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For other articles and previous issues click here. October 4, 2004 Eat
Well, Sleep Soundly How many patients present with daytime sleepiness, poor concentration levels, and excessive irritability? These may sound like symptoms of depression, but in reality they could be due to lack of sleep. Sleep is not only a time of rest; it’s a critical time for physical and mental renewal. Surveys conducted by the National Sleep Foundation (NSF) reveal that 60% of adults report having sleep problems a few nights per week or more.1 Sleep disorders occur in at least 40 million Americans, according to NSF data, yet more than one-half of patients seen by their primary healthcare providers are never asked about their sleep quality. According to the Sleep Disorders Center at the Mayo Clinic, Rochester, Minn., clinicians are becoming aware of sleep medicine at an accelerated rate. The number of sleep clinics accredited over the last decade by the American Academy of Sleep Medicine (AASM) and the number of sleep specialists credentialed by the American Board of Sleep Medicine has increased by almost 300%.2 According to the National Heart, Lung, and Blood Institute (NHLBI), the most common sleep disorder is sleep apnea, which has more to do with breathing than sleeping (the word apnea comes from the Greek term meaning “want of breath.”) The two types of sleep apnea are central and obstructive. Central sleep apnea, which is less common, occurs when the brain fails to send the appropriate signals to the breathing muscles to initiate respirations.3 Obstructive sleep apnea (OSA) is far more common and occurs when air cannot flow into or out of the person’s nose or mouth, although efforts to breathe continue.4 OSA’s Symptoms Health Risks In addition, sleep apnea has been linked to increased risk for heart disease and stroke. According to Wolfe, large population-based studies, such as the Sleep Heart Health Study, have shown cross-sectional, dose-dependent association between OSA and vascular disease.9 Therefore, treating and eliminating OSA can positively affect cardiovascular morbidity and mortality. According to the book Snoring and Obstructive Sleep Apnea, many factors contribute to OSA and one single reason cannot be pinpointed. For each factor that causes OSA, the problem will be that much worse; yet, on a preventive note, as each factor is corrected, the problem will be that much better.10 Diagnosing OSA Amongst other readings, OSA is present if the polysomnogram reveals an apnea (cessation of airflow)-hypopnea (repetitive airflow reduction) index (AHI) of five or greater per hour of sleep with evidence of unsatisfying or disturbed sleep, daytime sleepiness, or other daytime symptoms, or a single AHI of 15 or higher.11 Medical Nutrition Therapy The American Dietetic Association (ADA) Manual of Clinical Dietetics emphasizes the importance of an assessment for risk factors for diseases such as sleep apnea to be included in a nutrition assessment. By working with a registered dietitian (RD) to achieve gradual weight loss of 10% of one’s body weight over six months, the severity of OSA greatly decreases. In accordance with the evidence-based clinical guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults published by the NHLBI, healthcare providers should look at three factors: body mass index (BMI), waist circumference, and the existence of comorbid conditions.15 Since epidemiological evidence has shown OSA to coexist with cardiovascular risk factors such as excess abdominal fat (waist circumference greater than 40 inches in men and greater than 35 inches in women), the patient-RD relationship has been proven to be quite beneficial in helping to alleviate OSA. In counseling OSA patients for weight loss, healthcare professionals should reinforce the following16: • slow, gradual changes to healthful eating styles with an emphasis on increasing whole grains, fruits, and vegetables; • nonrestrictive approaches to eating based on internal regulation of food (hunger and satiety); and • gradual increases to at least 30 minutes of enjoyable physical activity most days of the week. Creating positive lifestyle strategies to combat obesity and help alleviate OSA is a paramount part of MNT for this population. Patients must be counseled on the practical aspects of energy intake and output, as well as how to incorporate this information into their lifestyles. Simply discussing ways to increase physical activity and reduce caloric intake (by 500 to 1,000 calories per day) is an unintimidating, attainable way to teach patients how to lose weight. Patients should be taught how to aim for daily improvements (eg, increase dietary fiber, drink more water, and/or walk to and from work). Patients should be given specific tasks such as keeping a food log, recording physical activity, or planning three meals plus two snacks per day. Expanding the Focus of Care Julie Friedman, PhD, health psychologist at Northwestern Memorial Hospital Wellness Institute in Chicago, works collaboratively with dietitians and physicians in treating obese patients with OSA. Friedman explains that once OSA is diagnosed, a health psychologist can work with a patient to improve weight reduction and what’s known as “sleep hygiene.” Sleep hygiene refers to establishing a regular sleep schedule; avoiding caffeine, alcohol, and tobacco two hours before bed; not eating a large meal before bed; and keeping a “worry journal.” Friedman emphasizes the importance of making the environment more conducive to sleep. By empowering patients to increase impulse control, tolerate hunger with a calorie restriction, and decrease the use of food as a mood regulator, Friedman helps with the overall treatment of OSA. Along with MNT and cognitive behavioral therapy, one of the most effective treatments is the continuous positive airway pressure (CPAP) mask, which is worn over the nose during sleep. Oral appliances such as a mouth guard or bite plate have been found beneficial; oral or nasal surgery is another option for OSA patients. If a patient is using CPAP therapy, it is important to monitor its effectiveness. Some key things to note at patient follow-up visits are weight changes since CPAP therapy was initiated, whether or not the patient is still experiencing sleepiness during the day, eating/behavior changes, and whether or not snoring or breathing pauses are still present (ask bed partner). Since many patients with OSA are overweight or obese, it is important for dietetics professionals to individualize treatment plans to fit each patient or client. OSA is a chronic disease that requires patient education, alleviation of upper airway obstruction, and ongoing follow-up with regular adjustment of treatment strategies.17 Long-term goals are more attainable if they become habitual, lifestyle changes. Expand the focus from just weight loss to healthy lifestyle changes, such as increased physical activity, improved energy level, healthier food choices, and/or more support from significant others. It is important to note that when left untreated, even patients with mild OSA have higher healthcare utilization rates and incur greater medical costs.18 Although future research is still needed to determine the exact cardiovascular risks and impact of treatment, current recommendations specify that if one or more clinical features such as loud snoring, choking, consistent apneas throughout the night, hypertension, large neck circumference (43 centimeters or greater), and/or obesity (=30 BMI) are present, initiate referral to a sleep center. As patient outcomes and treatment of OSA evolve, dietetics practitioners will continue to play an imperative role in treating sleep apneas and other sleep-related disorders in overweight and obese populations. — Victoria Shanta-Retelny, RD, LD, is a practicing dietitian at Northwestern Memorial Wellness Institute in Chicago, a freelance food and nutrition writer, and a culinary spokesperson. E-mail edit@gvpub.com for references. Table 1: Signs and Symptoms of Obstructive Sleep
Apneas — Source: Fairbanks DN, et al. Snoring and Obstructive Sleep Apnea. 3rd ed. 2003. For additional information on obstructive sleep
apnea and other sleep-related disorders, visit these Web sites: American Sleep Apnea Association American Thoracic Society National Sleep Foundation Sleep Research Society |
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