Obesity, Sleep Apnea, and Zepbound with Dr. Jeremy McConnell
Sleep apnea affects millions of people worldwide, and for the longest time, treatment options have been limited to devices like CPAP machines or surgical interventions. But now, for the first time ever, there’s a medication designed specifically to treat obstructive sleep apnea: Zepbound. This breakthrough offers hope for a condition that has been notoriously difficult to manage.
To dive deeper into this exciting development, I’ve invited someone whose expertise bridges the worlds of sleep medicine and obesity medicine. It’s the perfect time to have this discussion, and I couldn’t think of anyone better to explore the topic with than Dr. Jeremy McConnell.
Dr. McConnell is a diplomate of both the American Board of Obesity Medicine and the American Board of Family Medicine. As a master fellow of the Obesity Medicine Association—one of only about ten in the world—his expertise is unmatched. He also holds a certificate of added qualification in sleep medicine, making him uniquely equipped to discuss this topic.
He’s the co-founder and board chair of the Florida Obesity Society, as well as the founder of Florida Sleep Specialists and Discover Health. With his deep knowledge and experience, this conversation promises to shed light on Zepbound’s potential to transform sleep apnea management.
Let’s jump in!
CPAP Intolerance and Treating Sleep Apnea
Sleep apnea is often linked to obesity, and Dr. Jeremy McConnell knows this all too well. At 44 years old, weighing around 275 pounds, he was diagnosed with sleep apnea and began CPAP therapy. While it seemed like a promising solution at first, he quickly found himself struggling to tolerate it—a challenge many patients face as well.
“CPAP intolerance” might sound like a technical term, but it’s something many people experience firsthand. For Dr. McConnell, it wasn’t about the discomfort of the mask itself—it was about how it disrupted his sleep more than it helped. The mask, instead of providing relief, became more of an obstacle, and that’s a reality for many, even healthcare professionals, who may not fully understand the challenges involved.
Dr. McConnell points out that around 75% of people adapt well to CPAP when they receive the right support and instruction. However, about 25% run into serious problems. Some of the common hurdles include:
Mask Sensation: The sensation of a mask on the face can feel awkward or claustrophobic. There are about 45 different mask designs out there, and Dr. McConnell compares finding the right one to shopping for shoes—it’s all about comfort over appearance.
Pressure Intolerance: For some, the air pressure from CPAP is just too much to handle. In these cases, BiPAP therapy can be a better fit, as it adjusts pressure during exhalation.
Noise and Leaks: Mask leaks can create annoying noises, often humorously called “mask farting.” These leaks can disrupt not only the user’s sleep but their bed partner’s as well.
Maintenance and Travel: Keeping the CPAP machine clean and dealing with the hassle of traveling with it can make sticking with therapy a real challenge.
Despite these obstacles, Dr. McConnell is quick to point out how much CPAP therapy can improve quality of life for those who can tolerate it. “Many patients absolutely love it,” he says. “It’s life-changing for them, bringing better sleep and better overall well-being.”
But when CPAP isn’t an option, it’s crucial to find alternatives. Whether it’s experimenting with different masks, using BiPAP therapy, or considering other treatments, the goal is to help patients achieve restful, restorative sleep.
As Dr. McConnell puts it: “It’s all about two things: improving how people feel and restoring healthy sleep. With the right support and solutions, we can make both happen.”
Sleep Apnea Explained
Sleep apnea happens when someone stops breathing during sleep. The word “apnea” itself means “not breathing.” It’s a condition that primarily occurs because of the collapse of the upper airway. During wakefulness, the brain sends signals to keep the muscles in the airway open. When asleep, these signals relax, and the airway can partially or fully collapse.
A diagnosis of sleep apnea requires breathing to stop at least five times per hour. However, in severe cases, interruptions can occur 10, 20, or even 50 times per hour, adding up to hundreds of episodes each night.
The impact of sleep apnea extends far beyond restless nights. When airflow stops, the brain must decide between maintaining restful sleep or ensuring proper breathing. Naturally, breathing takes priority, triggering a fight-or-flight response to open the airway and leading to disrupted sleep patterns. This cycle repeats throughout the night, preventing the body from achieving deep, restorative sleep.
These repeated interruptions lead to common symptoms such as fatigue, poor focus, irritability, and a sense of non-refreshing sleep. The effects are far-reaching, impacting mood, memory, cognitive function, and even physical safety. Sleep apnea has been linked to an increased risk of motor vehicle accidents, workplace mistakes, and decreased academic performance.
The condition is surprisingly common. An estimated 18% to 25% of adults in the U.S. have obstructive sleep apnea, yet only 10% to 20% of cases are diagnosed. This highlights how important it is to recognize the signs. Complaints like constant tiredness, difficulty concentrating, and disrupted sleep could point to a larger issue.
With proper awareness and diagnosis, sleep apnea can be managed, leading to better health, improved quality of life, and the ability to finally enjoy uninterrupted, restorative rest.
Identifying Sleep Apnea: Key Questions and Signs
Sleep apnea is a condition that many people overlook, but it’s actually quite common, especially among those dealing with weight management issues or certain health conditions. If you're tired all the time or have trouble staying awake during the day, it could be a sign that something’s off, and sleep apnea might be the culprit. The first step in identifying sleep apnea is asking the right questions.
Dr. McConnell shares that when someone comes to him complaining of fatigue, he starts by asking, “Do you snore?” Snoring is a common symptom of sleep apnea, but not everyone who snores has the condition. It happens when there’s a partial blockage in the airway, causing vibrations in the soft tissues. While snoring on its own isn’t enough to diagnose sleep apnea, it’s still a red flag that requires further investigation.
Another crucial question Dr. McConnell asks is, “Has anyone ever told you that you stop breathing in your sleep?” If someone else has witnessed this, it’s another strong sign of sleep apnea. For those who sleep alone, he’ll ask, “Have you ever woken up gasping for air?” or “Have you felt your airway collapse as you fall asleep?” These are often signs of an apnea event.
Another key sign of sleep apnea is non-refreshing sleep—waking up feeling as tired as when you went to bed, or experiencing morning headaches. Dr. McConnell also notes that difficulty staying awake during the day is another clue. If you’re constantly nodding off while sitting at your desk or watching a movie, it’s a strong indication that something is disrupting your sleep. To assess this, he often uses the Epworth Sleepiness Scale, a tool that measures the tendency to fall asleep in various situations.
The Health Risks of Untreated Sleep Apnea and How to Manage It
Sleep apnea is also linked to several medical conditions, especially cardiometabolic disorders. A large percentage of people with type 2 diabetes or high blood pressure also have sleep apnea. These conditions are often bi-directional, meaning sleep apnea can worsen diabetes and high blood pressure, and vice versa. This makes sleep apnea something we need to consider when managing these health conditions.
Obesity is another risk factor for sleep apnea. As body mass index (BMI) increases, the severity of sleep apnea tends to increase as well. Around 80% of patients in obesity medicine clinics have obstructive sleep apnea, but many of them haven’t been tested for it. We need to improve our screening methods to catch this condition earlier.
There’s also a strong connection between sleep apnea and strokes, as well as atrial fibrillation (irregular heartbeat). People with these conditions should be evaluated for sleep apnea because it can affect the management of both.
If you’re listening to this and wondering if you might have sleep apnea, it’s worth bringing up with your doctor, especially if you’re struggling with weight, diabetes, high blood pressure, or other related conditions. It’s not uncommon for someone with these health challenges to also have sleep apnea.
The good news is that testing for sleep apnea has become much easier. Most tests can now be done at home, making it more accessible and less intimidating for patients. In many cases, insurance will cover a home sleep test, so you don’t have to worry about expensive or complicated procedures. Plus, CPAP (the most common treatment) isn’t the only option for managing sleep apnea. While it works for some people, there are other treatments available.
It’s crucial to understand that untreated sleep apnea can contribute to or worsen other health problems, like weight gain, high blood pressure, and poor blood sugar control. By addressing sleep apnea, we can make a significant impact on improving these other health issues. For many, treating sleep apnea is a key step in achieving better overall health and wellness.
So, if you’re concerned about sleep apnea, don’t hesitate to talk to your doctor. There are more options available than ever, and finding the right treatment could improve your quality of life in ways you might not expect.
Exploring Effective Treatment Options for Sleep Apnea
There are several treatment options for sleep apnea, and each has its own advantages, depending on the severity of the condition and individual needs. The most common and effective treatment is the CPAP (Continuous Positive Airway Pressure) machine, which keeps airways open during sleep by delivering a steady stream of air. With modern technology, these machines can transmit data, allowing specialists to monitor and adjust the treatment as needed.
For mild to moderate cases, oral appliances are another option. These devices work by positioning the jaw forward, helping to open the airway at the base of the tongue. While effective for some, it’s not suitable for everyone. Sometimes it’s also used in combination with CPAP.
Surgical treatments are often considered when other methods haven’t worked, though they tend to have mixed results. Surgery is generally reserved for more severe cases of sleep apnea, when other treatments haven’t provided sufficient relief.
A newer option for those who haven’t had success with CPAP is the Inspire device. This implantable device stimulates the tongue muscle to move forward, keeping the airway open. It’s implanted under the skin on the chest, and a lead runs to the jawline to control the tongue muscle during sleep. Inspire has shown a high success rate, particularly for people with obesity, with some practices reporting a success rate of over 90%. Proper patient selection, surgery, and post-implant care are key to its success.
While CPAP remains the gold standard, alternatives like oral appliances, surgery, and the Inspire device offer effective solutions for those struggling with sleep apnea. If you’re dealing with sleep apnea, it’s worth exploring all available treatment options with your doctor to find the best fit for your needs.
Addressing the Effectiveness of Inspire for Patients with Higher BMI
The challenge with Inspire is that it’s less effective at higher BMIs. In individuals with higher BMI, lateral wall collapse can occur in the airway, meaning the airway in the throat collapses both front to back as well as side to side. Inspire only moves the tongue forward, which opens the airway in that direction. As a result, it’s not as effective for individuals with higher BMIs, leading to debates on whether Inspire should be used for these patients.
Dr. McConnell explains that they’re currently involved in a five-year clinical outcomes trial for patients with higher BMIs who are using Inspire, focusing on the durability of the results over time. This trial aims to address a common challenge faced by patients who have both sleep apnea and obesity. Many insurance companies set the BMI cutoff for Inspire at 35, which limits its availability to those with higher BMIs.
Dr. McConnell shares that they have successfully treated many patients with BMIs higher than 35 who couldn’t tolerate CPAP. By first helping them reduce their weight through other methods, these patients were able to qualify for Inspire. After the procedure, they’re now thriving, with their apnea successfully corrected.
How Weight Loss Impacts Sleep Apnea: The Role of Tongue Fat and Respiratory Dynamics
The relationship between weight loss and the treatment of sleep apnea has been a topic of ongoing interest. For many years, sleep medicine physicians have consistently noted that weight loss can play a significant role in managing sleep apnea. However, the rationale and outcomes from this approach have been mixed over the past 20 to 25 years.
One area of research that has garnered attention is the work being conducted at the University of Pennsylvania, where MRI scans of the tongue are being used to better understand the connection between fat accumulation and airway obstruction.
As obesity specialists know, and many listeners may be aware, individuals cannot control where fat is stored in the body. While it is common for people to wish they could target fat loss in specific areas, such as the abdomen or thighs, the body dictates where fat is stored and where it is lost. This unpredictability is particularly significant when considering how fat affects different areas of the body, including the airway.
People often exhibit different body types or phenotypes, traditionally classified as "apple" or "pear" shapes. Those with an "apple" shape typically store fat in the central area, known as central adiposity, while "pear" shapes tend to store fat more in the lower body. Fat can also accumulate in internal organs, with the liver being one of the most commonly known sites. However, fat can also build up in other organs, including the tongue. In some individuals, fat deposits in the tongue may lead to a weakening and thickening of the tongue muscles. As the tongue becomes both thicker and weaker, it becomes more prone to obstruction. The increase in tongue mass, along with a reduction in its ability to stay forward in the mouth, results in a larger obstruction that can interfere with normal breathing during sleep.
Although it is not possible to target fat loss in specific areas of the body, weight loss as a whole can have a positive effect on sleep apnea. Reducing overall body fat can lead to a decrease in the mass of the tongue, which in turn may help reduce airway obstruction. In addition, weight loss can reduce fat surrounding the airway, decreasing outward compression. When abdominal fat is reduced, the diaphragm is able to move more freely, and the chest and upper body fat that compresses the chest wall lessens too. This overall reduction in fat can enhance respiratory dynamics, leading to improved breathing, not just in the upper airway, but across the entire respiratory system.
How much weight does someone need to lose for improvement in their apnea?
The effectiveness of weight loss in addressing sleep apnea largely depends on its severity. If the condition is more severe, weight loss alone may have a lower chance of resolving it. Generally, we focus on achieving a 10% reduction in body weight as a benchmark. For instance, if someone starts at 250 pounds, we aim for a 10% weight loss and then reassess. However, the response to weight loss varies, and the impact can differ significantly from person to person. In some cases, a 10% weight reduction may reduce sleep apnea by 20% to 25%, but in others, the improvement might be more pronounced.
Several studies, such as the Look AHEAD trial, have demonstrated the positive effects of weight loss on obstructive sleep apnea. This study followed participants for 10 years and found that those who lost weight in the first year showed substantial improvements in their apnea scores. The likelihood of resolution was higher for those with milder cases.
Other research, including the SCALE OSA study involving the medication Saxenda (liraglutide), has also shown significant improvements in sleep apnea severity. Similarly, a study with Qsymia (phentermine-topiramate) revealed a notable reduction in apnea scores, with the average score dropping from 44 to 15 over the course of 40 weeks.
While medication and treatments like bariatric surgery can have a positive impact, the focus should remain on overall weight reduction. It’s important to understand that sleep apnea might not fully resolve with weight loss alone, especially considering that about one-third of people with the condition are of normal weight. This highlights the complexity of sleep apnea and its various patterns.
For optimal management, the goal is to retest patients after they reach key weight loss milestones—such as 10%, 20%, and 30%—to monitor progress, possibly refit their device, and assess how much their apnea has improved.
Zepbound as a Treatment for Sleep Apnea
Obstructive sleep apnea (OSA) has long been a challenging condition to manage, often requiring CPAP machines or other interventions that don’t always work for everyone. The recent FDA approval of Zepbound is changing that narrative, marking it as the first medication specifically for OSA. While not a cure, it’s offering a fresh approach to treatment that combines effectiveness with added health benefits.
Earlier this year, the SURMOUNT-OSA trial revealed just how impactful Zepbound can be. The study involved participants with moderate to severe OSA and a BMI over 30, split into two groups: one combining CPAP with Zepbound and the other using Zepbound alone.
The results were striking. At the start, participants experienced an average of 51 apnea events per hour, a figure that signals severe OSA. After one year, this dropped by nearly 50% to about 25–26 events per hour in Zepbound group. Even more remarkable, around half of the participants saw their OSA go into remission.
For those with milder cases, the potential improvements could be even greater. While Zepbound might not completely resolve severe cases, it’s making a noticeable difference, such as reducing the pressure settings required for CPAP machines.
Zepbound isn’t only about managing OSA—it’s also showing incredible results as a weight-loss treatment. During the trial, participants achieved an average weight loss of 18–20%. This is a major win, as weight loss directly influences OSA severity and reduces health risks associated with obesity. Long-term consistency is crucial. Like many treatments, discontinuing Zepbound can result in weight regain and the return of OSA symptoms.
Zepbound’s effectiveness may go beyond weight loss. Studies suggest that it can specifically target tongue fat, a major contributor to OSA severity. This unique mechanism could explain why some patients experience greater benefits than anticipated, making it an exciting option for a wider range of cases.
With its FDA approval, Zepbound offers a new direction for managing OSA. While accessibility might depend on insurance coverage and cost, the potential benefits are undeniable. For those struggling with the dual challenges of OSA and obesity, Zepbound provides a promising new avenue for relief.
This is just the beginning of what could be a game-changer for sleep apnea management, offering a better quality of life for countless individuals.
To wrap up, sleep apnea is a condition that affects millions, but with breakthroughs like Zepbound and other innovative treatments, there’s hope for better management. If you’re struggling with sleep apnea or suspect you might have it, it’s important to talk to a doctor and explore your options. To learn more about the latest developments in sleep apnea treatment and how it connects to overall health, listen to the full episode with Dr. Jeremy McConnell. Don’t miss out—tune in now!
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