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OSA and comprehensive weight management in sleep medicine

CE / CME

Comprehensive OSA Care With Effective Weight Management Strategies: Current Practices, Barriers, and Future Directions

Physician Assistants/Physician Associates: 0.50 AAPA Category 1 CME credit

Nurse Practitioners/Nurses: 0.50 Nursing contact hour

Physicians: maximum of 0.50 AMA PRA Category 1 Credit™

ABIM MOC: maximum of 0.50 Medical Knowledge MOC point

Released: June 24, 2025

Expiration: June 23, 2026

Jaime Almandoz
Jaime Almandoz, MD, MBA, MRCPI, FTOS, DABOM
Radhika S. Breaden
Radhika S. Breaden, MD, MPH, DABMS, DABOM
Babak Mokhlesi
Babak Mokhlesi, MD, MSc
Amanda J. Piper
Amanda J. Piper, PhD
Rafael Sepulveda
Rafael Sepulveda, MD, DABMS, DABOM
CME/CE Information

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How Do You Approach Weight Management as a Sleep Specialist?

Babak Mokhlesi, MD, MSc:
I might be biased because both Dr Piper and I are interested in obesity and hyperventilation syndrome, and these patients often have an extremely high body weight. So I inevitably have a discussion about their weight with them. I feel like I might do this more than my colleagues, but maybe not because I am not always in the room with them.

At the end of the day, I do not know if I do a good job because part of the issue is the delivery. Can I do it in a way that I can get buy-in from patients? I think that is a challenge for us all. It takes time for the patients to get on board and understand that obesity is a chronic disease and that it is not going to be solved within the day.

For example, those with hypertension are told to change their diet (eg, low sodium). Then they start taking antihypertensives and are going to be taking them for a long time. Why should obesity be any different, right?

The other challenge I run into sometimes is that patients do not want to talk about their weight with me. Therefore, I think it can be problematic from both ends for HCPs and patients.

Radhika S. Breaden, MD, MPH, DABMS, DABOM:
Sleep medicine as a field is heterogeneous. We come at it from many different fields. I think there are different levels with sleep medicine specialists. Some were in internal medicine for 15 years, whereas others were a primary care provider (PCP) for 15 years. How we approach discussions on weight are going to be different. This may be especially true of someone who was a neurologist or pulmonologist by training. It really depends on how that HCP got into sleep medicine. That is going to make a difference. Click here to hear Dr Almandoz comment on this topic.

Furthermore, we have advanced practice providers (APPs) who practice in sleep medicine in the United States, too. Many come from different fields of medicine, yet some may not have been in any field at all. As an aside, I recently presented on motivational interviewing and the stages of change with the HCPs at my institution. We have discussed this in the past, but I wanted to give a refresher for everybody to discuss this around OSA and obesity. After asking everyone about their background in learning this my colleagues told me that they never learned it formally. They learned about motivational interviewing and the stages of change while on the job. They were taught it while they were seeing patients. Therefore, nobody ever showed them the diagrams or made them think about it methodically. And they never received any do's and don’ts.

It was interesting to me because sleep specialists come into practice with such varied backgrounds and education. So our comfort around how you broach any health behavior change topic is going to be different.

Rafael Sepulveda, MD, DABMS, DABOM:
From my standpoint, HCPs know that there is still a lot of obesity bias in the healthcare industry. So the way that I try to approach it is to simply put weight management in my report as a recommendation like I would for CPAP therapy or use of a mandibular advancement device for someone with OSA. I ask them for permission to initiate the discussion.

You can implant the idea of: “Hey, this is something that could potentially help us.” And you can do it without being too invasive, aggressive, or harsh toward patients. That approach has helped me start the conversation more fluently with patients.

Jaime Almandoz, MD, MBA, MRCPI, FTOS:
From what I am hearing from my patients—this is secondhand from what I hear once people get to see me in the weight wellness program—there is no longer a delay in starting the conversation. But the way in which it is done is often not helpful and stigmatizing, or weight is brought up in a way that leads to frustration because they were told to lose the weight, returned for their CPAP progress, and in fact not lost weight. Some tell me they were given no tools beyond advice to lose weight as part of a clinical process metric and/or something that was pulled from integrated resources that talked about a low-fat diet, Mediterranean diet, or something else in that context.

I think there is a paradigm shift in terms of looking at obesity centrally for treating many diseases like metabolic dysfunction–associated liver disease/metabolic dysfunction–associated steatohepatitis and OSA. People want treatment; they definitely want pharmacotherapy. Click here to hear Dr Almandoz comment on this topic.

As Dr Breaden said, given the diversity in how HCPs get into sleep medicine, there are a lot of different types of training and background. HCPs may or may not have mastery of nutrition, lifestyle, or motivational interviewing. Even among my institution’s internal medicine residents, I tell them that this is their opportunity to work on their motivational interviewing skills. They have very blunt tools. For example, some might ask patients, “Help me understand the benefits of you not using your CPAP.” This is not motivational interviewing. In their minds, the internists are trying to get to the motivating factors as to why the patient is nonadherent. Even when they think they should use motivational interviewing, the skills and tools that they have are unrefined.

Amanda J. Piper, PhD:
I think it all comes back to multidisciplinary care. You have lots of patients turning up, clinics are full, and staff do not have the time to spend on these things. It ends up being just a tick of a box, as patients simply are told to lose weight or change their diet.

In particular we tend to see heavier patients whose weight issue is not just physical. There are all the psychological sides of things and a lack of support. We cannot underestimate how many people have gotten where they are—particularly looking at it from the female side—based upon the horrific histories regarding their perception of themselves and how that all came about. Simply chatting with patients and talking about therapy and/or weight loss is not enough. I do not think enough of us have these skills because we are not psychiatrists or psychologists. Those HCPs spend a lot of time on this and know how to do it properly. Click here to hear Dr Piper talk about this topic.

In addition, many sleep clinics are not dedicated to multidisciplinary care; rather the HCPs are trying to be a jack-of-all trades. You can refer some of the more severe patients off to obesity specialists. But to get them into a weight loss clinic patients have to have a BMI >40 and comorbidities. It is not useful for those patients who have weight problems, but are not within that BMI range.

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