CE / CME
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
How Should Weight Management Be Incorporated into Comprehensive OSA Care?
Babak Mokhlesi, MD, MSc:
My wish list would be for me to become more educated in terms of how to best implement weight management, including use of antiobesity agents and not having to deal with the barriers of getting these treatments for patients.
Then to be able to recognize which patients are best served by obesity experts and endocrinologists would help. I am thinking of patients with OSA who are already diagnosed with diabetes. Of course some of those patients would already be on insulin, but I do not think I would feel comfortable with managing these patients’ care. So coming up with ways to recognize which patients are the appropriate ones for me to manage and to do it in a safe way without having so many barriers is the ideal. I think a lot of us are shying away from or concerned about the whole prior authorization business.
Radhika S. Breaden, MD, MPH, DABMS, DABOM:
Honestly, what I would say is that every single sleep clinic would need to reinvent the wheel on their education, which is incredibly daunting. I would like to see something like the narcolepsy treatment models where resources are given to me and patients through a nurse-care management system that is provided through the manufacturer.
I also would like to have educational resources that explain to patients what obesity is, that it is a chronic disease, and basic information on the available treatments. This way I can tell patients that if they are interested in these agents, they are wonderful tools. I could have them watch educational modules and then sit down with them to talk about their individual preferences. Then I would not have to go through the basics every single time for every single patient.
Then having some nurse follow-up and an online resource that hosts food diary resources, nutritional education around protein, and maybe some discounted exercise opportunities would be ideal. Again, it is not as if every single HCP must reinvent the wheel for all of the parts of care in their area of expertise. But it becomes a comprehensive care program, not just a therapy that I was prescribed to a patient.
If we had a comprehensive care program to help patients manage their OSA, I can then prescribe and help get them that additional information. I also could log into something on the cloud were patients could log their weight and diet. With this, I could better understand where they are and what is going on. That would be my wish list for integrating weight management into comprehensive OSA care.
Rafael Sepulveda, MD, DABMS, DABOM:
My wish is that my staff would not have to spend so much time on prior authorizations. Rather, I would like them to spend more time educating patients. All my staff are well versed in almost everything about tirzepatide, but I find that they spend more time fighting with health insurance companies than actually helping patients.
I would like to see registered dietitians and APPs more involved in care of patients because we have to reinforce that nutritional component. And maybe adding some more culinary medicine into treatment plans via a registered dietitian or other HCPs.
Jaime Almandoz, MD, MBA, MRCPI, FTOS:
I do not need the infrastructure; I have my wish list already in my office. In hearing all of this, I would like to outsource some of this to the manufacturers. I would like to have an easier process so that office staff is not bogged down by this.
When it comes to the comanagement of patients’ cardiometabolic issues (ie, blood pressure, titration) is that something sleep specialists are willing to own? Or is this something that sleep specialists do not want to own and need to partner with primary care? I have not heard about this kind partnership yet. Also, does that relationship need to be strengthened or reinforced as part of this? Or do we think that the dedicated sleep societies are going to update or release new guidelines with care pathways for sleep specialists and their APPs, indicating that these HCPs own all of this as part of treating OSA?
Radhika S. Breaden, MD, MPH, DABMS, DABOM:
I think they must partner.
Rafael Sepulveda, MD, DABMS, DABOM:
In my case, it is a little bit weird because I own the weight management and sleep aspect of OSA care. I am in a small community-based clinic. I know all the PCPs in the area, and we will call each other when there is a concern. But not everybody has that type of connection with their community HCPs.
Amanda J. Piper, PhD:
In Australia and probably the United Kingdom/Europe, it is called a sleep clinic, and people are only presenting at these clinics due to concerns about their sleep. I think there are so many other comorbidities that these patients have, but we do not have the skills to address them right across the board. Having a more multidisciplinary model where patients come in and can see an endocrinologist and dietitian would be ideal.
In addition, a lot of the bigger hospitals are seeing the more complex patient cases and patients can only be seen on a fairly limited basis; maybe once every 3, 6, or 12 months. These patients need that follow-up. Click here to hear Dr Piper comment on this topic.
I think primary care needs support. We need some community management of these patients because treating obesity requires treatment of a multisystem disease. It is not just about sleep; it is about all these other things that we have brought up. Community support, psychological care, and dietitian and nutritionist visits are all important aspects of this because it is easy for people to just tick a box and provide a pill that will allow patients to lose weight.
Addressing Complex Patient Cases and Changing Attitudes
Babak Mokhlesi, MD, MSc:
Most patients with obesity that I see have gone through the challenges of dieting and making lifestyle modifications. For the most part the majority of patients have tried those things and they have had success and failures over their lifespan. So we are almost preaching to the choir, right? Therefore, my question is, how frequently do patients present to a sleep clinic and are just interested in these agents? What is the right approach? Because ideally we want to provide that comprehensive approach. If patients are not interested in doing the necessary lifestyle modifications and just want therapy, is it the right thing to give it to them or not? Dr Almandoz, what is your approach?
Jaime Almandoz, MD, MBA, MRCPI, FTOS:
I will flip this question around. Imagine you are seeing a patient for posthospital follow-up after myocardial infarction and stenting. In evaluating their diet recall, you notice that the patient is eating ultra-processed food and a lot of saturated animal fat. In this case, would I say to them: “I do not think you care enough about changing your diet for me to give you the statin or PCSK9 inhibitor.” Is this the right thing to do?
What we do have is evidence-based therapy. But HCPs are introducing different levels of bias and stigma into their clinical decision-making that they may not hold for other disease states. For example, HCPs might not bother sending a prescription through because they do not want to go through the headache of the paperwork if they think the patient will not adhere to the treatment.
If we look at obesity through the same lens as other disease states, we would realize that we treat it very differently. I will push back a bit because I think what somebody's assessment is in a 15- to 20-minute office visit—if the patient’s baseline motivation to do what that HCP thinks is the most appropriate thing to do for them—is perhaps not the best way to treat a very complex disease.
Radhika S. Breaden, MD, MPH, DABMS, DABOM:
As a sleep specialist, I am going to discuss the SURMOUNT-OSA study. The general weight loss guidelines recommend 150 minutes a week of physical activity and 500-1000 kilo calorie reduction per day.7 One study found that a 20% reduction in BMI is associated with a 57% reduction in AHI.8 I would expect a general willingness from patients to attempt lifestyle modifications as part of their readiness for change and a part of their OSA treatment. In the same way when I prescribe CPAP, I expect that patients are going to pick it up and attempt to put it on their face. Do I think they are going to do it perfectly with 100% compliance? No, because we are all human. But I would expect them to have the willingness to try it. I also would expect to work with them in offering support and overcoming barriers. Click here to hear Dr Breaden comment on this topic.
If patients tell me that they are not going to exercise or make changes to their diet, but they want an antiobesity agent—that is not the attitude that I really think is appropriate for using this therapy for treating OSA. That is my objective as a sleep specialist. I am not giving it for obesity personally in my clinic. I do not run an obesity clinic.
Furthermore, patients cannot just have it their way all the time. If they present to a sleep clinic just for a prescription because they happen to have OSA as a diagnosis on their list and we write that prescription, we run the risk of those patients disappearing and never coming back or attempting to do follow-up for their OSA.
Rafael Sepulveda, MD, DABMS, DABOM:
A lot of this is about commitment. For example, I have a lot of patients who are postbariatric surgery and experience significant weight regain. I also have patients who are in wheelchairs because of their weight. At that point, they really cannot do aerobic physical activity that easily. It also is about meeting them where they are and building up from there.
Amanda J. Piper, PhD:
It also comes back to having education emphasize that using these agents is not just about treating obesity. Patients have a chronic disease and there are other aspects to it. It is not just about giving a pill or injectable. It might take time for patients to absorb all that information. Yes, we want to try and get that weight off because that is going to have benefits, but we also need to continue to manage patients as an entire person.
That is why either engaging them with some community program or with us as HCPs is incredibly important. We need to change their minds about antiobesity agents. They are not just a tool to lose the weight but it is helping them manage a chronic disease. Obesity is a multisystem disease that has all sorts of factors. There might also be some other psychological and mental aspects to it. So patients need support beyond just receiving a prescription. We should ensure that they understand this and that we provide a supportive environment for them.
Closing Thoughts
Babak Mokhlesi, MD, MSc:
I really liked what Dr Almandoz said about other chronic conditions that are actually even more serious than obesity, where people get evidence-based medications. Thinking about advanced heart failure, hepatitis C, HIV; these patients get their treatments and then go about their business. Many times, they do not follow all the other recommendations that we give them.
My fear is of course that we discuss lifestyle changes and engage patients but we do not have the resources in a 15- to 20-minute visit. It becomes very complicated, and we just do not have the time. What I tell my colleagues is that we can refer patients to nutrition and obesity clinics to start the intervention. But whether patients go to those clinics or those clinics can get them in within 3 months is a matter of debate. Do we then deny them the antiobesity agent while they are waiting? Those are the back and forth things we were seeing. And I feel like everybody is struggling with that because it is a real issue.
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