Introduction:
Obstructive sleep apnoea [OSA] is a disease characterized by repetitive narrowing or periodic collapse of the upper airway during sleep.[1] As a result, there is apnoea, hypopnoea, or both due to complete or partial obstruction of the airway. Several population-based studies have shown the prevalence of Obstructive sleep apnoea [OSAS] to be 0.3–5.1% [2–6]. In India especially amongst the urban population, there is an increase in incidence due to changes in the lifestyle. Prevalence of OSA and OSAS among Indian population is 9.3 and 2.8 respectively.[7] Increase in some diseases and lifestyle disorders like hypertension, cardiovascular disease, stroke, pulmonary hypertension, cardiac arrhythmias, and altered immune function is attributed to OSA. Motor vehicle accidents occur commonly due to dozing off.[8]
Every 10 kg increase in the weight increases risk of sleep apnoea by two times. Every increase in BMI by six increases risk by four times[2]. Morbid obesity with a BMI greater than 40–44.9 kg/m2 has been linked with reduced life expectancy and is one of the leading preventable causes of death worldwide.[5,6,9]
Dietary weight loss reduces upper airway collapse by modifying anatomy and function in obese OSA patients; 13% of weight loss can decrease nasopharyngeal airway collapsibility in obese patients with OSA.[10] Therefore in obese patients, even minimal weight loss can be beneficial as it is thought to be related to preferential loss of visceral fat first as opposed to subcutaneous fat which has metabolic advantages.[11]
Obesity is usually due to behavioral risk factors such as improper diet and lack of physical activity as well as due to genetic predisposition. Moreover, food availability, cost, meal preparation, cultural and social customs also lead to unhealthy eating habits.[3,4] Behavioral factors influenced by individuals lifestyle, culture, socioeconomic status, education and awareness status may lead to excessive caloric intake and inadequate energy expenditure due to lack of, or less of physical activity can be an explanation of most cases of obesity. [12] Other reasons which might lead to obesity may be genetics, psychiatric illness or medical problems.[13] Emergence of obesity as an endemic in today's developing and developed society is apparently due to easy availability and affordability of highly palatable unhealthy foods as well as lack of time for preparation of healthy food at home. [14,15]
At present, food perceptions of OSA patients and barriers in healthy eating are unresearched. It requires a critical insight through research of this specific population which will help the medical and paramedical team in knowing about limitations to healthy eating by this group and thus will further help in improving upon the therapeutic strategies of tackling OSA. Urgent emphasis needs to be there on inculcating healthy food habits to be rooted deep within for keeping common noncommunicable diseases (NCD) at bay and nipping the branching of new NCD’S such as OSA.
This study provides an insight into the prevalent eating habits and certain myths about foods which prevent healthy eating in OSA patients especially the obese.
Materials and Methods:
All patients having OSA on polysomnography were enrolled from out-patient Department of Otolaryngology of a tertiary care hospital from July 2016 to September 2017. It was an observational study. Informed consent was obtained from all the patients before making them participate in food and lifestyle survey and calculating their nutritional status.
When patients were called for the initial nutritional status evaluation, seeing and documenting their lack of awareness about healthy food as well as its relation to their present dietary status, a questionnaire was formed to gauge health awareness, knowledge, attitude and beliefs towards healthy eating and regard to comorbidities and OSA. Epworth Sleepiness Scale Questions were also used to obtain responses. One day food recall was asked/ probed from the patients, starting from the meal preceding the interview by using food models for identifying the exact portion size. They were asked for their awareness about healthy food items which included questions about which fats and oils they considered better to use, their opinion and frequency of consumption of sugar-free sweets, fresh and tinned juices, various beverages, sweet and salty snacks, biscuits and frozen food usage. Patient’s age, gender, height and weight was recorded to calculate their BMI; and their target weight loss inquired if they had any weight goal in their mind. Any family history of obesity or OSA was elicited. Patients were asked about their concept of healthy foods, weight gain (good, fair, and poor). The responses to various questions regarding their perceptions of food intake and any barriers to healthy eating were in the form of a yes or a no in the questionnaire. There was no right or wrong answers. A 24 hour recall form was used to take their one-day food recall. A total of
64 questionnaires were collected. Standard formula was used to calculate body mass index in kg/m2 using patient’s height and weight measurement. Average, ratios and percentages calculated for nutritional and lifestyle parameters.
Results
Majority of OSA patients were found to be men (88.28%) in the total of
64 questionnaires collected (Table-1). The average age of the patient was 43.23 ± 9.81 years (Range-20-67 years). Among them, 51% of patients were pure vegetarian, 32% were non-vegetarians, and 17% were 'eggetarians' (did not eat meat OR vegetarians but ate egg).
Of the patients, 13% had type-2 diabetes, 49% were hypertensive, 19% had NAFLD (non-alcoholic fatty liver disease) and 29% had CVD (Cardiovascular disease) (Table-2). Of the patients, 92% were from urban areas whereas 8% had the rural background (Table -1). Out of
64 patients (Table-3), 48 (43.24%) were overweight (BMI 23.9-29.9 kg/m2) with a minimum BMI of 26.2kg/m2, 29% of these overweight subjects had some weight goal to be achieved in their mind. Also, 48 patients (43.24%) were obese grade-1(BMI-.30-34.9kg/m2); out of whom, 32% had weight loss target in their mind with a specific weight number; 11 patients(9.9%) were obese grade-2 (BMI 35-39.9kg/m2) and 4 patients (6.25%) were obese grade-3(BMI=40kg/m2). Of those who were grade -2 obese, 49% had a target weight whereas of the obese grade -3 patients, 54% had a target weight.
Table 1: Demographics |
| Number of Subjects |
64 |
Age(years) |
42.48 ± 10.15 |
Males |
56 |
Females |
8 |
Vegetarian |
33 |
Non-vegetarian |
14 |
Eggitarian |
17 |
Urban population |
59 |
Rural population |
5 |
Table 2: Underlying lifestyle diseases in OSA patients |
| Diabetes |
8 |
Hypertension |
31 |
NAFLD |
12 |
CVD |
18 |
It was found that 62% of the patients showed awareness of relation of obesity and CVD, 36% patients showed awareness about obesity and diabetes, but only 3.9% showed awareness about obesity and its link with OSA. None of the patients knew anything about carbohydrate counting. Interestingly 64% of patients rated all packaged foods like chips, etc., as junk food but did not include packed salty fritters as junk food. Homemade potato pyramids, funnel cake and vegetable fritters were not categorized as junk food by 46% of patients; 73% of patients felt that olive/refined oil is a healthier choice, has fewer calories than animal fat and so can be used liberally in their diet. And 62.5% of patients consumed a packet a day of ‘high fiber' biscuits considering them to be a healthy food as advertised (on average 3-4 cookies with bed tea, 3-4 biscuits in evening tea and 2-3 biscuits on the go the whole day). When asked about healthy juice, 35.6% answered as fresh juice being healthy and consumed it as a part of breakfast or mid-morning meal whereas 34% responded unsweetened packed juices to be healthy and drank it as breakfast or mid-morning snack.
Amongst nonvegetarians, consumption of fresh chicken/mutton was on an average once a week, but frozen items were eaten four times a week with alcohol, as the evening snack or at dinner time. Usage of frozen vegetarian foods like frozen potato fries, potato cutlets, vegetable cutlets was found to be at least three times a week on an average as a breakfast item, tiffin item, evening snack item or with alcohol by vegetarian subjects. Eating out amongst urban population was on an average twice a week but ordering food at home or getting street food or hotel food at home was found to be thrice a week. Of the patients, 49.8% were under the perception of sugar-free sweets as being healthy and hence indulged. In 59% of patients, fresh fruit was not a part of their diet, and 27% did not have even one serving of vegetables as their daily diet. Also, 43% of patients described cottage cheese dish as a ‘vegetable.' Exercise routine (brisk walk, sports, swimming, etc.) was found to be missing in all the subjects. Subjects considered doing daily routine activities like household chores, going to the nearby market as exercise. Average energy intake of
64 patients per day was found to be 2886±1234kcal, protein intake was 90.5±44.62g, fat intake was 109.50±59.55 g, and carbohydrate intake was 375.68±155.69 g.
Table 3: Obesity grading and Goal weight |
| Grading of Obesity (N=64) |
Percentage of subjects |
Patients Having Weight Goal in Mind |
Overweight (with minimum BMI of 26.2kg/m2)
(BMI=23.9=29.9kg/m2) |
41.6% (N=27) |
29% (N=8) |
Obese Grade-1 (BMI=30=34.9 kg/m2) |
35.4% (N=23) |
32%(N=7) |
Obese Grade-2 (BMI=35=39.9 kg/m2) |
16.3% (N=10) |
49%(N=5) |
Obese Grade-3 (BMI=40 kg/m2) |
6.25% (N=4) |
50%(N=2) |
Overweight patients exhibited average energy, protein, fat and carbohydrate intake at 2487±796kcal/day, 80.37±43.55gm/day, 94.88±45.33gm/day and 318.8±135.84gm/day respectively.
In obese grade-1 patients, average daily intake was found to be 30002± 992 kcal of energy, 399.07±158.77 g of carbohydrates, 90.12±38.11g of protein and 110.50±62.53g of fat
Obese grade-2 patients showed average daily energy intake as 3470±788 kcals, 481.6±140.78 g of carbs and 110.89 ±42.31 gm of protein and 123.23±71.88 g of fat.
Obese grade -3 patients had an average intake of 4264±673 Kcal/day, 549.9±123.95g of carbohydrate per day, 133.9±66.36 g of protein per day and 169.9±72.43 g of fat per day (Table-4)
Macronutrient intake (energy and protein) was found to be significantly more (p=0.01) in grade-3 obese patients followed by grade-2, grade -1 and overweight patients respectively. Energy intake was mostly from carbohydrates followed by fats and proteins.
The calorie intake of the study subjects was on an average 40kcal/kg /day as compared to an ideal of 25-30kcal/kg/day for a sedentary activity.
Table 4: Macronutrient Intake as Compared to Recommended Dietary Allowances (RDA) |
| Macronutrients |
Intake in OSA Patient |
% of Energy intake (Kcals/day) |
48% more than RDA |
% of Protein Intake (g/day) |
17% less than RDA |
% of Carbohydrates (g/day) |
15% more than RDA (of which 38% were simple carbohydrates) |
% of Fats (g/day) |
39% more than RDA |
Discussion
Obstructive sleep apnoea is fast developing as a significant product of noncommunicable disease biggest trigger; that is obesity. Healthy lifestyle modification in which taming one's diet forms the most critical part can be the only preventive and somewhat curative measure for the same.
Above results show that 71% of overweight patients did not have any goal weight, partly because they did not consider their weight to be a problem. With increasing BMI, patients showed increasing tendancy to have weight goals, with obese grade 1, 2 and 3 showing goal weight percent at 32, 49 and 50 respectively. It is probably because as and when the magnitude of problems (difficulty in breathing/snoring/sleep apn oea/obesity-related health issues) increased, people wanted to achieve their target weight to avoid medical complications. The importance of losing weight without causing any significant co-morbidity should be advocated by all clinicians since obesity strongly correlates with increased risk of long-term lifestyle diseases. Obesity and its relation to OSA education were lacking in all the patients. It was found that 62% of the patients showed awareness of association of obesity and CVD, 36% patients showed awareness about obesity and diabetes but only 3.9% showed awareness about obesity and its link with OSA. This is because OSA is not yet declared a Noncommunicable disease (NCD) unlike diabetes and heart problems and is not on preventable disease public forum, so hence negligible awareness was found regarding OSA in relation with obesity. This impartment of knowledge seems urgent seeing the fact that even 10% of weight loss significantly decreased AHI (Apnea Hypopnea Index) from 24.3 to 2.9 in morbid obese OSA patients[16]. Any increase in BMI by one standard deviation leads to a risk elevation by four times of having an AHI greater than five per hour.
Indian diets are rich in carbohydrates, but when asked about knowledge about carbohydrate counting, no patient answered on a positive note. Therefore, it becomes essential for health caregivers that obese patients should be made aware of the same. This point gets emphasized by the f act from the above survey that 62.5% of the patients consumed at least a packet a day(75 g) of biscuits unaware of the fact that on an average two small (14g each) or one large cookie is equivalent to carbohydrate of 1 Indian bread (chapatti). Interestingly patients don't even count biscuits as an essential item to be told to the nutritionist/dietician during 24-hour recall intake that they consumed cookies. It always had to be probed that 'do you eat biscuits with morning or evening tea? And only then they came out with the answer. A case studies, showed that a diet low in carbohydrates might be an effective intervention for weight loss in obese patients with OSA.[17]
Consuming a fresh fruit a day was not a part of diet regimen of 59% of patients. Fresh juice was considered to be a healthier option over fresh fruits by 35.6% of patients, being unaware of the fact that juice is without any fiber and the calorie as well as sugar content of one serving of juice over one serving of fruit would be more than double. Also, 34% of patients considered ‘unsweetened' packaged juices to be healthier over fresh juice or fruit as they were fascinated by the word 'unsweetened' thinking them to be lower in calories and thus a healthier, readily available and ready to consume option despite these being sweet.
Patients were consuming packaged salty fritters as snacks did not consider them to be a significant source of calories despite the fact that 25 g (a hand full) of this type of meal gives approximately 150 kilocalories and 135 mg of sodium. Usage of refined oils was found to be rampant for cooking and frying since it was considered a low-calorie oil as compared to animal fat. Subjects were unaware of the fact that animal fat and the equal amount of vegetable oil has same calories.
Another fact that came to light was that it seemed that nobody bothered to either read the nutritive value labeling or they did not understand due to sheer lack of awareness and knowledge. Many studies have proved that consumers are getting confused with the information available on the nutrition label.[18] Usage of frozen foods both by vegetarian and nonvegetarian patients was found to be at least thrice a week emphasizing on the fact that patients perceived food preparation as a more significant barrier. This is also true for increased frequency of eating out or ordering food at home. One reason might be long working hours and thus celebration with ‘eating out’ culture or ‘ordering at home.' Food addiction/palatability is an also major issue to ponder upon as far as eating out or ordering fast food like ‘Chinese food,' pizzas and burgers were concerned since studies have correlated addition of mustard, sauces, spices such as oregano, various cheese flavorings and adding monosodium glutamate with enhanced palatability[19]. Patients reported no exercise routine in this survey and considered daily household routine as a part of an exercise of their body. It is documented though that exercise alone probably does not work well.[20] A meta-analysis on weight loss techniques concluded that diet alone might give as good results for losing weight like diet and exercise together give.[21]
It is imperative and pertinent for a multidisciplinary approach to promoting a healthy lifestyle in a patient as well his family members since the patient eats what the family makes. Whole family’s literacy level and understanding of healthy food /meals need to be studied, rectified, monitored and reinforced. In patients suspected to be having OSA especially with obesity, a questionnaire can give a clue to the diagnosis. Risk factors, consequences, and treatment for OSA can be discussed with the patients since obesity is the most modifiable risk factor which can be tackled by all the above strategies thus minimizing hospital visits, medical bills, and invasive surgeries. Detailed probe into the beliefs and exposure to the kind of food during childhood and growing years along with his food habits about food timings, types and amount and his perception ab out his health and healthy eating is of utmost importance to gauge the nutrition-related literacy concepts and to rectify the same. Taste and palatability is a significant deterrent in developing good food habits, so healthy taste preferences should be groomed in children right from the beginning of their life. This is only possible if a family is well informed about right nutrition and healthy foods choices.
Conclusion
A lack of compatibility between what obese OSA patients ate and what they perceived to have eaten regarding nutritive value of their diet was majorly contributed by lack of knowledge and awareness and due to some misconceptions about certain foods. Weight loss needs to be a parallel strategy in OSA patients even with other medical and surgical interventions. Education is a method of prevention of obesity-induced sleep apnoea. Therefore, nutritionists and dieticians have an essential role to play in nutrition education with the co-operation of other medical team s to provide a better, consistent and rationale multidisciplinary approach to promote healthy eating amongst the patients.
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