One of the things that my patients consistently tell me is that they seem to be sleeping more poorly than ever.  I hear many versions of this, but the common thread is that as my patients gained weight over the years they have had a harder time falling asleep and had a much more difficult time obtaining restful sleep through the night.  The partners of my patients report increased snoring and wakefulness, as well as early waking in the wee hours of the morning, and somehow it is just too hard to get back to sleep.

Why should sleeping become so difficult?  There may be quite a few reasons as sleep disturbances are truly multifactorial problems.  Part of the problem stems from the impaired mechanics of breathing that occurs with weight gain.  With weight gain we snore more, we have more soft tissue obstruction in the mouth and throat, and it takes more effort to move the “bellows” of our chest and achieve good full breaths.  But there are lots of other factors at work here.

As most of us know, there is a strong psychological aspect of sleep.  If we are more stressed or more depressed, more anxious, more upset, we tend to sleep poorly.  And  weight-related health problems play a role. Pain from degenerating joints can keep us awake. Some medications interfere with good sleep.

How can weight loss help?  Successful weight loss improves all the mechanical factors and physiological factors that impair sleep.  Some of these are “diseases” in their own right such as obstructive sleep apnea (OSA).  Others are just a milder form of sleep disturbance.  But what also happens is perhaps more amazing:  people who begin to feel better about themselves physically and see themselves as working toward an important purpose of weight loss and health improvement, feel better about themselves psychologically as well. And this has tremendous positive impact on sleep and restfulness.

With weight loss, often the physical and psychological aspects of sleep improve. And better sleep means feeling better throughout the day.

In our practice, we developed a sense that all problems resolve after weight loss surgery. I bet if you polled the nurses, the nurse practitioners, office staff, physician assistants and the doctors at Western Bariatric Institute, you would find that through the experience of thousands of patient having undergone weight loss surgery, our clinical staff has come to believe that most health problems fade away and disappear.

This is not hubris; it is just the impression one gets from seeing people in follow up who gradually reduce the number of medications they are on and show up years later looking like an entirely new, and healthier, person. It is very common for people to have been on eight or twelve medications plus CPAP machines for their obstructive sleep apnea, only to return a year or two or three later not only looking like an entirely different person, but also having stopped all their medications and their CPAP.

This impression may be accurate for many people. However, there is some concern among the sleep specialists that obstructive sleep apnea may be a bit more complex disease than we have imagined. In the world of medically supervised weight loss and in bariatric surgery, we tend to view all diseases as being purely weight-related or obesity-related. But that of course is not entirely true.

Around 25% of people with obstructive sleep apnea are not obese. Their risk factors may be more of an anatomic one, having to do with the shape of their mouth and jaw and pharynx. So if a normal weight person has obstructive sleep apnea and then goes on to gain weight, you can imagine that the sleep apnea becomes more severe. Once the weight is lost through bariatric surgery or medically supervised weight loss, the structure of the face and throat has not really changed, so it stands to reason that some degree of obstructive sleep apnea would continue.

As weight loss doctors, we have not taken a highly sophisticated approach to the long-term follow up of obstructive sleep apnea. We probably thought that if the patient reported they were sleeping better and feeling better, and they had lost weight, then what would be the reason for more studies of their sleep?

Well, although there is not much long-term data out there on this question, it may be the case that people with obstructive sleep apnea do need long-term follow up and many of them do need ongoing CPAP. Most of the people who lost weight and kept it off do not need the same level of CPAP. For example, they do not need the pressure settings to be as high as 15 or 18 cm, but rather they can use CPAP more comfortably at 7 or 8 cm. But the big reason to continue with CPAP and to continue visiting the sleep doctors is that independent data shows that untreated sleep apnea carries its own risks of mortality and contributes to other health problems including hypertension and daytime sleepiness.

We see such dramatic resolution of patient’s health conditions like high blood pressure, diabetes and high cholesterol that we naturally lump in obstructive sleep apnea in the same categories and expect its complete and total resolution after weight loss surgery. The truth is probably a bit more complicated. Patients with obstructive sleep apnea undergo weight loss surgery, lose weight and markedly improve or resolve their sleep apnea, but many patients will benefit from ongoing CPAP at lower pressures to avoid the long-term risks and adverse effects of untreated obstructive sleep apnea.

One future study we may undertake at Western Bariatric Institute will be a long-term observation of obstructive sleep apnea over the course of ten years and beyond after their weight loss surgery. This would provide really meaningful data on the need for ongoing sleep studies and titration of CPAP.

What has changed?

I find that a very high percentage of my own patients are working more than ever, have less free time, have less time to exercise, and rely to a greater and greater extent on fast food and restaurant food options. This is a real recipe for disaster with weight gain and a high risk of developing obesity. Today it might be said that we are living in an area of a “perfect storm” with respect to weight gain and obesity.

• Food manufacturers and restaurants have succeeded in making meals more delicious than ever, but also higher in calories and carbohydrates.

• Advertisers tempt us at every turn with the sights, sounds and smells of succulent offerings.

• Schools depend on fast food and soft drink purveyors to fund their programs.

• Most parents work and nobody has much time to prepare healthy meals.

• The streets are not always safe and we spend less time outdoors exercising.

• TV, computers and video games are more entertaining, and more sedentary, than ever

The number of people among the population who were overweight or obese held steady for many years until the 1980s. Then, a sharp rise in the level of obesity occurred in the United States. Over a roughly 30 year time period, we have seen a dramatic increase in the percentage of Americans in almost every state who are now considered overweight or obese.

To be considered overweight, you must have a body mass index of greater than 25. To be considered “obese” in the medical sense, you must have a body mass index over 30. Today, more than 2/3 of Americans are overweight.

So what has changed in that relatively short time frame of 30 years or so? Well if you are old enough, think back to what was different then. You probably realize that most people ate more meals at home, portions were smaller, and people tended to have more time on their hands to be active and outdoors.

You might not be aware of the extent to which meals have increased in size and in calorie content over that time frame. For example, the average meal has increased in calories by approximately 1/3. Greater numbers of people eat more of their meals in restaurants and fast food establishments. Those same establishments have dramatically increased the portion sizes and calorie content of their offerings. And, people have less time to shop, cook, prepare fresh fruits, vegetables and grains and exercise outdoors. Think for a moment if any of that information seems surprising to you or if it fits your own lifestyle.