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Sleep Disturbance and Obesity
Changes Following Surgically Induced Weight Loss
John B. Dixon, MBBS, FRACGP;
Linda M. Schachter, MBBS, FRACP;
Paul E. O'Brien, MD, FRACS
Arch Intern Med. 2001;161:102-106.
ABSTRACT
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Background Obesity causes sleep disturbance and is the most significant risk factor
for sleep apnea. Only surgical methods provide substantial sustained weight
loss for most severely obese subjects.
Objective To study sleep disturbance in patients undergoing laparoscopic adjustable
gastric banding with a commercially available product (Lap-Band).
Methods In this study, 313 consecutive patients with severe obesity (body mass
index [calculated as weight in kilograms divided by the square of height in
meters] >35) completed a preoperative sleep questionnaire and clinical assessment.
One hundred twenty-three patients completed the same assessment 12 months
after surgery. The characteristics of sleep disturbance and changes in responses
to weight loss have been assessed.
Results There was a high prevalence of significantly disturbed sleep in men
(59%) and women (45%), with women less likely to have had their sleep disturbance
investigated. Observed sleep apnea was more common in men, but daytime sleepiness
was not affected by sex. Waist circumference was the best clinical measure
predicting observed sleep apnea (R = 0.36; P<.001). The group lost an average of 48% (SD, 16%)
of excess weight by 12 months. There was a significant improvement in the
responses to all questions at follow-up, with habitual snoring reduced to
14% (preoperative value, 82%), observed sleep apnea to 2% (preoperative value,
33%), abnormal daytime sleepiness to 4% (preoperative value, 39%), and poor
sleep quality to 2% (preoperative value, 39%) (P<.001
for all).
Conclusions Obesity-related sleep disorders improve markedly with weight loss. Sustainable
weight loss should be a primary aim in the management of severely obese patients
with significant sleep disturbance, including sleep apnea. Low-risk laparoscopic
obesity surgery should be considered for selected patients with this important
comorbidity.
INTRODUCTION
SLEEP-DISORDERED breathing (SDB), particularly in the form of obstructive
sleep apnea (OSA), occurs in approximately 4% of men and 2% of women in the
general population.1 Obesity, especially upper
body obesity, is considered a major risk factor for OSA, and clinical assessments
and sleep studies1 indicate a prevalence of
OSA in very severe obesity (ie, body mass index [BMI] [calculated as weight
in kilograms divided by the square of height in meters] >40) to be 42% to
48% in men and 8% to 38% in women.
Sleep-disordered breathing is recognized as a major health problem and,
with the increasing prevalence of severe obesity, it is likely that the prevalence
of SDB is also likely to increase. Obstructive sleep apnea, with its associated
increase in daytime sleepiness, has been linked to marked psychosocial morbidity,2 cognitive dysfunction,3
and a greater likelihood of involvement in motor vehicle crashes.4 In addition, obese patients without SDB have a significant
increase in sleep disturbance and daytime sleepiness compared with nonobese
control subjects, possibly related to metabolic or circadian disturbance.5, 6 Obesity is also associated with other
conditions that cause sleep disruption, such as asthma,7
gastroesophageal reflux,8 osteoarthritis,9 and nocturia.10
Many studies11, 12, 13, 14
have shown that there are major improvements in sleep disturbance and SDB
in obese subjects associated with weight loss. These improvements are consistent
for medical, dietary, and surgical methods of weight loss.11, 12, 13, 14
Sleep disturbance understandably recurs with weight gain.
This study assesses the prevalence of sleep disturbance and daytime
sleepiness in a group of morbidly obese subjects presenting for weight loss
surgery and assesses changes that have occurred with weight loss.
PATIENTS AND METHODS
Patients with a BMI greater than 35; with significant medical, physical,
or psychosocial disabilities; and who have attempted weight reduction by other
means for at least 5 years were considered for surgery using an adjustable
gastric banding system (Lap-Band; BioEnterics Corporation, Carpinteria, Calif).
The form of gastric restrictive surgery used involves the laparoscopic
placement of an adjustable silicone band 2 to 3 cm below the gastroesophageal
junction. Food within the small pouch of the stomach and above the band produces
an early sense of satiety, thereby weight loss. The band has a balloon incorporated
in its inner wall, and this is attached via tubing to a subcutaneous reservoir.
Adjustments to gastric restriction are made by adding or removing isotonic
sodium chloride solution from the reservoir.
Preoperative assessment included a medical assessment, including history
of any diagnosed sleep disorder, previous sleep studies, and use of nasal
continuous positive airway pressure, and a questionnaire on sleep symptoms
and quality of sleep. The questionnaire inquired about habitual snoring, observed
sleep apnea, and nocturnal choking. Patients also indicated subjective sleep
quality and the presence of morning headaches or tiredness on waking. Responses
to the written questionnaire were reassessed at clinical interview, where
responses were clarified and the nature of sleep disturbance explored. Clarification
of who observed habitual snoring, sleep apnea, and nocturnal choking was obtained
from all patients, and input from the sleep partner and household members
was encouraged. The Epworth Sleepiness Scale (ESS), a validated instrument
that measures daytime sleepiness, was also completed.15, 16
The community norm mean ± SD score is 4.0 ± 3.0, with excessive daytime sleepiness defined as an ESS score of
greater than 10. Patients were considered to have significant sleep disturbance
if they reported habitual snoring and poor sleep quality, habitual snoring
and an ESS score of greater than 10, or habitual snoring and observed sleep
apnea. Anthropometric measurements, including weight, height, neck circumference
(measured at the level of the cricothyroid cartilage), and waist and hip measurements,
were taken preoperatively and at yearly follow-up. Correlations between preoperative
sleep disturbance and preoperative clinical and biochemical features were
assessed.
Preoperative excess weight is calculated as the weight (in kilograms)
at the time of surgery less the ideal weight (in kilograms), as measured by
the Metropolitan Life Tables (1985). Percentage of excess weight loss is calculated
by dividing the weight loss by the excess weight preoperatively, multiplied
by 100.
The appropriate hospital ethics review board approved the questionnaires
used. All patients gave preoperative written informed consent to the procedure
and follow-up requirements.
Mean ESS scores were obtained, and a paired 2-sided t test was used to test the significance of differences. A  2 test was used to test the significance of differences between categorical
variables and responses to the questionnaire. Data are given as mean ±
SD. Bivariate, binary logistic, and stepwise linear regression analysis, using
a statistical software package,17 was used
to assess for clinical correlation with significant sleep disturbance, significant
sleep apnea, and ESS score. P<.05 was considered
significant.
RESULTS
The preoperative characteristics of the 313 consecutive study patients
are shown in Table 1.
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Table 1. Patient Demographic Characteristics Before Surgery*
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PREOPERATIVE SLEEP DATA
Observed Sleep Apnea
The reported incidence of habitual snoring (Table 2) was high in men and women, with observed sleep apnea in
men and women being more than 10 times that reported in the adult community.
Men reported a higher incidence of observed sleep apnea, habitual snoring,
and nocturnal choking, but there was no difference in reported daytime tiredness,
daytime sleepiness, and poor sleep quality between men and women (Table 2). The mean ESS scores in men and
women were 9.0 (SD, 5.8) and 8.4 (SD, 4.8), respectively, both significantly
higher than the community normal score of 4 (P<.001).
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Table 2. Prevalence of Self-Reported Sleep Disturbance in Patients
Presenting for Surgery*
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Ninety-five patients (30%) reported habitual snoring and excessive daytime
sleepiness (ESS score of >10). In this group, 52 (55%) reported observed sleep
apnea; 48 (51%), poor sleep quality; and 62 (65%), morning headaches. Only
22 (23%) of these patients had their sleep disturbance investigated before
referral for obesity surgery, and significantly more of the men than women
(50% [11/22] vs 15% [11/71]; P<.01) underwent
polysomnography.
Male sex (P<.001), high BMI (P<.001), and high waist-hip ratio (P =
.001) are significant independent predictors of self-reported sleep apnea.
However, the best predictor was waist circumference (R
= 0.36; P<.001), and no other factors, including
sex, were predictive after correcting for this. Sleep apnea was reported by
42% (45/108) of those with a waist circumference of 126 cm (median) or above
and in 10% (10/102) of those with a waist circumference below this value. Figure 1 shows a linear relation of reported
sleep apnea for each quartile of waist circumference. Several biochemical
measurements were also predictive, including a high plasma insulin level (R = 0.15; P = .03) and a low high-density
lipoprotein cholesterol level (R = 0.17; P = .01), but did not explain any significant variance when controlled
for the waist circumference.
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Figure 1. The prevalence of reported OSA
vs quartiles of waist circumference. There were only 3 men in Q2 (1 reported
OSA) and none in Q1. The correlation coefficient for observed OSA vs waist
circumference is R= 0.36 (P<.001). OSA indicates
obstructive sleep apnea; Q1, quartile 1; Q2, quartile 2; Q3, quartile 3; and
Q4, quartile 4.
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Daytime Sleepiness
Daytime sleepiness, as measured by an increased ESS score, was significantly
correlated with nocturnal choking (R = 0.34; P<.001), observed sleep apnea (R
= 0.33; P<.001), habitual snoring (R = 0.27; P<.001), poor sleep quality (R = 0.27; P<.001), BMI (R = 0.20; P<.001), and age
(R = 0.15; P<.01). All
had significant independent effects on the variance of the ESS score. These
significant independent factors were found to account for a little more than
20% of the variance in ESS score (R2 =
0.21). Sex, anthropometric measurements (including waist circumference and
waist-hip ratio), and biochemical markers of the metabolic syndrome (plasma
glucose level, plasma insulin level, and lipid profile) did not show predictive
value. These findings indicate a clear relation between daytime sleepiness
and obesity in general but not to central obesity.
Epworth Sleepiness Scale score (R = 0.32; P<.001) and waist circumference (R = 0.33; P<.001) are independent significant
predictors of reported OSA.
Significant Sleep Disturbance
By combining the groups with symptoms of habitual snoring and any 1
or more of observed sleep apnea, daytime sleepiness (ESS score of >10), and
poor sleep quality, a group with significant sleep disturbance was defined
and included 59% (36/61) of the male and 45% (113/252) of the female patients
overall. This definition provides us with an indication for further evaluation
by sleep study. As was found for OSA, there were many predictors of significant
sleep disturbance, including male sex, high BMI, and the anthropometric measures.
The best single predictor was waist circumference (R
= 0.37; P<.001) and, when corrected for this,
no other measurement added significantly to the variance of significant sleep
disturbance. Sixty-two percent (67/108) of patients with a waist circumference
of 126 cm or greater (median) reported significant sleep disturbance, with
only 28% (29/102) of patients with a smaller waist circumference reporting
such a disturbance.
SURGICAL RESULTS
Laparoscopic placement of the adjustable gastric band was achieved in
300 patients. In only 1 was conversion to an open approach necessary, due
to the presence of a massive liver preventing adequate access. The remaining
12 patients underwent elective open placement of the band, as all were undergoing
revision after previous gastric restrictive surgery (gastroplasty in 10 and
nonadjustable banding in 2). The median hospital stay for laparoscopic placement
is 2 days.
Weight loss is progressive during the first 2 to 3 years, with a plateau
out to 6 years. The results of all 740 persons treated with this method by
one of us (P.E.O.) are shown in Figure 2.
Early complications in our study group of 313 were 4 wound infections (1 [0.3%]
of 300 after laparoscopic surgery and 3 [23%] of 13 after open surgery). There
was no clinical evidence of deep venous thrombosis or pulmonary embolus in
this series. There were no patients requiring postoperative respiratory support.
The most significant late postoperative problem is prolapse of the stomach
through the band. This occurred in 29 (9%) of these patients, and presents
with symptoms of gastroesophageal reflux and band stomal obstruction; opening
the band stoma relieves symptoms, and laparoscopic surgical revision is required.
The incidence of prolapse is decreasing, probably as a result of better fixation
of the band to the stomach. There were 4 (1%) erosions of the band into the
stomach and 4 (1%) cases of tubing leaks, requiring surgical correction.
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Figure 2. Body mass index (BMI) (calculated
as weight in kilograms divided by the square of height in meters) after surgery
with an adjustable gastric banding system (Lap-Band) (N = 740, consecutive
series).
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SLEEP AFTER WEIGHT LOSS
One-year follow-up data are available for 123 of the 313 patients, and
these patients have completed a follow-up clinical review and questionnaire.
This group had a mean initial weight of 129.7 ± 24.0 kg and an initial
BMI of 46.0 ± 7.5. At 1-year follow-up, the mean weight was 98.5 ±
18.0 kg and the BMI was 35.3 ± 5.8. This represents a mean weight loss
of 31.2 ± 13.0 kg and a percentage excess weight loss of 48% ±
16% at 12 months. The preoperative and follow-up data for sleep disturbance
are shown in Table 3. Highly significant
improvement is seen for all measures of sleep disturbance. Table 4 shows the change in the ESS score and indicates a marked
improvement in daytime sleepiness for men and women. The mean ESS score at
12-month follow-up of 4.0 ± 3.4 is identical with the community norm.
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Table 3. Paired Responses to Sleep Questionnaire of 123 Consecutive
Patients Returning for Review 12 Months After Surgery*
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Table 4. Epworth Sleepiness Scale (ESS) Scores Preoperatively and at
the 12-Month Follow-up*
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Of the 123 patients followed up, 10 were using nasal continuous positive
airway pressure for treatment of OSA preoperatively. At follow-up, 7 were
no longer using this therapy and symptoms had resolved. The remaining 3 reported
sleep improvement with weight loss but still used continuous positive airway
pressure therapy. One is awaiting upper airway surgery. This small group had
an ESS score of of 13.1 preoperatively and 2.75 at follow-up (P<.001).
COMMENT
This study confirms that sleep disturbance is a common comorbidity of
obesity in men and women. The measured prevalence of habitual snoring, observed
sleep apnea, and nocturnal choking of 52% of men and 26% of women is likely
to be an underestimate, as many patients have not been observed during sleep.
In addition, there may be differing reporting characteristics of men and women
partners, with men perhaps less likely to report observed sleep apnea in a
female partner.
Men on presentation to us are more likely to have had documentation
of sleep disturbance by an overnight sleep study. Only 15% of women presenting
with morbid obesity, habitual snoring, and excessive daytime sleepiness had
been investigated, compared with 46% of men. This may indicate a belief that
SDB predominantly affects men and, therefore, symptoms of sleep disturbance
may not be elicited or recognized in women. Janson et al,8
studying sleep disturbance in young adults, found that young men were more
likely to report habitual snoring and women more often reported daytime sleepiness.
Our data indicate that obese women with sleep disturbance who present for
weight loss surgery are underinvestigated.
There is clearly significant correlation between weight, BMI, and waist,
hip, and neck measurements. Measurements that correlated best with obesity-related
sleep disturbance were BMI and waist measurements, with neck measurements
of less predictive value. Deegan and McNicholas18
found that waist measurement was a better predictor of the apnea-hypopnea
index than was neck measurement in men, with the opposite being true in women.
We found waist circumference a better predictor of reported sleep disturbance
than neck circumference in men and women. For a waist measurement of greater
than 126 cm in men or women, there is a high prevalence of sleep disturbance
and this simple test is easily performed in any physician's office.
Obstructive sleep apnea in morbidly obese subjects has clear associations
with male sex, increased waist circumference, and high waist-hip ratio—the
android weight distribution. In contrast to this, we found that neither sex
nor weight distribution nor the biochemical markers of the metabolic syndrome
affect daytime sleepiness, after adjusting for BMI and age. It would appear
that daytime sleepiness is a common feature of morbid obesity and, unlike
OSA, is not related to weight distribution. This finding concurs with that
of Vgontzas et al,6 who found that daytime
sleepiness in obese patients is not always associated with SDB and may be
related to other factors such as metabolic or circadian abnormalities. Daytime
sleepiness can be a major disability with obvious effects on patients' work,
leisure, and safety. This study has found major improvement in daytime sleepiness
associated with weight loss in men and women, with complete resolution of
this important comorbidity in most of our patients.
Weight loss using the adjustable gastric banding system dramatically
improves and often abolishes symptoms of SDB in morbidly obese patients. Symptoms
directly due to upper airway obstruction, habitual snoring, observed OSA,
and nocturnal choking are all improved. Asthma and gastroesophageal reflux
are also improved after placement of the adjustable gastric band and subsequent
weight loss.19, 20 In addition
to improving SDB, nasal continuous positive airway pressure also improves
asthma and gastroesophageal reflux, both common comorbidities of obesity and
often aggravated by OSA.7, 21 There
are likely to be multiple mechanisms for the improvement in upper and lower
airway obstruction with weight loss.
While the exact nature and spectrum of obesity-related sleep disorder
might be debated, it is clear that patient-reported sleep disturbance and
daytime sleepiness improve substantially with weight loss. There are many
studies11, 12, 13, 14
showing that weight loss using dietary and surgical methods improves sleep
disorders in obese subjects. The primary aim of management of obesity-related
sleep disorder, including SDB in obese patients, should be sustainable weight
loss. Surgery is the only available method to achieve this effect in severely
obese subjects. Recent advances in weight loss surgery, particularly the use
of the laparoscopic or minimally invasive approach and the ability to adjust
the degree of gastric restriction, provide a safe, effective, and acceptable
way to treat selected cases of obesity-related sleep disorder.22, 23
Obesity surgery should be considered as one of the management options of SDB
and excessive daytime sleepiness, both significant public health issues.
AUTHOR INFORMATION
Accepted for publication August 3, 2000.
This study was supported by BioEnterics Corporation, Carpinteria, Calif.
The Department of Surgery at Monash University, Melbourne, Australia,
is conducting clinical studies on "The clinical evaluation of the Lap-Band:
an adjustable gastric banding system used in morbidly obese patients." These
studies are part of an international multicenter retrospective and prospective
evaluation of the Lap-Band.
From the Department of Surgery, Monash University–Alfred Hospital
(Drs Dixon and O'Brien), and the Department of Respiratory Medicine, Austin
and Repatriation Medical Center (Dr Schachter), Melbourne, Australia.
Corresponding author: John B. Dixon, MBBS, FRACGP, Department of
Surgery, Monash University–Alfred Hospital, Melbourne 3181, Victoria,
Australia (e-mail: john.dixon{at}med.monash.edu.au).
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