Cases in Practice: Prioritizing Weight Loss for People With Sleep Disorders and Overweight/Obesity

Co-Chairs and Presenters, Jaime Almandoz, MD, MBA, FTOS, and Safia Khan, MD, discuss obesity in this CME/MOC activity titled “Cases in Practice: Prioritizing Weight Loss for People With Sleep Disorders and Overweight/Obesity.” For the full presentation, downloadable Practice Aids, and complete CME/MOC information, and to apply for credit, please visit us at https://bit.ly/43chazP. CME/MOC credit will be available until June 20, 2025.

1. Cases in Practice
Prioritizing Weight Loss for People With
Sleep Disorders and Overweight/Obesity

Jaime Almandoz, MD, MBA, FTOS
Medical Director, Weight Associate Professor
Weliness Program Program Director, Sleep Medicine Fellowship

Fa Safia Khan, MD
Associate Professor of | Department of Family Medicine

Internal Medicine Department of Neurology

Division of Endocrinology and Metabolism Vice-Chair for American Academy of Sleep
University of Texas Southwestern [= Medicine Accreditation Committee

Medical Center _ University of Texas Southwestern

Dallas, Texas Medical Center

Dallas, Texas

Go online to access full CME/MOC information, including faculty disclosures.

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2. Our Goals for Today

Equip you with strategies to treat obesity-related sleep
disorders as part of a long-term and multifaceted approach

Enhance your confidence to initiate conversations

with patients about weight and sleep history

Inspire you to engage in team-based care using
evidence-based guidelines and emerging therapies

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3. Recognizing the Connection

Between Excess Weight and
Common Sleep Disorders

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4. Overview of Obesity-Related Sleep Disorders!

+ Sleep-disordered breathing + Central sleep apnea
— OSAis the most prevalent — May co-occur with OSA
> Obesity contributes — May be induced by CPAP
substantially to its + Insomnia
pathogenesis

+ Primary snoring
— Hypopnea

k + Restless legs
— Respiratory effort-related syndrome
sleep arousal z
+ Obesity hypoventilation syndrome

— Typically has prolonged daytime

hypercapnia \
— 90% also have OSA
1. Pennings N etal. Obes Pilars. 2022:4:100043, PeerView.com

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5. OSA Basics

: A Among Those With OSA?
In OSA, obesity contributes to + Approximately 50% of patients with OSA have obesity
the pathogenesis’ + Risk factors for OSA
+ Increased fat deposition in the tongue ” Ale Canoe merite
+ Pharyngeal airway narrowing and/or height ratio
increased abdominal obesity - Older age
Typical Anatomical
Normal Aneto Changes in OSA?

Among Those With Obesity?

+ Approximately 45% of patients with obesity have OSA
+ Obesity-related sleep disorders

- OSA

= Sleep-disordered breathing

= Primary snoring

= Insomnia

= Restless legs syndrome

1. Pennings Net a. Obesity Pitars. 2022:4:100043, 2. Lévy P et al. Not Rev Dis Primers. 2018:1:16018. 3, Pennings N ot al. Obosty Pars. 2022:4:100043, PeerView.com

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6. Pathways Linking OSA to Cardiometabolic Complications!

Sleep fragmentation
leads to increased
stress hormones
which leads to insulin

hypertension, and
other cardiometabolic
complications

‘Activation of HPA axis

Microvascular and macrovascular complications

1. Reutrakul 8, Mokhesi 8. Chest 2017:18215}1070-1086. PeerView.com

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7. Follow-up after treatment initiation
1. Kapur VK eta. J Cin Stoop Med. 2017:13(3)479-604

Algorithm for Implementation
of AASM Clinical Practice Guidelines!

Clinical Suspicion of OSA

Perform PSG by an accredited slop cantor under tho
‘supervision of a board-certiie sleep physician
tow a ping po ia appropriate an oa

Evaluate for other stoop disorders OR
perform PSG when OSA has ot yt bean ruled out
Foo a pt ig protocacncalyeberoprate and lose

sep
OR repeat nad PSG

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8. AASM Clinical Practice Recommendations for Diagnosing
Patients With Suspected OSA'

A comprehensive sleep evaluation (which includes a sleep history and physical examination
of respiratory, cardiovascular, and neurologic systems) should take place prior to diagnostic testing

Clinical Tools
+ Itis recommended that clinical tools, questionnaires, or prediction algorithms NOT be used to diagnose OSA in adults in
the absence of PSG or HSAT

Assessment for Diagnosis
+ Itis recommended that PSG or HSAT (with a technically adequate device) be used to diagnose OSA in uncomplicated adult
patients presenting with signs/symptoms that indicate an increased risk of moderate to severe OSA

Is negative, inconclusive or technically inadequate, that PSG be per

1. Kapur VK etal J Glin Stoop Med. 2017:13(3)479-504. PeerView.com

PeerV

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9. Nighttime In-Laboratory PSG Is the Gold Standard
for OSA Diagnosis

Hypopnea with 230% reduction in airflow for

AASM-Recommendations! >10 s with desaturation from baseline

+ Clinical tools, questionnaires, or predictio
algorithms should NOT be used to diagnose

OSA in adults in the absence of PSG
or HSAT

PSG or HSAT (with a technically adequate
device) should be used to diagnose OSA in
uncomplicated adult patients presenting with
signs/symptoms that indicate an increased
risk of moderate to severe OSA

$ A ui
DOIPAD—

Severity of OSA based on
AHI,* REI, or pAH?

+ Mild: 5 to 15 events/

te: >15 to 30 events
0 events/h

Potysomnagram courtesy o Safa Khan. MO.
"AH apnea-hypopnea index, ste number of apnea or hypepnea events during the sleep perio, vidad by the numberof hours of sleep. RA
1. Kapur VK eta. J Cin Stoop Med. 2017:13(3)479-604 2 Slowk JM et al. StafPoaris 2022. tips: www. ncbLnim.ih gov/DoOks/NEK 458252. PeerView.com

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10. An Overview of Recommended OSA Treatments

Continuous Positive

Airway Pressure!

+ First line for moderate
to severe OSA

+ Provides fixed
continuous air
pressure

+ Inconsistent results

+ Patient follow-up
important for machine-
related trouble and
compliance

Bi-Level Positive
Airway Pressure!

+ Used to treat obesity
hypoventilation
syndrome and OSA
associated with
restrictive lung
diseases

AA Oromandibular

Devices

+ Automatically adjusts

the pressure to meet
each person's

+ Second-line treatment
after PAP therapy

+ Devices prepared by
dentists; patients
followed up by sleep
physicians to
corroborate
improvement clinically
and on sleep study

breathing needs, which
may change
throughout the night

+ Weight loss via diet and exercise are essential for treatment of OSA and should be
supplemented with definite treatment for OSA'45
+ Until a patient begins to lose weight, most therapies have low efficacy?

1. Pat SP etal. J Cin Stoop Mod. 2019:15:335-343.2. ntps www sleeptoundaton orgicpapiapap-machlne. 3. Siowk JM et al. StatPoark. 2022.

ips ww ncbi im ih gov/booksNBK459252. 4. Bllings ME et al. Am J Respir Crt Coro Mod. 2018,198:405-408. 5. Hudgel DW et al. Am J Rasp Crit Caro Med.

2018.198:070.087.

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11. Does CPAP Use Increase or Decrease BMI/Weight?
Evidence Is Mixed

Study BMI Increase No Difference BMI Decreased
‘Among those
A A + with $5 h use/night
Chen B et al; meta-analysis' à CUS - ‘Among those with CVD

+ with dysglycemia
Drager LF et al; meta-analysis? Among those with OSA. - -

‘Among those with newly
diagnosed OSA, basal
= = metabolic rate decreased in the
absence of changes in physical
activity and total caloric intake

Tachikawa R et al; assessed
energy metabolism?

‘Among those using CPAP.

Quan SF et al; 24 hinight on 270% of nights

randomized study* gained the most vs
nonadherent CPAP users

At 3.78-y follow-up, no
aia u significant differences in weight _
Endpoints (SAVE)* change or BMI between CPAP

users and controls

4. Chan 8 et al AnnalsATS. 2021:18(10) 1717-1727. 2. Drager LF ot al Thorax 201570259264, 3. Tachikawa R ta. Am.JRospr Cat Caro Med. 2016:1946)720- =
738. 4. Quan SF at al. J Cin sloop Mod. 2013;9(10} 980-993, 5. Ou Q et al. Chest 2018; 155(4):720-729. PeerView.com

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12. The 5 S’s for Sleep Management in Clinical Practice:
A Practical Guide for Primary Care!

Download the

SURVEY
Assess comorbidities, current sleep behavior, and knowledge of sleep

Practice Aid
y LES
SUPPORT
Outline the pros and cons of behavior change
SHARED DECISION-MAKING?

Collectively set SMART goals for sleep behavior change
SMART: specific, measurable, achievable, realistic, time-bound

SOLUTIONS
Encourage patient-selected solutions

SIGNPOST
Provide access to information and/or referral pathways
1. Henson Jet al. Diabetes Caro. 2024:47:331-343. 2. Aterbum DE et al. JAMA. 2020.324:879-287 PeerView.com

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13. Targeting Weight Loss to
Improve the Management of

Obesity-Related Sleep Disorders

14. Obesity Is Increasing in the United States

Self-Reported Obesity, 20221 Obesity Trends, 1999-20182

60 -74% of the US population has
overweight or obesity
Obesitys jog 24

40 357 949 222
343 337 >
305 305 322

Percentage

o .

1990. 201 2006 2005 207 2000. 2 200 2016 2017
2000 2002 2004 2006 2008 2010 2012 2014 2016 2018
Survey Years

«re sted 30 goon US ibys aa rn ARES AA D AS San

1. hts www. e govlobesityidatalprevalence-maps hin. 2. ps www. c.govinchslproducsidatabnefsicb360.him.
3. MacEwan JP et a. Obes Sei Pret, 2024:0726,

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15. Obesity and OSA: Mechanisms of Disease’

Cardiovascular and <— visceral fat
metabolic comorbidities

Fatinfitraion
in the neck

N Abnormal upper sway _ erased leptin

neuromechanical control

un View.
1. Lévy P at a. Nat Rev Dis Primers. 2015::15015. PeerView.com

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16. Visceral Fat Mass Has a U-Shaped Association With
Sleep Duration: Evidence From NHANES, 2011-20141

+ NHANES is a demographically

representative, cross-sectional =
survey of the US population 550
»
+ N =5,151 adults aged 18-59 years Eso
+ 23% self-reported trouble sleeping E
450
+ 15% self-reported a sleep disorder 2
+ Fat mass ascertained through body =
measurements 350
zs 6 I e
Sleep Duration, h
1. Giannos P et al. Sleep Med, 2023:105:78-84, PeerView.com

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17. How Does Weight Loss Affect OSA?
Evidence From Clinical Trials

MIMOSA!
6-month RCT
180
Adults with moderate-to-severe OSA

Weight Loss vs AHI Dose-Response’

and overweight or obesity
3 interventions 50
— Standard care

210% weight

- Mediterranean diet . À es group |
- Mediterranean lifestyle e ie H
2
6 +
Separately, a meta-analysis of 10RCTs | = +
calculated the following rates for
changes in AHI using various lifestyle ws pe
interventions lasting up to 1 year? 400
+ -8.61 events/h, diet alone m"
+ -8.08 events/h, exercise alone 0 15
+ -8.15 events/h, diet + exercise Weight Change, %
a Metal 3 E Sop Log 2022 18 ESTAR! E Eowans BA ct al Rospobgy. 201024740751 PeerView.com

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18. There Is Room for Improvement in Obesity Management
in Patients With OSA, So Let's Get Started!1-4

Weight management is rarely addressed in OSA care—why?

Clinician Barriers to Obesity Care

+ Observing but not addressing obesity per USPSTF guidelines

+ Limited understanding of physiologic basis of obesity and its management
+ Bias against people with obesity

+ Misperception that patients are unmotivated

Patient Barriers to Obesity Care

+ Time delay between first developing obesity and discussing with PCP.
+ Need for referrals and extra follow-up appointments

+ Lack of access to multidisciplinary obesity care

“If you see something, say something, then do something”

1. Hudgel DW et a. Am J Respir it Caro Med, 2018:198:070-087.2.Stansbury R et al. J Clin Med, 2022:11:4449. 3. Osman AM et al. Nat Sci Stop, 2018;10:21-34 m
4: LeBlanc ES et al JAMA. 2018:920:1172-1101. PeerView.com

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19. CMA Guidelines on Obesity Management!

This guideline tells us HOW TO DISCUSS WEIGHT with our patients

ASK Permission
“Would it be all right if we discussed

your!
+ Shows compassion and empathy
+ Builds patient-provider trust

ASSESS Their Story
Determine goals that matter to the patient
Measure and classify (BMI and waist circumference)
Stage disease severity (Edmonton Obesity
Staging System)

Medical

ADVISE on Management

1. Wharton Set al. CMAJ. 2020.192:E875-£891.

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Bariatric
Nutrition Exercise Psychological Medications
Therapy | | ie
AGREE on Goals ASSIST With Drivers & Barriers
+ Collaborate on a personalized, + Focus on patient-centered health outcomes versus
sustainable action plan ‘weight loss alone

Download the
Practice Aid

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20. USPSTF Guidelines on Obesity Management (2018)1-3

Population Recommendation Grade
Adults The USPSTF recommends that clinicians offer or refer adults with a B
BMI of 230 kg/m? to intensive, multicomponent behavioral interventions

+ Behavior-based weight loss interventions with or without weight loss medications
were associated with more weight loss and a lower risk of developing diabetes than
control conditions

+ Weight loss medications, but not behavior-based interventions, were associated with
higher rates of harms

+ Long-term weight and health outcomes data, as well as data on important subgroups,
were limited

| This guideline tells us WHO to treat, but the advice on HOW is outdated

An update for this topic is in progress?

1. ips ww usprevontvoservicostaskorc.org uspstliocommendatln/obesiy.n-adulisinterventons. 2. LeBlanc ES et al. JAMA. 2018:320:1172-1191
3. ips vin usproventivesarvicestasklore org uspstlrat update Summary/behavoral Counseling inarventons-promote-healthy det physical-acviy-weightloss-

prevent-carciovascular-dsease-aduis.

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21. Selected Medications for Comorbidities Within These
Treatment Classes May Cause Weight Gain or Worsen OSA122

Download the

i i i il e Hormone
pl Antihy Ip
Antidepressants ntinyperalyeemics ]{ Hormone |
Antipsychotics | theta
Myorelaxants Anticonvulsants

Corticosteroids

u

Antihistamines
Review full medication list for weight-
promoting agents; replace with weight- Antihypertensives
sparing agents for the same indication

2 Te ft of weight promoting and OSA-arsening agent is lengthy: const reernces fru. ñ
1. hips Jobesiycanada ca wp-contontupioads202 108/6-Obesty-Assessment.v6-wi-inks pl. 2. Jullan-Desayes | et al. Br y Cin Pharmacol. 2017:83688.708. PeerView.com

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22. The Complex Etiology of This Chronic Disease!

Obesi

Physiologict3 Behavioral? Genetic* Environmental55
+ Altered levels of + Diet + Epigenetics + Socioeconomic status
hormones and + Inactivity + Mutations +» Access to/affordability

gastrointestinal peptides + Emotional factors + Single offood
+ Altered homeostatic and + Lack of sleep nucleotide Built/physical environment

reward system pathways ; jon Polymorphisms + Cultures
+ Weight positive Smoking cessation PolymorPh + Sociocultural attitudes
medications + Endocrine-disrupting
+ Health conditions chemicals
1. Loan Mey eta. tJ Obes (Lone. 2018022 632.2. Yu YH ot Obes Row 2015:16:24-27. 3. wu shih goheatneatntpesopicobeleasest. A
4 Moles À at a. Curr Obes Ro. 201322331. 5. Sharma AM ot al Obes Ray: 2010.11:202370. 6. Chaput JP el al Obes Rov 2012:13081091 PeerView.com

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23. Homeostatic Regulation of Set-Point Body Weight!

Ahomeostatic weight regulatory system prevents deviation from a body-weight set point

Metabolic signal
to increase appetite drive

x

Energy
expenditure

1.Yu YH tal. Obes Rev. 2018:16:234-247 PeerView.com

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24. 1. Yu YH tal. Obes Rev. 2015:16:234-247

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Homeostatic Regulation of Set-Point Body Weight!

Ahomeostatic weight regulatory system prevents deviation from a body-weight set point

Metabolic signal Metabolic signal
to increase appetite drive to decrease appetite drive

S

Weight

GAIN

Energy Energy
expenditure expenditure

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25. Homeostatic Regulation of Set-Point Body Weight!

Ahomeostatic weight regulatory system prevents deviation from a body-weight set point

Metabolic signal Metabolic signal
to increase appetite drive to decrease appetite drive

S

Weight

Energy Energy
expenditure expenditure

Deviation from this set point elicits a physiologic compensatory
mechanism controlling food intake and energy expenditure

1. Yu YH tal. Obes Rev. 2018:16:234-247 PeerView.com

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26. How Does Weight Loss Affect OSA?

General Guidance for Weight Loss‘? OSA Outcomes in Two Notable Trials®4
Lifestyle Bariatric
Intervention Surgery
10%
to Sleep AHEAD SM-BOSS
15% N= 264 N=217
Improves OSA; 10.5% weight loss ~25% weight loss (or
may resolve (10.8 kg loss) with more) with bariatric
mild OSA intensive lifestyle surgery induced
intervention induced OSA remission in
OSA remission in ~45% of participants
May reduce OSA severity 13.6% of participants with obesity
by 50% in patients with with obesity and T2DM

moderate OSA

1. American Thoracie Society. ps www horace rg’patents/palentrosourcostesourcosweighios-and-loop-apnea pl. 2. Pacheco D, DeBanto J
his in stone apreta spearen 79479, Updated rca 24, 204. Accessed Ap 8,204.3 Foster GO D 7s any,
‘al Arch Item Mod. 2009:169:1619-1626. 4. Peter Reta. JAMA. 2018:319-255-265, 'eerView.com

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27. FDA-Approved AOMs1-5

Off-Label Medications
Metformin
GLP-1 RAs
SGLT2 inhibitors
Topiramate
Bupropion
Other stimulants TT
LP-1/G

2 Approved for short term use ony.
1. Side courtesy o Jaime Amand. MO.

2 Tak VJ, Loo SY. Cum Obes Rp, 202:10:1430. 3. Gruzz N. Cin Diabetes 2020:38313:31. 4. Angeli AM a al. Ender Rov. 2022:43 07-887. a

$5. Brandt 83 etal. Peptides. 2018;100:190-201, 6. Tschöp M et al. Diabotología. 2023.66:1796-1808. PeerView.com

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28. Download
the Practice
Aid

Mean Long-Term Weight Change Reported in Phase 3
Trials of Current AOMs and Bariatric Surgery’?

Counsel patients that these results were achieved after a year or more

Phentermine/ Naltrexone/ — Liraglutide Semaglutide Tirzepatide Sleeve Rouxen-Y
Orlistat topiramate bupropion 3.0 mg 24 mg 15 mg gastrectomy gastric bypass
XENDOS* CONQUER COR SCALE STEP SURMOUNT-1 SM-BOSS SM-BOSS
ty 56 wk 56 wk 56 wk 68 wk 72 wk Syr Syr
o
2.5 =] EI | 1 24
Ex 6.2 6.1
&g0 36 -80
Os 106
5 -14.8
3
= -20.9
5
5 = Placebo Intervention 5250
= -28.6
35
+The mean weight change in th cita group is ing. notin pecan (stipe bas). m
PeerView.com

1. Chakthoura M ot al. eClnicalMiedicine. 2023,58:101882. 2. Pati R ot a. JAMA. 2018:319255-265,

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29. An Overview of Recommended Treatments
for OSA and/or Obesity

OSA Treatments! Treatments for Both Obesity Treatments’

Behavioral therapy to
improve sleep patterns and
positional therapy

+ Liraglutide 3.024
+ Tirzepatides+
Bariatric procedures*

Nutritional intervention
+ Physical activity

+ CPAP + Behavioral therapy
BPAP + Pharmacotherapy

Oral appliances for long-term use
= Mandibular repositioning devices = Naltrexone/bupropion

= Phentermine/Topiramate
= Semaglutide 2.4 mg

+ OSA is not an FDA approved indication for this medication

4. Pennings Net al. Obes Piers 20224100043, 2. Blackman A et al. In J Obes. 2016.40:1310-1319.3. https ww pmewsvir.comvnews-seleasesfizepatide-

‘cuca. dep gnc evry nao also ep apne nd abst RE SES Ni Ke Day Ae al ur it

‘Mod. 2014:25 922-925, 5. Jebb SA et al Lancet 2011:378 1485-1492. 6. Ton Jet a. Odes Algortim Sides, presented bythe Obesiy Medi us
‘Associaton wi. obesiyagorthm or, 2023. pe. /obesiymedeine rg’obosty-algarihm-powerponu. 7. Bayes HE era. OBosiy Paar 20222 100018. PeerView.com

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30. Liraglutide + CPAP Better Than CPAP Alone in
Moderate/Severe OSA in PwO Without T2DM'

Change in AHI

AHI, events/hour
&

E
202168004622 2% O
Time, wh

Change in AHI by Weight
Change Category

8

Liraglutido 3.0 mg

Change in AHI, events/hour

.
a bain 51e
| Placebo (n = 165)

a

& 73 9 © 0 m 3
386 442 235 182 163 00 84 18
Weightloss. Weightloss Weightloss Weight oss
o «TOO 215%

Weight Change Category

Greater decrease in mean AHI in liraglutide vs placebo (-12.2/h vs

1. Blackman A et al int J Obes. 2016:40-1310-1319.

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31. Liraglutide + CPAP Better Than CPAP Alone
in Moderate/Severe OSA in PwO and T2DM

Patients With Overweight
and T2DM (N = 90)

+ 3-mo RCT; baseline
BMI = 26.5-27.0 kg/m?
Liraglutide + CPAP reduced
AHI more than CPAP alone
(26.127.1/h vs 31.6 +6.9/h;
P< .05)

+ BMI, AHI and mean systolic
BP significantly lower 3
months later in liraglutide +
CPAP group (P< .05)

+ AC declined slightly more in
the liraglutide group (0.23%
vs 0.07%), but the difference
between groups was not
significant

1. Jang Wet a. Stop Broath. 2022:27:1687-169.

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Change, units as specified

= Liraglutide group (n = 44)

15

‘= Control group (n = 45)

04

ABMI, kg/m?

49

AAHI, events/h

42

56
ASBP, mmHg

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32. Tirzepatide Improved OSA Symptoms in Moderate-to-Severe
OSA + Obesity: Topline Results From SURMOUNT-OSA!

Change in AHI Change in Weight
mTirzepatide mPlacebo mTirzepatide mPlacebo
0 0
£ 43
4% 48 = 8 5 =>
20 A
gs 20
= -20 £
= 3 -15
2 -25 5
5
8 6 20 184
6 -30 274 zei an
35 % reduction
55% || -5% 63% || -6% -25
‘rom BL
— == —— ——
Study 1 Study 2 Study 1 Study 2
(no PAP) (PAP) (no PAP) (PAP)

1. Mos Amen meno cominewsolasostizopatdo-oducod-soep-2pnea-sovorty up tomen morral tr obstuctvo-sioep-apnea-osaand- AR
obesiy-302118929 him PeerView.com

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33. Weight Regain Associated With AOM Treatment Cessation
Shows the Need for Chronic Therapy’?

STEP-1 Extension Study SURMOUNT-4
68-Week Treatment 52-Week Off-Treatment 36-Week Open-Label — Mer Double.Glind

Pe Phase , Extension Phase og LeadlnPeriod Treatment Period
go Loi
5 a Ea
EM ¿3

4 Ls E 2.
Es 2 3
É i 3
Es 0% à
$ 107
HE dos
8. 3 82] Timapatisiestin
g 5
Bus List E,
5 100 3
I 5 0

OF eiaI6d ze do da 82 do 68 76% o O48 1216202070009640 = 66 7 8
Time Since Randomization, wk Time After Start of Lead-In Period, wk

1. Wilding JPH eta. Diabetes Obes Metab. 2022.8:1553-1564.2. Aronne L et al. JAMA, 2024:331:38-48. PeerView.com

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34. Durable Effectiveness of GLP-1 RA Therapy at 4 Years13

®
SELECT Trial Es =
+ N= 17,604 ¿ lacebo
+ Adults with a history § *
of MACE or at high =
CV risk a 6
+ No T2DM at baseline 5 ;
+ 64.5% with prediabetes Es Sema 2.4 mg
baseline 8 %
$

0 2 à © 2 & To wa 17 m0 Ua 156 189 12 195 28 21
Time Since Randomization, wk

Soma 24mp 8704 7434 6830 5912 6240 SAS7 6096 5300 5971 4785 4.670 2000 3.800 2820 2270 1305 000 118
Procedo 8782 7.621 7.273 6287 G81Z 5001 6005 5026 6.612 5252 5200 4.0% 4314 3001 2485 1465 755 126

ay Letal Out (Stor Sp) 202891111222. Lo AM tl No En Mod 2023908 22-2323, Ryan OM a Nt Mad 2024 May 3 ñ
(Online ahead of prin PeerView.com

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35. Bariatric Surgery Has Durable Effects for Obesity’

Swedish Obesity Study
+ N=4,047

+ Nonrandomized
prospective study

+ Surgical group

- n=2,010

- 68.1% VBG

— 18.7% banding

— 13.2% gastric bypass
+ Controls (usual care)

- n=2,037

1-SJostróm Let al. JAMA, 2012:307:56-6.

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Weight Change, %

Control
s
10
ae Banding
en VBG
= GBP
36

01234 6 68 1 5 20

Follow-Up Time, y

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36. Taking Action to Encourage Multidisciplinary Management
of Obesity and Obesity-Related Sleep Disorders

Jeff, a Man Aged 45 Years

+» BMI: 37.2 kg/m?; height: 70 inches (178 cm); Let's discuss some cases we
weight: 259 Ib (117 kg) often encounter in practice
Suppose that Jeff was

+ Medical history diagnosed with OSA and

— Gained 30 Ib (13.6 kg) over the last initiated CPAP, but it didn’t
2 years work well for him ...

— Hypertension

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37. Jeff, a Man Aged 45 Years With Intolerance to CPAP

BMI: 37.2 kg/m; height: 70 inches (178 cm);
weight: 259 Ib (117 kg)

AIC: 5.7%; BP: 135/84 mmHg

TC: 170 mg/dL; LDL-C: 94 mg/dL; HDL-C: 46 mg/dL;
TG: 151 mg/dL

Family history: father had a stroke 10 years ago, reports early
Alzheimer’s disease, CVD, and moderate OSA; mother had TIA
10 years ago

Medical history: hypertension, severe OSA diagnosed

6 months ago

Current medications: lisinopril
Current OSA treatment: CPAP (not using)

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Visit Notes
+ Today's visit is to follow up for OSA

He is a high school teacher and gained
weight after separation from his wife

2 years ago

Feels exhausted most days; eats meals
alone in front of the TV, unless he has his
two boys with him

He's worried about the heart problems
that run in his family; knows his weight
isn't good for his heart

Tried CPAP; states he is claustrophobic
and has difficulty using the mask

at night

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38. Multidisciplinary Management Has Arrived in OSA!

That Was Then ... .… This Is Now

Recognition and Diagnosis

Diagnosis and Prognosis

Archetypal Presentation | Diagnosis
+ Daytime sleepiness | Polysomnography —

Snoring obtain AHI
Witnessed apnea
+ Obesity
4. Sutherland K ota. Mutidisoh Respir Mod. 2018;13:44, PeerView.com

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39. Shared Decision-Making in Obesity Management!

Download the

ASSESS Their Story Practice Aid
+ Determine goals that matter to the patient

ASK Permission
“Would it be all right if we discussed

Tee + Measure and classify (BMI and waist circumference)
> Se ee + Stage disease severity (Edmonton Obesity
+ Builds patient-provider trust ‘Staging System)

ADVISE on Management

Bariatric
Surgery

Psychological

Medications |

AGREE on Goals ASSIST With Drivers & Barriers

+ Collaborate on a personalized, + Focus on patient-centered health outcomes versus
sustainable action plan ‘weight loss alone

1. Wharton $ etal. CMAJ 2020:192:875-E891. PeerView.com

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40. Multidisciplinary Management Has Arrived in OSA!

That Was Then ... .… This Is Now

=

Prescribe CPAP

therapies

1. Sutherland K et al. Mutidisoh Respir Mod. 2018:13:44 PeerView.com

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41. + BMI: 37.2 kg/m?; height: 70 inches (178 cm);

Jeff, a Man Aged 45 Years

weight: 259 Ib (117 kg)
+ Medical history

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— Gained 30 Ib (13.6 kg) over the last
2 years

— Hypertension

Let’s look at another
common situation.

What if Jeff’s situation

was different?

What if he regained weight
after a surgical intervention?

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42. Jeff, a Man Aged 45 Years With History of RYGB Surgery

BMI: 37.2 kg/m?; height: 70 inches (178 cm);
weight: 259 Ib (117 kg)

A1C: 5.7%; BP: 135/84 mmHg

Family history: father and brother have T2DM and

mild OSA; mother has early Alzheimer's disease
Medical history: hypertension, dyslipidemia,
Roux-en-Y gastric bypass 8 years ago

Current medications: lisinopril, simvastatin,
multivitamin

Current OSA treatment: none

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Visit Notes |
+ Today's visit is to discuss poor

sleep quality (self-referral)

He is a locomotive operator; feels
exhausted and tired most days,
worried it may affect his job

Lost 50 Ibs after RYGB, but weight
has steadily increased despite dieting
Frustrated that RYGB “hasn't worked”

He wants to feel healthy, have more
energy, and sleep better

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43. Multidisciplinary Management of OSA Includes Sleep Medicine,

Primary Care, and Potentially Other Medical and Surgical Speci

Bel
health

Oropharyngeal
ialties
Oral surgeon
ENT

Primary
care

Ities!7

Physical
medicine
Respirology

ties
Physical therapy surge pecialties

Personal trainer ‘Nutritionist

Internal medicine
specialties
Cardiology
Endocrinology
‘Neurology

Sleep specialist

Sleep medicine
Behavioral sleep
specialist

1. htpssleepeducation orggetnvolvedicount-on-sleop/providrslalgorthm-rferal 2. Weber M etal. J Cin Otorinaaryngol 20213: DOI: 103157972602:

195621020, 3. Él Arab RA et al Appl Sol 2023.193910. 4, Bray GA et al Endocr Rov. 2018:39:79.132. 5. Sutherland K eta. Mutidici Respl Med. 2018: 13:44
6. Hudgel DW eta Am J Respir Crt Caro Med. 2018:198:970-e87, 7. Pennings N etal. Obes Plas. 2022:4:100043,

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44. Shared Decision-Making in Obesity Management

An Overview of Recommended Obesity Treatments"?

m _m m T

Use SDM to identify appropriate and individualized goals and reach agreement on treatment changes®

1 de:
SA Employ SDM to collaborate with E a SDM can help improve decisions, patient
patients on individualized goals & EG Knowledge, and patient risk perception
®\ SDMhelps to acknowledge SOM has been linked o beter
and address emotional needs selon,

4. Ton ot a Obesty Algom Sides, presented by the Obesiy Medicine Associaton 2023, www obastyalgorthm or —
2. Bayes HE ot al. Obesity Pilar, 2022:2:100018. 3. Boeder S etal. Diabetes Ther. 2023,14:425-46. PeerView.com

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45. Multidisciplinary Management Has Arrived in OSA!

That Was Then ... .… This Is Now

Follow-Up

Monitor CPAP adherence

ZT and efficacy (residual AHI)
icacy ( ) > ua]
‘CPAP AP
= Treatment effectiveness
and optimization
1. Sutherland K ota. Mutidisoh Respir Mod. 2018:13:44. PeerView.com

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46. Key Takeaways: Obesity Management in
Patients With Sleep Disorders

Improving Sleep Disorder Management

+ Weight management improves the effectiveness
of other treatments for OSA

+ AHl event rates decrease as weight
decreases—even modest amounts of weight
loss may be beneficial

+ Weight management needs to be integrated into
multidisciplinary management of sleep disorders

+ Sleep specialists are well-positioned to
initiate conversations about weight with
their patients

Improving Obesity Management

Obesity has many causes, few of which are
under an individual's voluntary control

Ask permission before discussing a
patient’s weight and always use respectful,
nonjudgmental language

The amount of weight loss needed to resolve
OSA is likely to exceed what is possible with
lifestyle modifications alone

Bariatric surgery and some AOMs have high
efficacy for reducing weight

Bonus Take-Aways
+ AOMs can be used with CPAP; re-evaluate the need for CPAP after weight loss

Multidisciplinary management is needed to address the full spectrum of complications

associated with obesity and obesity-related sleep disorders

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