which may mediate the development of glucose intolerance, insulin resistance, and, ultimately, type 2 diabetes. Because diabetes is also a risk factor for cardiovascular disease, the interrelationships may partly explain why OSA predisposes to cardiovascular disease (Punjabi and Beamer, 2005).

Obstructive Sleep Apnea May Contribute to Obesity

Up to 40 percent of people who are morbidly obese have OSA (Vgontzas et al., 1994). This finding may reflect the role of obesity as a well-established risk factor for the development of OSA. It may also reflect obesity as a consequence of OSA, although the evidence is not yet conclusive (Grunstein, 2005b). Patients with newly diagnosed OSA, compared with controls matched for BMI and percent body fat, show recent weight gain (Phillips et al., 1999). Data from the Wisconsin Sleep Cohort also show that individuals with OSA have reduced levels of physical activity; OSA-related sleepiness may contribute to changes in activity and energy expenditure, and thus contribute to weight gain. OSA-related hormonal changes may also contribute to obesity. In general, patients with OSA have higher levels of leptin, the appetite-suppressing hormone (Phillips et al., 2000; Palmer et al., 2004; Patel et al., 2004) than controls. However, their morning levels are relatively lower than evening levels (Patel et al., 2004). Thus, either via leptin resistance (where high levels of leptin are present, but tissues are poorly responsive to leptin’s action) or because of disturbances in diurnal variability in leptin, individuals with OSA may be predisposed to lower effective levels of appetite suppressing hormones. Although CPAP reduces leptin levels, it is not known whether such effects relate to differences in the effectiveness of leptin’s actions (Chin et al., 2003). Furthermore, obesity also affects the severity of OSA. Significant weight loss in adolescents who underwent gastric bypass surgery (mean, 58 kg) was associated with a dramatic reduction of OSA severity (Kalra et al., 2005).

Etiology and Risk Factors

In simplest terms, OSA is caused by narrowing or collapse of the airway as a result of anatomical and physiological abnormalities in pharyngeal structures. Apnea episodes cause hypoxemia (insufficient oxygen in the blood) and hypercapnia (high concentration of blood carbon dioxide). The episodes also increase the output of the sympathetic nervous system (Narkiewicz and Somers, 2003), the effect of which is to restore pharyngeal muscle tone and reopen the airway. Although increased sympathetic activity is beneficial for restoring normal breathing and oxygen intake over the short term, it has long-term deleterious effects on vascular tone and blood pressure, among other effects (Caples et al., 2005). These early events—which are



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