Southeast Houston Sleep Medicine

WEIGHT LOSS IN THE TREATMENT OF SLEEP APNEA

Many doctors and patients overlook one of the most important
therapies in the treatment of obstructive sleep apnea – weight loss
. Data published by the American College Of Physicians and the
American Academy of Sleep Medicine indicate that substantial weight
loss will cure sleep apnea in eighty-four (84%) to eighty-six (86%) of patients with severe obesity. Although these patients often require CPAP therapy initially to treat the sleep apnea, substantial weight loss will usually negate the need for CPAP.

In addition to improving sleep apnea, weight loss in severely obese patients offers a host of other health benefits, including improvement in blood pressure, decreased cholesterol levels, reduced risk of diabetes, and less risk of heart disease and stroke.  Substantial weight loss in severely obese patients even reduces the incidence of breast cancer, endometrial cancer, colon cancer, and prostate cancer.


DIET AND EXERCISE:

Physicians usually recommend diet and exercise as the first treatment.  Although there are many diet plans available, the successful diet plans limit caloric intake to below the quantity of calories used on a daily basis.  Even in patients with the most resistant and unfavorable metabolisms, a sedentary person requires about 1000 kilocalories of food a day.  This requirement can increase well above 2000 or even 3000 kilocalories a day in people with active lifestyles, vigorous exercise programs, or favorable metabolisms.

  In addition to restricting caloric intake, successful diets ensure patients are receiving the requisite quantity of minerals, vitamins, protein, and other nutrients.  Although diet plans  espouse the ingestion of large amounts of protein with minimal amounts of carbohydrates, these unbalanced plans are less likely to result in permanent weight loss.  Patients using diet plans that recommend excessive amounts of protein with minimal amounts of carbohydrates often gain any weight they loss back very quickly astop their diets . 

The succesful diet plans combine substantial amounts of protein with vegetables, whole grain, breads, and other complex carbohydrates such as brown rice.  Patients who are serious about losing weight need to restrict the amount of simple carbohydrates and sugars  -- such as white flour, white rice, sweets, and packaged foods containing high amounts of fructose, as well as fat intake.  In general, a healthy diet should contain no more than 30% fat with the complete elimination of trans-fats and saturated fats.

MEDICATIONS

A large variety of weight loss medications have come on and off the market over the past twenty years.  Initially, many of these medications were stimulants similar to amphetamines. Although many of these stimulant-type medicines have been removed from the market, Bontril and Phentermine still remain available in the United States with a prescription.

Amphetamine and Bontril both fall into the category of sympathomimetics.  They speed up people’s metabolism and promote weight loss.   Although these medications are safe for the short term, problems have been reported with long-term usage including irregular heart rhythms, weakening of the muscles of the heart, high blood pressure, and tremors.  Some of the short-term side effects include insomnia, restlessness, palpitations, and changes in bowel habits.

Orlistat (Xenical) is the medication recommended by the American College of Physicians as the best first-line agent for weight loss.  Xenical prevents the absorption of fat in the intestine.  This decreases the amount of calories absorbed through the gastrointestinal tract.  By decreasing the ingestion of these calories from fat, Xenical decreases the overall caloric intake and promotes weight loss.

Although Xenical is not associated with severe long-term side effects, it has been associated with unpleasant and embarrassing short-term side effects. Patients taking Xenical often experience excessive amounts of flatulence, oily stools, diarrhea, and abdominal bloating.  With time, these side effects often subside, as the patient learns to avoid foods that are high in fat.  In some studies, Xenical was used for up to two years without any long-term side effects.

Meridia is a stimulant-type medication that causes less nervousness, insomnia, and tremulousness than Phentermine or Bontril.  It has been associated with high blood pressure and is contraindicated in those patients with known high blood pressure.  Some new reports suggest a link between Meridia and increased pressure in the pulmonary artery, which connects the heart and the lungs.  Elevations in pulmonary artery pressure often go along with valvular problems of the heart as well. 

Although not marketed or approved as weight loss medications, some weight loss experts use high-dose Prozac at 60 mg a day or Wellbutrin to promote weight loss. Although these medications are generally prescribed as antidepressants, patients often experience weight loss as well. 

SURGICAL THERAPIES FOR WEIGHT LOSS

The surgical therapies for weight loss have been more successful than medications.  There are a wide variety of different surgeries that have been used for weight loss, but the two most common surgeries are the laparoscopic gastric banding and the Roux-en-Y gastric bypass.

The laparoscopic gastric banding is technically easier.  The patients generally have this done in a same day surgery unit.  With the assistance of the laparoscope and associated instruments, surgeons are able to wrap a band around the stomach, decreasing the size of ths stomsch and promoting satiety.  By decreasing the size of the stomach, patients become full earlier and only tolerate small amounts of food at a sitting.

Gastric banding procedures have been associated with substantial weight earlier on, but patients often gain the weight back. Some of the more common reasons for recurrent weight gain after gastric banding are ingesting large amounts of foods and carbonated beverages, which dilate the small stomach back to its original size.  Therefore, patients need to avoid carbonated beverages and large meals after receiving gastric banding procedures. 

The gastric bypass procedure is the most dramatic of the weight loss surgeries.  The patients generally lose large amounts of weight.  The disadvantages to the gastric bypass surgery are the technical expertise required and the invasive nature of the surgery. With a gastric byppass, the surgeon needs to divide the stomach into two parts.  The part closer to the esophagus is attached directly to the second part of the small intestine (the jejunum).  The lower half of the stomach is reconnected to the intestine at a level further down stream and closer to the colon.  This second connection allows acids and enzymes normally secreted by the stomach and pancreas to enter the small intestine and assist in digestion.

The bypass promotes weight loss by two separate mechanisms. Just like the gastric banding, patients cannot fit large amounts of food in this pouch.  This limits portion sizes  and promotes                                                                                                                                                                                                   weight loss.  In addition, the gastric bypass procedure interferes with normal absorption of calories and nutrients from the first part of the small intestine.  The long-term side effects of gastric bypass include malabsorption and deficiency in certain fat-soluble vitamins including vitamin A and vitamin D.  Generally, the physician following the patient after the surgery needs to check the vitamin A level, the vitamin D level, and the beta-carotene levels to make sure these levels do not fall below acceptable limits.  In addition, the gastric bypass can be associated with a "dumping syndrome", in which food goes directly from the stomach into the small intestine without proper digestion.  This can cause diarrhea, flatulence, dizziness, passing out, and low blood sugars.

There are short-term risks associated with gastric bypasses as well.  Occasionally the stiches between the two parts of the stomach and the intestine  leak into the inside of the abdomen, causing severe inflammation   Physicians refer to this problem as peritonitis.  It requires bowel rest, intravenous hydration, and antibiotics.

The gastric bypass procedure has been associated with other complications as well including infections of the wounds from the surgery and blood clots in the legs and lungs.  The best way to reduce the incidence of these complications is by using a "high-volume center."  The more gastric bypass surgeries and other weight loss surgeries done by particular surgeon and a particular institution, the lower the incidence of complications and problems.