Longer term effects of very low energy diet on obstructive sleep apnoea in cohort derived from randomised controlled trial: prospective observational follow-up study

Abstract

Objective: To determine whether initial improvements in obstructive sleep apnoea after a very low energy diet were maintained after one year in patients with moderate to severe obstructive sleep apnoea.

Design: Single centre, prospective observational follow-up study.

Setting: Outpatient obesity clinic in a university hospital in Stockholm, Sweden.

Participants: 63 men aged 30-65 with body mass index (BMI) 30-40 and moderate to severe obstructive sleep apnoea defined as an apnoea-hypopnoea index ≥ 15 (events/hour), all treated with continuous positive airway pressure.

Intervention: A one year weight loss programme, consisting of an initial very low energy diet for nine weeks (seven weeks of 2.3 MJ/day and two weeks of gradual introduction of normal food) followed by a weight loss maintenance programme.

Main outcome measure: Apnoea-hypopnoea index, the main index for severity of obstructive sleep apnoea. Data from all patients were analysed (baseline carried forward for missing data).

Results: Of 63 eligible patients, 58 completed the very low energy diet period and started the weight maintenance programme and 44 completed the full programme; 49 had complete measurements at one year. At baseline the mean apnoea-hypopnoea index was 36 events/hour. After the very low energy diet period, apnoea-hypopnoea index was improved by -21 events/hour (95% confidence interval -17 to -25) and weight by -18 kg (-16 to -19; both P<0.001). After one year the apnoea-hypopnoea index had improved by -17 events/hour (-13 to -21) and body weight by -12 kg (-10 to -14) compared with baseline (both P<0.001). Patients with severe obstructive sleep apnoea at baseline had greater improvements in apnoea-hypopnoea index (-25 events/hour) compared with patients with moderate disease (-7 events/hour, P<0.001). At one year, 30/63 (48%, 95% confidence interval 35% to 60%) no longer required continuous positive airway pressure and 6/63 (10%, 2% to 17%) had total remission of obstructive sleep apnoea (apnoea-hypopnoea index <5 events/hour). There was a dose-response association between weight loss and apnoea-hypopnoea index at follow-up (β = 0.50 events/kg, 0.11 to 0.88; P = 0.013).

Conclusion: Initial improvements in obstructive sleep apnoea after treatment with a very low energy diet can be maintained after one year in obese men with moderate to severe disease. Those who lose the most weight or have severe sleep apnoea at baseline benefit most. Trial registration Current Controlled Trials 70090382.

Fig 1 Design and treatment periods in obese men with moderate to severe sleep apnoea

Fig 2 Mean change from baseline in weight, waist circumference, neck circumference, and percentage body fat during and after treatment with very low energy diet for patients completing weight loss maintenance programme (n=44) and sensitivity analysis for missing data with multiple imputation (n=63), last observation carried forward (LOCF; n=63), or baseline observation carried forward (BOCF; n=63). Attendance was low at 15 and 23 weeks because of summer holidays. Error bars indicate 95% confidence intervals

Fig 3 Proportions with obstructive sleep apnoea at baseline and after treatment with very low energy diet and after one year in 63 participants (baseline observation carried forward for missing data). Apnoea-hypopnoea index: remission <5, mild=5-14.9, moderate=15-30, severe obstructive sleep apnoea >30 events/hour

Fig 4 Association between apnoea-hypopnoea index at baseline and follow-up for intention to treat population (BOCF=baseline observation carried forward) and weight loss categories in 63 participants. Dashed line represents cut off for severe sleep apnoea (index >30 events/hour)

Fig 5 Association between apnoea-hypopnoea index and weight loss (kg). Top: relation between apnoea-hypopnoea index and weight change in all 63 participants. Correlation coefficient and regression line based only on those with measured weight and index at baseline and follow-up (n=49). Bottom: relation between apnoea-hypopnoea index and weight for all participants with measured weight and index at baseline and follow-up (n=49). Lines indicate individuals. No participant gained weight, meaning that right-most observation represents baseline value