analysis. J. Clin. Sleep Med. 2009;5:573–581.
    1. Jurado-Gámez B., Guglielmi O., Gude F., Buela-Casal G. Workplace accidents, absenteeism and productivity in patients with sleep apnea. Arch. Bronconeumol. 2015;51:213–218. doi: 10.1016/j.arbres.2014.07.003.
    1. Senaratna C.V., Perret J.L., Lodge C.J., Lowe A.J., Campbell B.E., Matheson M.C., Hamilton G.S., Dharmage S.C. Prevalence of obstructive sleep apnea in the general population: A systematic review. Sleep Med. Rev. 2017;34:70–81. doi: 10.1016/j.smrv.2016.07.002.
    1. Senaratna C.V., English D.R., Currier D., Perret J.L., Lowe A., Lodge C., Russell M., Sahabandu S., Matheson M.C., Hamilton G.S., et al. Sleep apnoea in Australian men: Disease burden, co-morbidities, and correlates from the Australian longitudinal study on male health. BMC Public Health. 2016;16:51–61. doi: 10.1186/s12889-016-3703-8.
    1. Young T., Peppard P.E., Taheri S. Excess weight and sleep-disordered breathing. J. Appl. Physiol. 2005;99:1592–1599. doi: 10.1152/japplphysiol.00587.2005.
    1. Ong C.W., O’Driscoll D.M., Truby H., Naughton M.T., Hamilton G.S. The reciprocal interaction between obesity and obstructive sleep apnoea. Sleep Med. Rev. 2013;17:123–131. doi: 10.1016/j.smrv.2012.05.002.
    1. World Health Organization Obesity and Overweight. [(accessed on 13 May 2019)]; Available online: .
    1. Epstein L.J., Kristo D., Strollo P.J., Friedman N., Malhotra A., Patil S.P., Ramar K., Rogers R., Schwab R.J., Weaver E.M., 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. Zhao Y.Y., Wang R., Gleason K.J., Lewis E.F., Quan S.F., Toth C.M., Morrical M., Rueschman M., Weng J., Ware J.H., et al. Effect of continuous positive airway pressure treatment on health-related quality of life and sleepiness in high cardiovascular risk individuals with sleep apnea: Best apnea interventions for research (BestAIR) trial. Sleep. 2017;40 doi: 10.1093/sleep/zsx040.
    1. Sánchez A.I., Martínez P., Miró E., Bardwell W.A., Buela-Casal G. CPAP and behavioral therapies in patients with obstructive sleep apnea: Effects on daytime sleepiness, mood, and cognitive function. Sleep Med. Rev. 2009;13:223–233. doi: 10.1016/j.smrv.2008.07.002.
    1. Jurado-Gámez B., Guglielmi O., Gude-Sampedro F., Buela-Casal G. Effect of CPAP therapy on job productivity and psychosocial occupational health in patients with moderate to severe sleep apnea. Sleep Breath. 2015;19:1293–1299. doi: 10.1007/s11325-015-1162-6.
    1. Wolkove N., Baltzan M., Kamel H., Dabrusin R., Palayew M. Long-term compliance with continuous positive airway pressure in patients with obstructive sleep apnea. Can. Respir. J. 2008;15:365–369. doi: 10.1155/2008/534372.
    1. Morgenthaler T.I., Kapen S., Lee-Chiong T., Alessi C., Boehlecke B., Brown T., Coleman J., Friedman L., Kapur V., Owens J., et al. Practice parameters for the medical therapy of obstructive sleep apnea. Sleep. 2006;29:1031–1035.
    1. Kolla B.P., Foroughi M., Saeidifard F., Chakravorty S., Wang Z., Mansukhani M.P. The impact of alcohol on breathing parameters during sleep: A systematic review and meta-analysis. Sleep Med. Rev. 2018;42:59–67. doi: 10.1016/j.smrv.2018.05.007.
    1. Krishnan V., Dixon-Williams S., Thornton J.D. Where there is smoke… there is sleep apnea: Exploring the relationship between smoking and sleep apnea. Chest. 2014;146:1673–1680. doi: 10.1378/chest.14-0772.
    1. American Academy of Sleep Medicine . International Classifcation of Sleep Disorders. 3rd ed. American Academy of Sleep Medicine; Darien, IL, USA: 2014.
    1. Basoglu O.K., Tasbakan M.S. Gender differences in clinical and polysomnographic features of obstructive sleep apnea: A clinical study of 2827 patients. Sleep Breath. 2018;22:241–249. doi: 10.1007/s11325-017-1482-9.
    1. Harreiter J., Kautzky-Willer A. Sex and gender differences in prevention of type 2 diabetes. Front. Endocrinol. 2018;9:220. doi: 10.3389/fendo.2018.00220.
    1. Amaro-Gahete F.J., De-la-O A., Jurado-Fasoli L., Espuch-Oliver A., Robles-González L., Navarro-Lomas G., de Haro T., Femia P., Castillo M.J., Gutierrez A. Exercise training as S-Klotho protein stimulator in sedentary healthy adults: Rationale, design, and methodology. Contemp. Clin. Trials Commun. 2018;11:10–19. doi: 10.1016/j.conctc.2018.05.013.
    1. Sánchez-Delgado G., Martinez-Tellez B., Olza J., Aguilera C.M., Labayen I., Ortega F.B., Chillon P., Fernandez-Reguera C., Alcantara J.M.A., Martinez-Avila W.D., et al. Activating brown adipose tissue through exercise (ACTIBATE) in young adults: Rationale, design and methodology. Contemp. Clin. Trials. 2015;45:416–425. doi: 10.1016/j.cct.2015.11.004.
    1. Schulz K.F., Grimes D.A. Generation of allocation sequences in randomised trials: Chance, not choice. Lancet. 2002;359:515–519. doi: 10.1016/S0140-6736(02)07683-3.
    1. Friedberg J.P., Lipsitz S.R., Natarajan S. Challenges and recommendations for blinding in behavioral interventions illustrated using a case study of a behavioral intervention to lower blood pressure. Patient Educ. Couns. 2010;78:5–11. doi: 10.1016/j.pec.2009.04.009.
    1. Kapur V.K., Auckley D.H., Chowdhuri S., Kuhlmann D.C., Mehra R., Ramar K., Harrod C.G. Clinical Practice Guideline for Diagnostic Testing for Adult Obstructive Sleep Apnea: An American Academy of Sleep Medicine Clinical Practice Guideline. J. Clin. Sleep Med. 2017;13:479–504. doi: 10.5664/jcsm.6506.
    1. Boudewyns A., Sforza E., Zamagni M., Krieger J. Respiratory effort during sleep apneas after interruption of long-term CPAP treatment in patients with obstructive sleep apnea. Chest. 1996;110:120–127. doi: 10.1378/chest.110.1.120.
    1. Berry R.B., Budhiraja R., Gottlieb D.J., Gozal D., Iber C., Kapur V.K., Marcus C.L., Mehra R., Parthasarathy S., Quan S.F., et al. Rules for scoring respiratory events in sleep: Update of the 2007 AASM manual for the scoring of sleep and associated events. Deliberations of the sleep apnea definitions task force of the American Academy of Sleep Medicine. J. Clin. Sleep Med. 2012;8:597–619. doi: 10.5664/jcsm.217.
    1. Jasper H.H. Report of the committee on methods of clinical examination in electroencephalography: 1957. Electroencephalogr. Clin. Neurophysiol. 1958;10:370–375. doi: 10.1016/0013-4694(58)90053-1.
    1. Rechtschaffen A., Kales A. A Manual of Standardized Terminology, Techniques and Scoring System of Sleep Stages in Human Subjects. Brain Information Service, Brain Research Institute; University of California; Los Angeles, CA, USA: 1968.
    1. Mokhlesi B., Varga A.W. Obstructive sleep apnea and cardiovascular disease: REM sleep matters! Am. J. Respir. Crit. Care Med. 2018;197:554–556. doi: 10.1164/rccm.201710-2147ED.
    1. Oja P., Laukkanen R., Pasanen M., Tyry T., Vuori I. A 2-km walking test for assessing the cardiorespiratory fitness of healthy adults. Int. J. Sports Med. 1991;12:356–362. doi: 10.1055/s-2007-1024694.
    1. Oja P., Tuxworth B. Eurofit for Adults: Assessment of Health-Related Fitness. Council of Europe Publishing; Tampere, Finland: 1995. pp. 1–13.
    1. Ortega F.B., Sánchez-López M., Solera-Martínez M., Fernández-Sánchez A., Sjöström M., Martínez-Vizcaino V. Self-reported and measured cardiorespiratory fitness similarly predict cardiovascular disease risk in young adults. Scand. J. Med. Sci. Sports. 2013;23:749–757. doi: 10.1111/j.1600-0838.2012.01454.x.
    1. Marfell-Jones M.J., Stewart A.D., de Ridder J.H. International Standards for Anthropometric Assessment. International Society for the Advancement of Kinanthropometry; Wellington, New Zealand: 2012.
    1. Schröder H., Fitó M., Estruch R., Martínez-González M.A., Corella D., Salas-Salvadó J., Lamuela-Raventós R., Ros E., Salaverría I., Fiol M., et al. A short screener is valid for assessing Mediterranean diet adherence among older Spanish men and women. J. Nutr. 2011;141:1140–1145. doi: 10.3945/jn.110.135566.
    1. Banna J.C., Townsend M.S. Assessing factorial and convergent validity and reliability of a food behaviour checklist for Spanish-speaking participants in US Department of Agriculture nutrition education programmes. Public Health Nutr. 2011;14:1165–1176. doi: 10.1017/S1368980010003058.
    1. Becoña E., Gómez-Durán B., Alvarez-Soto E., García M.P. Scores of Spanish smokers on Fagerström’s Tolerance Questionnaire. Psychol. Rep. 1992;71:1227–1233.
    1. Ferrer M., Vilagut G., Monasterio C., Montserrat J.M., Mayos M., Alonso J. Measurement of the perceived impact of sleep problems: The Spanish version of the functional outcomes sleep questionnaire and the Epworth sleepiness scale. Med. Clin. (BARC) 1999;113:250–255.
    1. Sanz J.I., García-Vera A. BDI-FS, Inventario de Depresión de Beck Para Pacientes Médicos. Pearson; Madrid, Spain: 2011. MP y Dpto. I+D Pearson Clinical & Talent Assessment.
    1. Buela-Casal G., Guillén-Riquelme A., Seisdedos-Cubero N. Cuestionario de Ansiedad Estado-Rasgo: Adaptación Española. 9th ed. TEA Ediciones; Madrid, Spain: 2016.
    1. Spielberger C.D., Agudelo D., Buela-Casal G. Inventario de Depresión Estado/Rasgo (IDER) TEA Ediciones; Madrid, Spain: 2008.
    1. Rezaeitalab F., Moharrari F., Saberi S., Asadpour H., Rezaeetalab F. The correlation of anxiety and depression with obstructive sleep apnea syndrome. J. Res. Med. Sci. 2014;19:205–210.
    1. Chiner E., Arriero J.M., Signes-Costa J., Marco J., Fuentes I. Validation of the Spanish version of the Epworth Sleepiness Scale in patients with a sleep apnea syndrome. Arch. Bronconeumol. 1999;35:422–427. doi: 10.1016/S0300-2896(15)30037-5.
    1. Dinges D.F., Powell J.W. Microcomputer analyses of performance on a portable, simple visual RT task during sustained operations. Behav. Res. Meth. Instrum. Comput. 1985;17:652–655. doi: 10.3758/BF03200977.
    1. Khitrov M.Y., Laxminarayan S., Thorsley D., Ramakrishnan S., Rajaraman S., Wesensten N.J., Reifman J. PC-PVT: A platform for psychomotor vigilance task testing, analysis, and prediction. Behav. Res. Methods. 2014;46:140–147. doi: 10.3758/s13428-013-0339-9.
    1. Reifman J., Kumar K., Khitrov M.Y., Liu J., Ramakrishnan S. PC-PVT 2.0: An updated platform for psychomotor vigilance task testing, analysis, prediction, and visualization. J. Neurosci. Methods. 2018;304:39–45. doi: 10.1016/j.jneumeth.2018.04.007.
    1. Becker N.B., de Jesus S.N., Viseu J.N., Stobäus C.D., Guerreiro M., Domingues R.B. Depression and quality of life in older adults: Mediation effect of sleep quality. Int. J. Clin. Health Psychol. 2018;18:8–17. doi: 10.1016/j.ijchp.2017.10.002.
    1. Wersebe H., Lieb R., Meyer A.H., Miche M., Mikoteit T., Imboden C., Hoyer J., Bader K., Hatzinger M., Gloster A.T. Well-being in major depression and social phobia with and without comorbidity. Int. J. Clin. Health Psychol. 2018;18:201–208. doi: 10.1016/j.ijchp.2018.06.004.
    1. Royuela A., Macías J.A. Propiedades clinimétricas de la versión castellana del Cuestionario de Pittsburgh. Vigilia-Sueño. 1997;9:81–94.
    1. Catalán P., Martínez A., Herrejón A., Martínez-García M.Á., Soler-Cataluña J.J., Román-Sánchez P., Pinel J., Blanquer R. Internal consistency and validity of the Spanish version of the quality of life questionnaire specific for obstructive sleep apnea: Sleep apnea quality of life index. Arch. Bronconeumol. 2012;48:431–442. doi: 10.1016/j.arbres.2012.05.004.
    1. Alonso J., Prieto L., Antó J.M. The Spanish version of the SF-36 Health Survey (the SF-36 health questionnaire): An instrument for measuring clinical results. Med. Clin. (BARC) 1995;104:771–776.
    1. Lobo A., Pérez-Echeverría M.J., Artal J. Validity of the scaled version of the General Health Questionnaire (GHQ-28) in a Spanish population. Psychol. Med. 1986;16:135–140. doi: 10.1017/S0033291700002579.
    1. Adan A., Almirall H. Horne and Östberg morningness–eveningness questionnaire: A reduced scale. Pers. Indiv. Differ. 1991;12:241–253. doi: 10.1016/0191-8869(91)90110-W.
    1. Kim L.J., Coelho F.M., Hirotsu C., Bittencourt L., Tufik S., Andersen M.L. Is the chronotype associated with obstructive sleep apnea? Sleep Breath. 2015;19:645–651. doi: 10.1007/s11325-014-1070-1.
    1. Lucassen E.A., Zhao X., Rother K.I., Mattingly M.S., Courville A.B., de Jonge L., Csako G., Cizza G. Evening chronotype is associated with changes in eating behavior, more sleep apnea, and increased stress hormones in short sleeping obese individuals. PLoS ONE. 2013;8:e56519. doi: 10.1371/journal.pone.0056519.
    1. Edejer T.T.T., Baltussen R., Adam T., Hutubessy R., Acharya A., Evans D.B., Murray C.J.L. Making Choices in Health: WHO Guide to Cost-Effectiveness Analysis. World Health Organization; Geneva, Switzerland: 2003.
    1. Sanders G.D., Neumann P.J., Basu A., Brock D.W., Feeny D., Krahn M., Kuntz K.M., Meltzer D.O., Owens D.K., Prosser L.A., et al. Recommendations for conduct, methodological practices, and reporting of cost-effectiveness analyses: Second panel on cost-effectiveness in Health and Medicine. JAMA. 2016;316:1093–1103. doi: 10.1001/jama.2016.12195.
    1. Hlatky M.A., Owens D.K., Sanders G.D. Cost-effectiveness as an outcome in randomized clinical trials. Clin. Trials. 2006;3:543–551. doi: 10.1177/1740774506073105.
    1. Vallejo-Torres L., García-Lorenzo B., Serrano-Aguilar P. Estimating a cost-effectiveness threshold for the Spanish NHS. Health Econ. 2018;27:746–761. doi: 10.1002/hec.3633.
    1. Sacristán J.A., Oliva J., Del Llano J., Prieto L., Pinto J.L. What is an efficient health technology in Spain? Gac. Sanit. 2002;16:334–343. doi: 10.1016/S0213-9111(02)71933-X.
    1. Prochaska J.O., Velicer W.F. The transtheoretical model of health behavior change. Am. J. Health Promot. 1997;12:38–48. doi: 10.4278/0890-1171-12.1.38.
    1. Burgess E., Hassmén P., Welvaert M., Pumpa K.L. Behavioural treatment strategies to improve adherence to lifestyle intervention programmes in adults with obesity: A systematic review and meta-analysis. Clin. Obes. 2017;7:105–114. doi: 10.1111/cob.12180.
    1. Guillermo C., Boushey C.J., Franke A.A., Monroe K.R., Lim U., Wilkens L.R., Le Marchand L., Maskarinec G. Diet quality and biomarker profiles related to chronic disease prevention: The Multiethnic Cohort Study. J. Am. Coll. Nutr. 2019;10:1–8. doi: 10.1080/07315724.2019.1635921.
    1. St-Onge M.P., Mikic A., Pietrolungo C.E. Effects of diet on sleep quality. Adv. Nutr. 2016;7:938–949. doi: 10.3945/an.116.012336.
    1. Bozkurt N.C., Cakal E., Sahin M., Ozkaya E.C., Firat H., Delibasi T. The relation of serum 25-hydroxyvitamin-D levels with severity of obstructive sleep apnea and glucose metabolism abnormalities. Endocrine. 2012;41:518–525. doi: 10.1007/s12020-012-9595-1.
    1. Gao Q., Kou T., Zhuang B., Ren Y., Dong X., Wang Q. The Association between vitamin D deficiency and sleep disorders: A systematic review and meta-analysis. Nutrients. 2018;10:1395. doi: 10.3390/nu10101395.
    1. Cao Y., Zhen S., Taylor A.W., Appleton S., Atlantis E., Shi Z. Magnesium intake and sleep disorder symptoms: Findings from the Jiangsu Nutrition Study of Chinese adults at five-year follow-up. Nutrients. 2018;10:1354. doi: 10.3390/nu10101354.
    1. McHill A.W., Wright K.P., Jr. Role of sleep and circadian disruption on energy expenditure and in metabolic predisposition to human obesity and metabolic disease. Obes. Rev. 2017;18:15–24. doi: 10.1111/obr.12503.
    1. Yang C.L., Schnepp J., Tucker R.M. Increased hunger, food cravings, food reward, and portion size selection after sleep curtailment in women without obesity. Nutrients. 2019;11:663. doi: 10.3390/nu11030663.
    1. St-Onge M.P., Wolfe S., Sy M., Shechter A., Hirsch J. Sleep restriction increases the neuronal response to unhealthy food in normal-weight individuals. Int. J. Obes. 2014;38:411–416. doi: 10.1038/ijo.2013.114.
    1. St-Onge M.P., McReynolds A., Trivedi Z.B., Roberts A.L., Sy M., Hirsch J. Sleep restriction leads to increased activation of brain regions sensitive to food stimuli. Am. J. Clin. Nutr. 2012;95:818–824. doi: 10.3945/ajcn.111.027383.
    1. Wallace A., Bucks R.S. Memory and obstructive sleep apnea: A meta-analysis. Sleep. 2013;36:203–220. doi: 10.5665/sleep.2374.
    1. Martin A.A., Davidson T.L., McCrory M.A. Deficits in episodic memory are related to uncontrolled eating in a sample of healthy adults. Appetite. 2018;124:33–42. doi: 10.1016/j.appet.2017.05.011.
    1. Aiello K.D., Caughey W.G., Nelluri B., Sharma A., Mookadam F., Mookadam M. Effect of exercise training on sleep apnea: A systematic review and meta-analysis. Respir. Med. 2016;116:85–92. doi: 10.1016/j.rmed.2016.05.015.
    1. Iftikhar I.H., Kline C.E., Youngstedt S.D. Effects of exercise training on sleep apnea: A meta-analysis. Lung. 2014;192:175e84. doi: 10.1007/s00408-013-9511-3.
    1. Shook R.P., Hand G.A., Drenowatz C., Hebert J.R., Paluch A.E., Blundell J.E., Hill J.O., Katzmarzyk P.T., Church T.S., Blair S.N. Low levels of physical activity are associated with dysregulation of energy intake and fat mass gain over 1 year. Am. J. Clin. Nutr. 2015;102:1332–1338. doi: 10.3945/ajcn.115.115360.
    1. Shechter A. Obstructive sleep apnea and energy balance regulation: A systematic review. Sleep Med. Rev. 2017;34:59–69. doi: 10.1016/j.smrv.2016.07.001.
    1. Ueno L.M., Drager L.F., Rodrigues A.C., Rondon M.U., Braga A.M., Mathias W., Jr., Krieger E.M., Barretto A.C., Middlekauff H.R., Lorenzi-Filho G., et al. Effects of exercise training in patients with chronic heart failure and sleep apnea. Sleep. 2009;32:637–647. doi: 10.1093/sleep/32.5.637.
    1. Redolfi S., Arnulf I., Pottier M., Bradley T.D., Similowski T. Effects of venous compression of the legs on overnight rostral fluid shift and obstructive sleep apnea. Respir. Physiol. Neurobiol. 2011;175:390–393. doi: 10.1016/j.resp.2011.01.001.
    1. Evans R.A., Dolmage T.E., Robles P.G., Brooks D., Goldstein R.S. The effects of exercise modality and intensity on energy expenditure and cardiorespiratory response in adults with obesity and treated obstructive sleep apnoea. Chron. Respir. Dis. 2017;14:342–351. doi: 10.1177/1479972316643699.
    1. Buela-Casal G., Sierra J.C. Evaluación y tratamiento de los trastornos del sueño Evaluation and treatment of sleep disorders. In: Buela-Casal G., Sierra J.C., editors. Manual de Evaluación y Tratamientos Psicológicos. 2nd ed. Biblioteca Nueva; Madrid, Spain: 2004. pp. 393–438.
    1. Kitamura T., Miyazaki S., Koizumi H., Takeuchi S., Tabata T., Suzuki H. Sleep hygiene education for patients with obstructive sleep apnea. Sleep Biol. Rhythm. 2016;14:101–106. doi: 10.1007/s41105-015-0015-9.
    1. Chakravorty I., Cayton R.M., Szczepura A. Health utilities in evaluating intervention in the sleep apnoea/hypopnoea syndrome. Eur. Respir. J. 2002;20:1233–1238. doi: 10.1183/09031936.00.00014401.
    1. Ackel-D’Elia C., da Silva A.C., Silva R.S., Truksinas E., Sousa B.S., Tufik S., de Mello M.T., Bittencourt L.R. Effects of exercise training associated with continuous positive airway pressure treatment in patients with obstructive sleep apnea syndrome. Sleep Breath. 2012;16:723–735. doi: 10.1007/s11325-011-0567-0.
    1. Schrand J.R. Is sleep apnea a predisposing factor for tobacco use? Med. Hypotheses. 1996;47:443–448. doi: 10.1016/S0306-9877(96)90155-3.
    1. Becoña E. Programa Para Dejar de Fumar [Program for Smoking Cessation] Nova Galicia Edicións; Vigo, Spain: 2007.
    1. Foxx R.M., Brown R.A. Nicotine fading, self-monitoring for cigarette abstinence or controlled smoking. J. Appl. Behav. Anal. 1979;12:115–125. doi: 10.1901/jaba.1979.12-111.
    1. Becoña E., García M.P. Nicotine fading and smokeholding methods to smoking cessation. Psychol. Rep. 1993;73:779–786. doi: 10.2466/pr0.1993.73.3.779.
    1. Simou E., Britton J., Leonardi-Bee J. Alcohol and the risk of sleep apnoea: A systematic review and meta-analysis. Sleep Med. 2018;42:38–46. doi: 10.1016/j.sleep.2017.12.005.
    1. Issa F.G., Sullivan C.E. Alcohol, snoring and sleep apnoea. J. Neurol. Neurosurg. Psychiatry. 1982;45:353–359. doi: 10.1136/jnnp.45.4.353.
    1. Borrelli B. The assessment, monitoring, and enhancement of treatment fidelity in public health clinical trials. J. Public Health Dent. 2011;71:52–63. doi: 10.1111/j.1752-7325.2011.00233.x.
    1. Pinheiro J., Bates D., DebRoy S., Sarkar D., R Core Team Nlme: Linear and Nonlinear Mixed Effects Models. R Package Version 3.1-140. [(accessed on 3 July 2019)]; Available online: .
    1. Berger V.W. The reverse propensity score to detect selection bias and correct for baseline imbalances. Stat. Med. 2005;24:2777–2787. doi: 10.1002/sim.2141.
    1. Morris S.B. Estimating effect sizes from pretest-posttest-control group designs. Organ. Res. Methods. 2008;11:364–386. doi: 10.1177/1094428106291059.
    1. Knauert M., Naik S., Gillespie M.B., Kryger M. Clinical consequences and economic costs of untreated obstructive sleep apnea syndrome. World J. Otorhinolaryngol. Head Neck Surg. 2015;1:17–27. doi: 10.1016/j.wjorl.2015.08.001.
    1. Morsy N.E., Farrag N.S., Zaki N.F.W., Badawy A.Y., Abdelhafez S.A., El-Gilany A.H., El-Shafey M.M., Pandi-Perumal S.R., Spence D.W., BaHammam A.S. Obstructive sleep apnea: Personal, societal, public health, and legal implications. Rev. Environ. Health. 2019;34:153–169. doi: 10.1515/reveh-2018-0068.
    1. Hillman D.R., Murphy A.S., Pezzullo L. The economic cost of sleep disorders. Sleep. 2006;29:299–305. doi: 10.1093/sleep/29.3.299.
    1. Kao L.T., Lee H.C., Lin H.C., Tsai M.C., Chung S.D. Healthcare service utilization by patients with obstructive sleep apnea: A population-based study. PLoS ONE. 2015;10:e0137459. doi: 10.1371/journal.pone.0137459.
    1. Diaz K., Faverio P., Hospenthal A., Restrepo M.I., Amuan M.E., Pugh M.J. Obstructive sleep apnea is associated with higher healthcare utilization in elderly patients. Ann. Thorac. Med. 2014;9:92–98. doi: 10.4103/1817-1737.128854.
    1. Tarasiuk A., Greenberg-Dotan S., Simon-Tuval T., Oksenberg A., Reuveni H. The effect of obstructive sleep apnea on morbidity and health care utilization of middle-aged and older adults. J. Am. Geriatr. Soc. 2008;56:247–254. doi: 10.1111/j.1532-5415.2007.01544.x.
    1. Ronald J., Delaive K., Roos L., Manfreda J., Bahammam A., Kryger M.H. Health care utilization in the 10 years prior to diagnosis in obstructive sleep apnea syndrome patients. Sleep. 1999;22:225–229. doi: 10.1093/sleep/22.2.225.
    1. Derose S.F., Zhou H., Huang B.Z., Manthena P., Hwang D., Shi J.M. Does providing positive airway pressure for sleep apnea change health care utilization? Med. Care. 2018;56:901–907. doi: 10.1097/MLR.0000000000000963.

Source: PubMed

3
S'abonner