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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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Weight Loss With Bariatric Surgery as a Model

Jaime Almandoz, MD, MBA, MRCPI, FTOS:
If we use bariatric surgery as a paradigm, there currently is a lack of structure regarding antiobesity agents, especially with this new generation where patients are losing a significant amount of weight.2 In addition, patients may be more open to taking these agents vs going through bariatric surgery.

What is happening now with OSA is following the same kind of trajectory, as we look for cardiovascular risk reduction. I have seen commercial health insurers deny coverage for antiobesity agents that are prescribed for the FDA-approved indication of cardiovascular risk reduction. Yet I have seen Medicare cover this indication. This is why we fight with commercial insurers until the cows come home. The only people who are getting it covered for this indication are Medicare beneficiaries. So we have this older adult population that may have a host of social determinants of health, dentition, and/or issues with regards to nutrition. When putting them on a powerful antiobesity agent that is going to drop their body weight, is that really going to ultimately improve their health? If in the prescribing HCPs’ minds the goal is to get the patient to lose as much weight as possible as quickly as possible then they need to get patients titrated to the highest dose. That is not necessarily evidence-based obesity care. We are conflating simple weight loss because we now have the treatment to do this with good outcomes.

To get back to the question on bariatric surgery being a model—this highlights that we have a lack of structured baseline intake and assessment with regard to patients' nutrition quality, habits, and mental health. Click here to hear Dr Almandoz comment on this topic.

There is a lack of recommendations or guidance for “perititration” care for nutrition (checking in on the magnitude of weight loss), what is safe and appropriate weight loss during treatment or titration, and use of micronutrient supplements or checking certain risk groups. Again, a lot of thoughts about that when we use bariatric surgery as a paradigm for how we treat obesity.

Getting to a different question, this also demonstrates that surgery is not curative for obesity. Postbariatric weight recurrence is one of my research interests. Antiobesity agents are not curative for obesity either. I think we need to look at how to integrate this into a chronic model that emphasizes overall improvement in health, not simply weight reduction.

Babak Mokhlesi, MD, MSc:
Those are great points. My colleagues had that concern, too. Looking at the model that bariatric surgery clinics have taken, patients must show basic math skills in terms of adding up calories for each visit. My colleague is a psychologist who asked, “Well, if we want to really provide high-level care without necessarily referring patients to nutrition and obesity clinics based on the assumption that those clinics are overwhelmed too, how can we do it right? Who is going to educate us? Do we even have the bandwidth?” Those are some of the main concerns I have heard.

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OSA Guidelines Are Outdated

Babak Mokhlesi, MD, MSc:
The American Thoracic Society has guidelines on weight management in the treatment of adults with OSA. Those came out in 2018 and need to be updated with all this new research.

Rafael Sepulveda, MD, DABMS, DABOM:
If you look at those guidelines, literally the recommendation simply is weight reduction. It talks a little bit about bariatric surgery, but it does not define specific criteria or standards for weight reduction. There are no evidence-based methods for weight reduction in it.

Radhika S. Breaden, MD, MPH, DABMS, DABOM:
It only recommends a reduced-calorie diet, increased exercise/physical activity, and behavioral counseling.3

Babak Mokhlesi, MD, MSc:
To be fair, there are studies that have shown that these intensive lifestyle interventions in the short term do make an impact. Most of these studies look at results from 4 weeks to 24 months, but we do not have long-term data.4 With the novel antiobesity agents, they are still so new that we do not know about their long-term adverse effects yet.

Jaime Almandoz, MD, MBA, MRCPI, FTOS:
There are 4-year data on semaglutide from the SELECT trial that looked at cardiovascular outcomes in patients with obesity and without diabetes.5 Then there are 3-year data on tirzepatide from the SURMOUNT-1 trial that evaluated patients with obesity and prediabetes.6 There are long-term clinical trial data for that.

Radhika S. Breaden, MD, MPH, DABMS, DABOM:
Going back to bariatric surgery; so many of us sleep specialists have OSA clinics full of people who had bariatric surgery 5, 10, or 15 years ago. We are talking about the long-term follow-up that these patients never received. They may have gotten some follow up in the first 3 years, and then they never received support in the long term to help them sustain the benefits of that weight loss.

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