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Bottom Line: Studies show that modest weight loss (10%) can have a significant effect on sleep apnea severity, with each kilogram lost decreasing the apnea-hypopnea index by 0.78 events per hour. Sustained weight loss can provide full remission for some patients.
Sleep apnea is a condition that affects millions of people internationally and involves disrupted breathing during sleep, exacerbating overall health. For many patients, excess weight is not just a driver of their sleep apnea but often the primary cause. Understanding the extent to which weight loss will affect sleep apnea not only gives patients and providers the hope they are seeking but also a clearer path to improvement.
Obstructive sleep apnea is described as the repeated collapse of the upper airway during sleep, which leads to breathing interruptions while sleeping. Excess weight drives this process through several interconnected mechanisms.
Pharyngeal Fat Deposits: Excess weight creates fat deposits along the neck and throat (pharyngeal fat), which create a physical collapse of the upper airway as the muscles relax during sleep. This collapse narrows the upper airway and forces airflow to travel through a narrower area, creating snoring sounds and increasing the risk of upper airway collapse.
Abdominal Pressure: Abdominal pressure compressing the chest wall creates reduced lung volume and capacity due to increased girth around the abdomen from excess fat. The result is reduced lung function and airflow and reduced inward traction on the upper airway that occurs during inhalation. Thus, increasing the likelihood of airway obstruction during sleep.
Recent research highlights tongue fat as potentially the most important factor. Advancements have shown that most studies examining the association between tongue fat volume and sleep apnea improvements showed a strong positive correlation between the reduction in tongue fat volume and sleep apnea improvement (0.62). Infiltration of tongue fat affects tongue muscle function and plays a large role in airway obstruction.
We asked Dr. Michael Grandner, Ph.D., Sleep Expert, and Professor of Neuroscience and Physiological Sciences, what is the relationship between weight and sleep apnea? Dr. Grandner stated: "Weight loss reduces mechanical loading around the upper airway and reduces the risk of collapse," which enhances mechanical stability of the airway to promote patency during sleep and improves increased breathing efforts during sleep.
While the evidence is accumulating in support of the relationship between decreased weight and improved sleep apnea, much of the research focuses on clinical evidence, and it is clear, even a modest weight loss leads to improvements in sleep apnea.
The largest and only long-term randomized control trial to examine weight change was the landmark Sleep AHEAD study. This study followed 264 participants with Type 2 diabetes and sleep apnea, qualifying them to calculations over years. Participants that lost weight in the intensive lifestyle intervention arm (10.8 kg average, 24 lb) had significantly better improvements in the apnea-hypopnea index (AHI) compared to control groups.
Notable Findings:
A 10% decrease in body weight continues to be found valuable in the many studies that have provided clinically meaningful improvements in sleep apnea. For a 200-pound individual, this indicates that a 20-pound weight loss may produce a major reduction in breathing disruptions, improved sleep quality, and increased daytime alertness.
Long-Term Benefits: The 10-year follow-up study of the Sleep AHEAD participants suggests that weight loss still continues to provide sleep apnea benefits long after weight loss. Participants who were successful in maintaining their weight loss demonstrated improvements in their breathing characteristics during sleep.
Understanding how weight loss improves sleep apnea is helpful in explaining how even modest weight loss can be effective.
Reduction in Tongue Fat: Newer imaging studies suggest that weight loss reduces fat in the tongue to a meaningful extent. Reducing the fat in the tongue improves tongue muscle function and lessens the tongue's potential contribution to airway obstruction. In short, with a reduction in tongue size, the tongue is less inclined to collapse backward and obstruct breath during sleep.
Reduction in Lateral Wall Volume: Weight loss reduces the volume of the pharyngeal lateral walls—the soft tissue of the neck surrounding the airway. Not having pressure from fat volume allows pharyngeal soft tissues to shrink and reduces the chances of a complete airway collapse. Studies have shown a significant reduction in this structure correlates with improved breathing during sleep.
Reduction in Parapharyngeal Fat: Fat around the pharynx shrinks with weight loss, adding more airway space. Volumetric reconstructions have shown significant increases in retropalatal airway area related to the lateral pharyngeal area, in fact, where most airway obstruction occurs.
Enhanced Lung Volume: Weight loss of abdominal fat reduces pressures holding the diaphragm and chest wall down, thus increasing functional lung volumes. This enhanced lung function supports the inherent traction forces that assist in keeping the upper airway open during sleep. Improved lung mechanics will also support stable breathing patterns throughout sleep.
Improved Muscle Function: Fat infiltration in muscle is detrimental to muscle force, velocity, and power. Weight loss will decrease that fat infiltration and optimize the function of the muscles that are responsible for maintaining upper airway patency. The stronger, more responsive muscle will better compensate for the natural narrowing of the airway that occurs during sleep.
I asked Dr. Suzanne Gorovoy - a Sleep Expert, Clinical Psychologist, and Behavioral Sleep Medicine Specialist - about weight loss and physiological changes. She stated: "Reduction in visceral fat will reduce inflammation and enhance neuromuscular control mechanisms." That enhanced neural control can allow the upper airway to have a more effective response while breathing during sleep.
Structured Lifestyle Programs: The best evidence suggests that the most successful approach combines dietary change and increased physical activity. When reviewed, intensive interventions to improve both diet and physical activity resulted in greater weight loss and improvement in apnea hypopnea syndrome than educative programs. In these studies, the lifestyle programs included a combination of portion-controlled diets, meal replacement plans, and progressive exercise plans.
Dietary Approaches: The establishment of a caloric deficit by a combination of caloric restriction and portion size can be the foundation for successful weight loss for apnea hypopnea syndrome. Studies of a liquid meal replacement diet and structured meal plans have resulted in the greatest weight loss. The key is to establish a sustainable caloric deficit that includes sound nutrition.
Exercise: Exercise provides benefits outside of weight loss. Exercise improves cardiovascular health and reduces inflammation. There may also be a direct improvement in the severity of sleep apnea, through mechanisms that are independent of weight change. Even a modest level of physical activity can improve sleep quality and lessen excessive sleepiness during the day.
Medication: Some medications can help with weight loss when do-it-yourself changes are not successful. However, any medication for sleep should be considered for potential interactions with sleep apnea treatments, as well as effects on sleep breathing. Natural sleep medications may be safer for a person with a chronic breathing disorder.
Weight Loss Surgery: Surgical weight loss can cause amazing change in a severely (or morbidly) obese person. Weight loss surgery leads to substantial decrease in upper airway soft tissue volumes, and correlate with improvement in sleeping and breathing. Weight loss surgery must be seriously considered and have post-operative follow up.
Long-Term Sustainable Changes in Behavior: The 10-year Sleep AHEAD data indicates that the benefits of weight loss on sleep apnea can be maintained over time. Long-term monitoring of weight requires consideration, not just action, with dietary and activity choices. People who are successful at maintaining weight will usually have a plan, a practice of eating, and exercise regularly.
Monthly Work Visits or Coaching: Regrouping with several approaches with your physician to sustain weight loss is helpful. There are programs for continued sleep coaching helpful for both continued weight loss management and sleep hygiene. Follow-up to track progress and make modifications is useful to maintain weight and sleep apnea management.
Your CPAP therapy can be complemented with weight loss management. CPAP therapy should not be regarded as a replacement to the practice of weight loss. The requirement of pressure from the CPAP can decrease with weight loss, making the therapy more comfortable and more compliant with treatment. Depending upon your improvement in weight loss, in combination with sleep apnea management, you may be able to dispense with the CPAP altogether with sufficient weight loss.
All-Encompassing Sleep Management: CBT-I (Cognitive Behavioral Therapy for Insomnia) and other sleep interventions are a synergistic intervention alongside weight loss. Tackling multiple facets of sleep health can yield superior results compared to weight loss alone. We consulted a sleep expert, Dr. Areti Vassilopoulos, a Pediatric Health Psychologist, as well as a published Assistant Professor in Child Psychology, and she stated that: "Multi-modal interventions addressing weight or behavior or sleep hygiene yield the best improvements." This multi-modal approach recognizes that sleep apnea is best understood through the complicated interplay of physical and behavioral mechanisms.
Dietary Quality Implications: Research suggests that dietary quality plays a role, independent of weight, in sleep apnea severity. Anti-inflammatory diets may provide benefit in reducing upper airway inflammation when sleeping and enhance breathing while sleeping. Diets that include nutrient dense food arrive with improved weight management, which has implications for sleep quality.
Benefits Specific to Exercise: Exercise shows significant improvements to sleep apnea, independent of weight loss. Exercise is implicated in reducing inflammation and cardiovascular health, and has a potential effect on improving upper airway neuromuscular control. Further, exercise may have a positive effect on sleep architecture and reductions in daytime sleepiness.
Metabolically Driven Improvements: Weight loss will improve insulin resistance, reduce inflammation, and normalize hormonal patterns that can positively influence sleep apnea–including sleep-disordered breathing severity and duration. Importantly, these benefits can remain, depending on the method of weight loss— a purely behavioral weight loss program, for example, may help the individual retain a modest weight reduction, which can afford the metabolic benefit for sleep apnea.
In a study published in the American Journal of Respiratory and Critical Care Medicine (2020), a major new finding uncovered how weight loss repaid to sleep apnea, which transformed previous understandings of weight loss and how it helps sleep apnea. Through the implementation of advanced Dixon magnetic resonance imaging, the research team was able to follow the alteration of upper airway anatomy before and after weight loss in obese patients with sleep apnea.
Key Observations:
The work also identified tongue fat as a novel and previously unrecognized target. It explains why some patients experience significant improvements in sleep apnea with modest levels of weight greater than 15%. The tongue may be particularly sensitive to weight loss in certain individuals.
Clinical Balance: This indicates that one day we may actually be able to treat sleep apnea by targeting weight loss on the tongue local fat may decrease sleep apnea without requiring the patient to lose a significant amounts of over all body mass.
Mild Sleep Apnea: Patients with mild OSA (AHI 5-15 events/hour) will achieve complete remission with 10-15% weight loss. It has been reported that more than three times as many participants achieve complete OSA remission in the intensive weight-loss controlled compared to controls.
Moderate to Severe: The moderate to severe patient with OSA will greatly improve but may not achieve complete remission on weight loss alone. The prevalence of very severe obstructive sleep apnea (OSA) among successful participants in diet and exercise weight loss programs dropped by half, demonstrating meaningful patient benefit despite not achieving complete resolution.
Immediate Improvement: Some patients notice decreased snoring and improved sleep quality in the first few weeks after beginning a weight loss program. These early changes often support motivation to continue with their efforts and maintain the program.
Improvements: Bigger improvements in OSA usually take 6 to 12 months of consistent weight loss to demonstrate. The biggest improvements in breathing patterns are usually observed in conjunction with a 10% or more weight loss from baseline weight.
Sustained Improvement: Once sustained weight loss occurs, improvements can last for many years, or for some, a lifetime. However, recurrence of sleep apnea usually occurs after weight is regained, highlighting the importance of long-term lifestyle changes.
Weight loss is one of the most effective therapies for OSA. OSA research has consistently shown that even modest weight loss yields clinically meaningful improvements. The evidence shows that the loss of 10% of total body weight significantly reduced apneic events, improved resting sleep quality, and improved overall health outcomes.
The improvements of these health outcomes are due to complex interplays of reduced upper airway soft tissue volume, improved lung function, and improved neuromuscular control. Recent research showing the contributions of tongue fat have helped to explain why modest weight loss can be effective in some patients.
To be successful, patients must adopt a comprehensive approach (diet, exercise, and behavioral change). While the journey toward weight loss can be arduous; the results of significant improvements in sleep quality and overall health are a significant investment for patients who are currently suffering from OSA.
Individuals with OSA and body weight should seek the services of healthcare providers to develop a structured weight loss plan. All the evidence would suggest that when it comes to OSA, every pound lost can mean a significant difference, both in a person's breathing, quality of sleep, and satisfaction with their life.
If you would like further information about comprehensive sleep health and evidence-based sleep treatments, please review our other offerings on improving sleep health naturally and effectively.
Dr. Shiyan Yeo
Dr. Shiyan Yeo is a medical doctor with over a decade of experience treating patients with chronic conditions. She graduated from the University of Manchester with a Bachelor of Medicine and Surgery (MBChB UK) and spent several years working at the National Health Service (NHS) in the United Kingdom, several Singapore government hospitals, and private functional medicine hospitals. Dr. Yeo specializes in root cause analysis, addressing hormonal, gut health, and lifestyle factors to treat chronic conditions. Drawing from her own experiences, she is dedicated to empowering others to optimize their health. She loves traveling, exploring nature, and spending quality time with family and friends.
