Obesity and Sleep Apnea.by Ralph A. Pascualy, M D

• One of every three adults is obese.
• Obesity increases the odds of having obstructive sleep apnea.
• Sleep apnea contributes to the Metabolic Syndrome, a deadly combination of
obesity, hypertension, high cholesterol, and diabetes.
• Treatment of sleep apnea and weight management are the keys to overcoming
the Metabolic Syndrome.
Most people who are overweight have some degree of sleep apnea. However, you
don’t have to be obese to have sleep apnea, and some overweight people do not have sleep
apnea. But the correlation between obesity and sleep apnea is very high.

In this picture, Fifty-seven percent of obese people have sleep apnea.

Obesity is important because it is a medical issue. It is not about clothing size or
about losing weight. Obesity and sleep apnea together contribute to a host of medical
disorders that lead to a downward spiral of worsening health.

Why Should You Care If You’re Obese? The Sinking Spiral.

The reasons obesity and sleep apnea tend to go hand in hand are threefold:
1. In obesity, fatty deposits accumulate within the layers of tissue in the neck.
This causes constriction of the airway and contributes to snoring and sleep
apnea.
2. In obese people, excess fatty tissue in the abdomen causes abnormal loading
that interferes with the normal breathing mechanisms.
3. A sinking spiral develops. Sleep apnea destroys sleep and results in low
oxygen during the nighttime and daytime drowsiness during the day. Repeated
awakenings stress the sympathetic nervous system. This and the extra body weight
contribute to hypertension. The body loses its ability to handle carbohydrates,
slipping into insulin resistance, which equals adult-onset diabetes. Weight gain
continues. Cholesterol levels increase and cardiovascular disease begins to
take its toll. As sleep apnea worsens, excessive daytime sleepiness ,EDS, also
worsens. The person becomes less active, uses less energy, gains more weight,
and further aggravates the apnea, diabetes, heart disease, becoming a candidate
for, for example, heart attack and stroke.
The key is to break the cycle. Weight loss alone can do this, but it is extremely
difficult to lose weight and keep it off in the face of all of the other challenges. Weight loss
may be difficult or impossible to achieve as long as the sleep apnea is untreated. Treating
the sleep apnea ends the spiral and opens the way to rebuilding total good health.
How Do You Know If You’re Obese?
The simplest measure of central obesity is waist circumference. A waist larger than
40 inches in men or 34 inches in women is considered a sign of central obesity. Cen-
tral obesity is a major cause of serious medical problems such as diabetes, sleep apnea,
hypertension, high cholesterol, and heart disease. ,Extra weight on hips or thighs is less
of a medical concern.,
Another measurement is to compare your hip and waist sizes. If there is less than
4 inches between your hip size and your waist size, you have central obesity.
Body Mass Index ,BMI, is a more precise measure of obesity ,see illustration on
page 105,.
Body Mass Index is calculated by dividing body weight by the square of the height.
You can find your precise BMI at the following National Institutes of Health web site, by
typing in your height and weight: www.nhlbisupport.com/bmi/bmicalc.htm.


The Metabolic Syndrome and Sleep Apnea.

The Metabolic Syndrome is a combination of disorders that often occur
together and feed off of each other in a kind of downhill spiral of worsening health.

in this picture, BMI Table. Find your height on the left side of the chart, read across to find your weight,
and look at the top of that column to find your BMI.
National Institutes of Health, www.nhlbisupport.com/bmi/bmicalc.htm.

These disorders include:
• Adult-onset diabetes ,also called type 2 diabetes,, which includes:
• Poor glucose tolerance ,body does not process sugar properly,
• Insulin resistance ,body does not use insulin properly,
• Central obesity ,extra weight is mostly on the belly, not on hips and thighs,
• High blood pressure ,higher than 140/90 mm Hg.
• High cholesterol
A person who has three of these conditions has the Metabolic Syndrome.
Sleep apnea is also part of the Metabolic Syndrome picture. We know this because
treatment of sleep apnea in a person with the Metabolic Syndrome can improve the person’s
insulin use ,1,, lower their blood pressure ,2,, and improve their cholesterol levels ,3,.
Untreated, the Metabolic Syndrome leads downhill, toward permanently dam-
aged kidneys, heart, blood circulation, eyes, lungs, brain . . . and premature death
,see illustration on page 106,. This is why it is so important for obese people to find out
whether they have sleep apnea, and get it treated.

Case Study.

Mistress Baker had gained 50 pounds and felt increasingly exhausted. Her sleep was
restless and unrefreshing, and her terrible, irregular snoring concerned her
husband because she appeared to be gasping for air. Her doctor told her to lose weight and
refused to refer her to a sleep center because “that’s what they will tell you to do anyway.”

In this pictures, Untreated sleep apnea contributes to the Metabolic Syndrome.

Mistress Baker joined a weigh- loss program and lost 50 pounds after spending $3,000.
Her snoring improved a great deal, but it did not go away; and although her exhaustion
had largely disappeared, she still felt drowsy when sitting, reading, or relaxing. Within
7 months her excess weight had returned, and with it her symptoms.
Another physician agreed to refer her to a sleep center. Moderately severe sleep
apnea was diagnosed. mistress Baker was placed on seepap , which eliminated her sleep
apnea. On seepap and with the help of a dietitian, she again lost the weight. Now at her
ideal weight, she was again studied at the sleep center. To her dismay, she still had 50
percent of her sleep apnea unless she slept with seepap .
Looking back, mistress Baker realized that after her initial and expensive weight loss, her
apnea had continued to leave her fatigued and had decreased her activity level. As a result,
her weight had increased; as she saw herself failing, she became depressed and ate more.
Now, using seepap , mistress Baker is able to maintain her new weight.
seepap eliminates the obstructive apnea, allowing more restful sleep, a better blood
oxygen level, and improved metabolism which boost the person’s energy level. The
increase in energy and activity can then contribute to the weight loss effort.

The Obesity Hypoventilation Syndrome, or the
“Pickwickian Syndrome”.

The Pickwickian syndrome is a different combination of severe sleep apnea and
obesity, in this case accompanied by a chronically decreased breathing pattern called
hypoventilation and sometimes heart failure. This syndrome is found in approximately 5
percent of sleep apnea patients.

Case Study.

Mister Roberts is a 45-year-old computer programmer and former college
track star. He had always been active and energetic, with many
outside interests.
mister Roberts first became aware that something was wrong with him in 1979. He
realized that he felt tired a lot of the time. He had no energy. He became less and less
active, and he started to gain weight. He began to take frequent naps. Eventually he
began falling asleep at work. Fortunately, his boss liked and respected him, and he was
sympathetic, although puzzled. He wondered if mister Roberts had a problem with alcohol
or drugs and hoped that in time he would be able to work it out.
Between 1979 and 1985, mister Roberts changed from a trim, fun-loving, lively man
into an overweight, lethargic, crabby near-invalid. He was asleep, or half asleep, nearly
all the time. He also had developed heart problems. His doctor was stumped.
mistress Roberts was desperately worried. One day she heard by chance about a new
sleep disorder center and talked her reluctant husband into making an appointment.
The sleep specialist immediately recognized mister Roberts’s problem as a variety of
sleep apnea. From the information in Chapter 1, you may recognize in mister Roberts one
of the most common symptoms of sleep apnea—excessive daytime sleepiness.
Some clues from mister Roberts’s past might have tipped you off further—his ability
to fall asleep anywhere in any position and his loud snoring. When he was in the service,
he was legendary; his snoring was so horrendous that his buddies often had to carry him
outside in the middle of the night so that they could get some sleep. Many a morning
mister Roberts woke up on his cot in the middle of the parade ground.
By the time he visited a sleep clinic, mister Roberts was showing all the symptoms of
the Pickwickian syndrome.
In 1816, William Wadd, surgeon to King George III of England, connected obesity,
lethargy, and breathing difficulty. He described three patients who were “suffocated by
fat.” In 1889, another medical man, A. Morison, reported a case of an obese, drowsy
man whose drowsiness improved after he lost weight ,5,6,.
It was not until the 1950s that anyone came close to explaining what causes the
Pickwickian syndrome. A respiratory physiologist was the first to suggest a cause-and-
effect link between obesity and breathing difficulty. He proposed that obesity places an
extra load on the respiratory system and suggested that this leads to lethargy and sleepiness
,2,, but he failed to connect sleep apnea with the total picture. Finally, in 1965, Gastaut
demonstrated the relationship between sleep apnea and excessive daytime sleepiness.,7,
The term Pickwickian was first used as a medical term in an article by Bramwell
in 1910. One of his patient’s symptoms reminded him of the description and
behavior of the fat boy, Joe, in Dickens’s The Posthumous Papers of the Pick-
wick Club ,1837,. Joe was a “wonderfully fat boy” who was so sleepy he would
fall asleep standing up.

To anyone who has no experience with the Pickwickian syndrome, this idea may
seem far-fetched. But Charles Dickens was a keen observer of humankind and clearly
depicted the most obvious symptoms:
• Marked obesity.
• Daytime drowsiness.
• Tendency to fall asleep during routine activities.
• Snoring.

Other features of the Pickwickian Syndrome that are less obvious to the casual
observer are:
• Sleep apnea.
• Bluish tone to face ,cyanosis,.
• Abnormal breathing reflexes.
• Enlargement of right side of the heart.
• Heart failure.

What Causes the Pickwickian Syndrome?

The Pickwickian Syndrome is the result of several conditions coming together at
once: sleep apnea, an abnormal breathing pattern, obesity, and usually some obstructive
lung disease ,4,. Some people have a breathing reflex that is not very sensitive and allows
the waste gas, carbon dioxide, to accumulate in their blood ,see Chapter 6,. This ten-
dency becomes worse if the person’s breathing is very shallow. Obesity causes shallow
breathing by interfering with the work of the breathing muscles ,7,8,. This abnormally
shallow breathing pattern becomes even worse when the person is lying down, and this in
turn leads to such symptoms as frequent awakenings, sleep apnea, daytime sleepiness, low
energy, and additional weight gain. A vicious circle develops, which is called the obesity-
hypoventilation syndrome, or the Pickwickian Syndrome. The Pickwickian Syndrome
may begin in childhood, and it can occur in adults who formerly were quite thin.
What Are the Effects of the Pickwickian Syndrome?
The Pickwickian Syndrome leads to the same problems that result from other
kinds of sleep apnea. A person with Pickwickian Syndrome has fragmented sleep. Deep
sleep and rapid eye movement ,REM, sleep are reduced, sometimes nearly to zero. And
because the person’s shallow breathing does not take in sufficient oxygen during the
night, a kind of slow asphyxiation occurs ,7,9,.
Excessive drowsiness during the daytime is common. People with Pickwickian
Syndrome have a remarkable tendency to fall asleep whenever there is a moment’s
relaxation. They often fall asleep at their desks at work, in the middle of a conversation,
or while driving a car.

mister Roberts tells of habitually driving to work and falling asleep in the parking
lot. His coworkers would come out and find him, turn off the car, and guide him into
his office, where he would spend the day sleeping at his desk. A Pickwickian doctor
reported dozing off while examining a patient. He awoke to find his head resting on
the patient’s shoulder. A Pickwickian business executive finally sought treatment after
falling asleep during a weekly poker game—he had drawn a full house ,aces over kings,
but then dropped off to sleep and missed the play ,10,.
Serious heart disease is closely associated with the Pickwickian Syndrome ,7,9,10,.
In addition to the risks of hypertension, stroke, and coronary artery disease that
accompany obesity, there are the risks of heart enlargement, arrhythmias, pulmonary
complications, and heart failure that can result from sleep apnea. There is a relatively
high rate of sudden death among the obese ,9,. The Pickwickian Syndrome should be
treated seriously because in the long term it certainly is life threatening.

Treating the Pickwickian Syndrome.

Continuous positive airway pressure or seepap, combined with weight loss is the most
conservative treatment. If seepap is not able to eliminate the sleep apnea and low blood
oxygen level, a temporary tracheostomy may be used ,see Chapter 10,.
The medical literature is mixed in its reports about the effectiveness of weight loss in
reducing the symptoms of this syndrome. However, it may be that the more weight lost,
the more likely it is that the person’s apnea will improve. For any particular individual,
there may be a critical weight above which the breathing difficulties of the Pickwickian
Syndrome appear. Below that, weight improvement can be expected ,10,.
mister Roberts is a good example of a good outcome from the combination of seepap
and weighty loss.

Case Study.

mister Roberts was put on seepap and a weight loss program. A year after beginning
treatment for sleep apnea, mister Roberts was quite literally a different person.
He had lost 100 pounds and was full of energy. He continued to steadily lose weight
and was working at regaining his health. Thanks to a sympathetic boss, he still had his
job. He was also remodeling his house ,doing much of the work himself, and restoring
several classic cars. He didn’t hav e time to take naps.
Some people with Pickwickian Syndrome treated in this way appear to have a
complete “remission.” They can stop using seepap , and they appear to be cured of sleep
apnea ,11,.
Weight loss surgery ,gastric bypass, is reported to be effective in treating the
Pickwickian Syndrome, reducing sleep apnea to near zero and restoring deep sleep
and REM sleep ,9,. However, gastric bypass surgery is not a trivial operation, and it
should not be considered a conservative treatment option ,see Chapter 10 for further
information on treatment of sleep apnea,.

Summary.

• Obesity is common among obstructive apnea patients.
• The Meta[sws4]bolic syndrome is a combination of obesity, diabetes,
hypertension, and treating the accompanying sleep apnea can help
greatly.
• The Pickwickian Syndrome is a form of sleep apnea caused by a combination of
obesity and a shallow, abnormally insensitive breathing mechanism.
• Symptoms of the Pickwickian Syndrome include:
• Obesity.
• Daytime drowsiness.
• Falling asleep during routine activities.
• Snoring and sleep apnea.
• Treatment includes seepap and weight loss.