The United States is a nation of overweight, stressed, fatigued and sleepy individuals. Obesity is an epidemic, and it doesn’t seem to be getting any better. I am receiving more and more consults from primary care for patients that are fatigued. Clinicians assume that the fatigue is a sleep issue when nothing else is found. Often, people believe that obstructive sleep apnea may be the culprit. And in some cases, it is apnea. However, in other instances, fatigue may simply result from the patient being deconditioned and overweight.
As a sleep provider, fatigue is on most of my patients’ charts. When patients arrive here, they have already been tested for hypothyroidism, low vitamin B12, vitamin D deficiency, adrenal insufficiency, and low testosterone. In a lot of cases, these tests are all normal.
Assuming that sleep could be an issue is a good place to start – many people in the United States are sleep-deprived individuals who average about 6 1/2 hours of sleep per night or less. Have the patient keep a sleep diary for a week, and they’ll be surprised at how little they’re sleeping. When I tell a patient they’re only getting 5 1/2 to 6 hours of sleep, I am always amazed when they look at me as if that doesn’t matter. In the 1950s, people were sleeping 9 hours per night!
There are patients who have been diagnosed with apnea and use their equipment every night, yet they are still sleepy or fatigued. They changed their health for the better by starting CPAP therapy, but they didn’t change anything else about their health. They still sleep the same number of hours per night, eat the same kind of food, and decline regular exercise. Admittedly, there is a small subset of compliant sleep apnea patients who will have some continued sleepiness during the day because of the severity of their apnea, but that number is low.
So what is causing the fatigue and daytime sleepiness in the rest of these patients? Researchers from Pennsylvania State University think they may have the answer. They conducted a longitudinal study, following a study population for 7 1/2 years, and found that obesity and weight gain lead to daytime fatigue and sleepiness. With 30% of the U.S. population complaining of excessive daytime sleepiness (EDS) and 69% of adults being overweight or obese, it’s easy to see that we are going to be treating these conditions for a long time.
In the study, the researchers conducted medical evaluations and polysomnograms at baseline. They followed up with participants via telephone interviews. Being overweight or gaining weight was associated with a higher incidence and persistence of excessive daytime sleepiness. The researchers theorized that metabolic aberrations and chronic, low-grade inflammation may play a role in causing the fatigue and sleepiness. However, there was good news. Weight loss was a predictor of remission of fatigue and excessive daytime sleepiness!
It is important to tell patients that they have to exercise, get 7-8 hours of sleep per night, and lose weight if they hope to feel less sleepy and fatigued during the day. Patients are often looking for an answer to why they are sleepy, but they don’t want to hear that it is something they have to tackle themselves. Many want a quick fix such as stimulant therapy. The truth is that we have to be honest and explain to them that we can only do so much. They have the power to change how they feel. No medicine or surgery can do more than they can once they make a decision to change their circumstances.
Sharon M. O’Brien MPAS, PA-C, is a practicing clinician with an interest is helping patients understand the importance of sleep hygiene and the impact of sleep on health.
- Fernandez-Mendoza J et al. Natural history of excessive daytime sleepiness: role of obesity, weight loss, depression, and sleep propensity. SLEEP 2015; 38 (3):351–360.