Multi-night some sleep testing (HST) was created as a more convenient, inexpensive, and efficient means of detecting OSA. Until 2008, however, HST was considered unproven, and most third-party payers would not cover treatment with continuous positive airway pressure (CPAP) (Figure 3) when the diagnosis was made using a HST device.
In March 2008, the Centers for Medicare and Medicaid Services issued a National Coverage Determination policy stating that the evidence supported use of HST to establish the diagnosis of OSA in some patients and would cover CPAP treatment based on that diagnosis. With home testing now being an option, scores of patients who may have otherwise gone undiagnosed will be able to seek treatment for OSA.
Depression and weight gain often go hand in hand. Antidepressants commonly cause weight gain during acute and long-term use. Individuals who struggle with obesity are often characterized by negative body image, depressed mood and unrealistic weight goals.
Cognitive behavioral therapy (CBT) remains a mainstay for depression treatment and works to challenge and change these unhealthy beliefs. However, many patients with clinical depression seek other nonpharmacologic interventions for reasons of cost, accessibility and convenience.
There has been increased interest in exercise, yoga and meditation in the treatment of mild to moderate depression. An extensive literature review reveals exercise produces meaningful reductions in depression symptoms that are comparable to those achieved through CBT.21,22
High-energy aerobic exercise (i.e., weekly expenditure of >17.5 kcal/kg) or resistance training has been shown to produce greater reduction of depression symptoms than low-energy exercise (i.e., weekly expenditure of <7 kcal/kg).23 Yoga is also recommended as a therapeutic option for depression treatment. Mindful meditation, which often incorporates hatha yoga, has been shown to reduce stress, depression and fatigue. Mindful meditation can also be combined with CBT to treat depression.24
The most common liver disease in the Western world, nonalcoholic steatohepatitis (NASH) is closely associated with components of the metabolic syndrome (i.e., obesity, hypertriglyceridemia and type 2 diabetes). The combination of advancing age, increased weight and type 2 diabetes leads to an increased risk of developing NASH and advanced fibrosis.25 The primary goal of treatment is to slow the progression of fibrosis and prevent cirrhosis, which occurs in 15% of NASH patients.26
The accepted standard of NASH treatment is gradual weight loss of 10% body weight plus aerobic exercise. Many research studies have shown the impact that dietary changes have on obesity and improving insulin sensitivity, two major risk factors for NASH. In addition to lifestyle and diet modifications, pharmacologic treatment modalities are now available for select patients.
TZDs act by improving insulin resistance and promoting the redistribution of fat from the liver and muscle to adipose tissue. Multiple randomized controlled trials have examined the effectiveness of thiazolidinediones in NASH. The recently published PIVENS (Pioglitazone or Vitamin E for NASH Study) — the largest randomized, placebo-controlled clinical trial of therapies ever conducted for NASH — found that pioglitazone (Actos) use was associated with highly significant reductions in steatosis and inflammation as well as improvements in insulin resistance.27
TZDs are associated with weight gain, however, which may weaken their long term usefulness. Currently, there are no American Gastroenterological Association recommendations for pharmacologic treatment of NASH. However, many clinicians use TZDs (specifically pioglitazone) as second-line treatment, with the possible exception of some patients with diabetes and NASH.25
Vitamin E is a fat-soluble vitamin with powerful antioxidant properties. PIVENS has shown that a daily dose of 800 µg of a specific form of vitamin E (α-tocopherol) is associated with significant improvement in NASH compared to placebo.27 Liver enzymes tend to worsen after vitamin E discontinuation, indicating a need for long-term use.25
It is important to note that the benefits of vitamin E have not been supported in patients with diabetes or cirrhosis. The FDA has not approved vitamin E for the treatment of NASH. Nevertheless, many clinicians recommend its use and start patients with active NASH and without diabetes on vitamin E (α-tocopherol) 800 µg/day.25
Obesity and its myriad of comorbidities continue to increase. Although research will lead to novel approaches to management, the mainstay of obesity treatment and prevention is lifestyle change.
The Diabetes Prevention program, as well as the more recent Look Ahead trial, exemplifies the impact that lifestyle modifications have on weight and metabolic risk factors. It is imperative that PCPs encourage, motivate, and educate their patients on the importance of lifestyle change to help combat the obesity epidemic.
Ms. Cleary is a nurse practitioner with the Lipid Disorders and Metabolic Syndrome Clinic at the Northwestern Medical Faculty Foundation’s Center for Lifestyle Medicine in Chicago, where Ms. Webb is a family nurse practitioner and diabetes educator.
- Finucane MM, Stevens GA, Cowan MJ, et al. National, regional, and global trends in body-mass index since 1980: systematic analysis of health examination surveys and epidemiological studies with 960 country-years and 9·1 million participants. Lancet. 2011;377:557-567.
- Sjöström L, Narbro K, Sjöström CD, et al. Effects of bariatric surgery on mortality in Swedish obese subjects. N Engl J Med. 2007;357:741-752.
- Buchwald H, Estok R, Fahrbach K, et al. Weight and type 2 diabetes after bariatric surgery: systematic review and meta-analysis. Am J Med. 2009;122:248-256.
- Ratner RE, Rosenstock J, Boka G; DRI6012 Study Investigators. Dose-dependent effects of the once-daily GLP-1 receptor agonist lixisenatide in patients with Type 2 diabetes inadequately controlled with metformin: a randomized, double-blind, placebo-controlled trial. Diabet Med. 2010;27:1024-1032.
- Buse JB, Drucker DJ, Taylor KL, et al. DURATION-1: exenatide once weekly produces sustained glycemic control and weight loss over 52 weeks. Diabetes Care. 2010;33:1255-1261.
- FDAnews Drug Daily Bulletin. Amylin eyes bydureon resubmission in second half of year.
- PRNewswire. Bydureon receives marketing authorization in Europe.
- World Health Organization. The top 10 causes of death.
- World Health Orginization. Global health risks: mortality and burden of disease attributable to selected major risks.
- Katholi RE, Rocha-Singh KJ, Goswami NJ, Sobotka PA. Renal nerves in the maintenance of hypertension: a potential therapeutic target. Curr Hypertens Rep. 2010;12:196-204.
- Mosca L, Benjamin EJ, Berra K, et al. Effectiveness-based guidelines for the prevention of cardiovascular disease in women–2011 update: a guideline from the American Heart Association. Circulation. 2011;123:1243-1262.
- Olin JW, Sealove BA. Peripheral artery disease: current insight into the disease and its diagnosis and management. Mayo Clin Proc. 2010;85:678-692.
- Korf-Klingebiel M, Kempf T, Schlüter KD, et al. Conditional transgenic expression of fibroblast growth factor 9 in the adult mouse heart reduces heart failure mortality after myocardial infarction. Circulation. 2011;123:504-514.
- Krishna KA, Krishna KS, Berrocal R, et al. Myocardial infarction and stem cells. J Pharm Bioallied Sci. 2011;3:182-188.
- Henning RJ. Stem cells in cardiac repair. Future Cardiol. 2011;7:99-117.
- Kappelle PJ, van Tol A, Wolffenbuttel BH, Dullaart RP. Cholesteryl Ester Transfer Protein Inhibition in Cardiovascular Risk Management: Ongoing Trials will End the Confusion. Cardiovasc Ther. 2010 Jul 14 (published online ahead of print).
- Becker DJ, Gordon RY, Halbert SC, et al. Red yeast rice for dyslipidemia in statin-intolerant patients: a randomized trial. Ann Intern Med. 2009;150:830-839.
- Jones PJH, Kubow S. Lipids, sterols, and their metabolites. In: Shils ME, Shike M, Ross AC, et al, eds. Modern Nutrition in Health and Disease. Philadelphia, Pa.: Lippincott Williams & Wilkins:92-122.
- Ahmed MH, Byrne CD. Obstructive sleep apnea syndrome and fatty liver: association or causal link? World J Gastroenterol. 2010;16:4243-4252.
- Rahaghi F, Basner RC. Delayed Diagnosis of Obstructive Sleep Apnea: Don’t Ask, Don’t Tell. Sleep Breath. 1999;3:119-124.
- Mead GE, Morley W, Campbell P, et al. Exercise for depression. Cochrane Database Syst Rev. 2009;3:CD004366.
- Daley A. Exercise and depression: a review of reviews. J Clin Psychol Med Settings. 2008;15:140-147.
- Legrand F, Heuze JP. Antidepressant effects associated with different exercise conditions in participants with depression: a pilot study. J Sport Exerc Psychol. 2007;29:348-364.
- Michalak J, Heidenreich T, Meibert P, Schulte D. Mindfulness predicts relapse/recurrence in major depressive disorder after mindfulness-based cognitive therapy. J Nerv Ment Dis. 2008;196:630-633.
- Satapathy SK, Sanyal AJ. Novel treatment modalities for nonalcoholic steatohepatitis. Trends Endocrinol Metab. 2010;21:668-675.
- Ekstedt M, Franzén LE, Mathiesen UL, Thorelius L, Holmqvist M, Bodemar G, Kechagias S. Long-term follow-up of patients with NAFLD and elevated liver enzymes. Hepatology. 2006 Oct;44(4):865-73.
- Sanyal AJ, Chalasani N, Kowdley KV, et al. Pioglitazone, vitamin E, or placebo for nonalcoholic steatohepatitis. N Engl J Med. 2010;362(18):1675-85.