Dietary and Lifestyle Considerations
Weight loss has been demonstrated to decrease the severity of obstructive sleep apnea, and has been called “the most important major modifiable risk factor associated with obstructive sleep apnea.” A study in 690 adults found that a 10% weight loss was predictive of a 26% drop in apnea-hypopnea index, while a 10% weight gain predicted a 32% increase in apnea-hypopnea index (Peppard 2000; Araghi 2013; Mitchell 2014; Bonsignore 2013). Also, it may be easier for people with obstructive sleep apnea to lose weight when dietary weight loss measures are accompanied by CPAP (Bonsignore 2013).
A six-month randomized study in 40 obese subjects with moderate-to-severe obstructive sleep apnea found that a low-calorie Mediterranean diet, combined with increased physical activity, was more effective for both weight loss and reduction in severity of sleep apnea than a low-calorie diet with a smaller increase in physical activity (Papandreou 2012). The Mediterranean diet emphasizes whole grains, legumes, fruits, vegetables, nuts, and fish (OPT 2015). Mediterranean eating patterns have also been shown to benefit people with diabetes, as well as help reduce risk of diabetes, high blood pressure, cardiovascular disease, and many other conditions (Salas-Salvado 2014; Esposito 2014; Domenech 2014; Toledo 2013; Estruch 2013; Ajala 2013; Khatri 2014; Filomeno 2014; Lourida 2013).
A thorough discussion of weight loss strategies is included in the Weight Loss protocol.
Exercise, even without weight loss, appears to reduce severity and symptoms of obstructive sleep apnea (Iftikhar 2014). This was demonstrated in a study in 10 adult men and one adult woman who participated in a supervised exercise program of two hours twice weekly for six months. At enrollment, the participants already completed three months of CPAP, but the exercise program reduced a measure of respiratory disturbance (Giebelhaus 2000). Another study in subjects with obstructive sleep apnea found that a supervised exercise program involving 150 minutes per week of moderate intensity aerobic exercise plus strength training led to reductions in sleep apnea severity, depressive symptoms, and fatigue, and also improved daytime functioning (Kline 2012).
Acupuncture may benefit individuals with obstructive sleep apnea, reducing the number of apneic and hypopneic events and improving oxygen levels (Bo 2008; Freire 2007; Freire 2010; Xu 2009). In one randomized, placebo-controlled study, 36 subjects with sleep apnea were divided into three treatment groups: acupuncture, sham acupuncture, and no treatment. After 10 weeks, subjects in the acupuncture group showed an improvement in the apnea-hypopnea index and a reduction in the number of respiratory events compared with the sham-acupuncture group. The no-treatment group exhibited an increase in the number of respiratory events during the study (Freire 2007). More well-designed studies are needed to firmly establish the role of acupuncture in the treatment of sleep apnea.
Preliminary studies also suggest that auricular therapies, in which acupuncture points on the external ear are stimulated, may be helpful for people with sleep apnea, but more research is needed in this area (Wang 2009; Wang 2003; Wu 2012).
Smokers have a higher risk of developing obstructive sleep apnea, and at a younger age, than non-smokers. Also, people who smoke more cigarettes for a longer time are at greater risk for more severe sleep apnea. It is thought that smoking-related airway inflammation and loss of pharyngeal muscle tone due to nicotine withdrawal during sleep may contribute to increased risk among smokers (Lin 2012; Hizli 2013; Quan 2014; Boussoffara 2013).
Alcohol and Sedative Avoidance
Alcohol is a central nervous system depressant that can contribute to obstructive sleep apnea (Scanlan 2000; Juntunen 1984). Like other sedatives, it can decrease respiratory center activity and weaken the drive to inhale (Motamedi 2009; St John 1986; Stein 2005). It may also cause weakness in the muscular structures of the pharynx, increasing the tendency for airway collapse, causing snoring and obstructive apnea. People with sleep apnea have also been found to be more susceptible to the effects of alcohol and may have a higher risk of alcohol-related automobile accidents compared to people without sleep apnea (Vakulin 2009).
For some people, sleep position has a marked impact on severity of apneic and hypopneic breathing during sleep. Lying on one’s back (supine position) has been linked to greater severity of sleep apnea, but studies show that certain people are more likely to benefit from a position change. Individuals with positional sleep apnea tend to be thinner and younger, have a smaller neck circumference, and have milder sleep apnea. In some cases, adjusting sleep position is all that is required to satisfactorily relieve obstructive sleep apnea (Menon 2013).
Strategies for maintaining a non-supine position during sleep include using barriers such as firm pillows or other props like tennis balls sewn into the back of a shirt to prevent rolling onto the back (Skinner 2008). However, many patients find these methods uncomfortable and stop using them (Oksenberg 2006; Bignold 2009; Park 2011).
Allergy and Asthma Management
People with allergies and asthma have a higher risk of obstructive sleep apnea. Airway resistance and nasal congestion may contribute to this relationship (Braido 2014; Koinis-Mitchell 2012). One study found that treatment of obstructive sleep apnea with CPAP eliminated nighttime asthma (Salles 2013).
Low Sodium Diet
High levels of aldosterone, an adrenal hormone that regulates the concentration of sodium and potassium in the body, have been noted in people with sleep apnea and treatment-resistant hypertension (Calhoun 2004; Grossman 2014). One research group found that in people with obstructive sleep apnea who also have hypertension and hyperaldosteronism, urinary sodium level independently predicted severity of sleep apnea (Pimenta 2013). A similar study found that higher morning urinary sodium was linked to more severe obstructive sleep disordered breathing in children (Kaditis 2010). Since urinary sodium is generally a reflection of dietary sodium intake, and dietary sodium is related to obstructive sleep apnea severity in patients with resistant hypertension and hyperaldosteronism, dietary sodium restriction has been proposed as a treatment strategy for reduction of obstructive sleep apnea severity in such patients (Pimenta 2013; Grimes 2013; Cirillo 1997).