Misconceptions about Sleep Apnea and Weight

By Anh – Licensed Practical Nurse

There are quite a few misconceptions when it comes to the link between weight and sleep apnea. Through my experience over the years, I came to realize that people generally think that people who are overweight are more likely to either have or develop Sleep Apnea. 

I have had patients who held a preconceived notion that they could not have sleep apnea because they are very thin. Or, they would say that, according to their physician, they are not a typical candidate for sleep apnea. This was always interesting to me. 

The most common things we should look at are anatomy and common risk factors, not just weight alone. 

In this article, I will discuss the misconceptions about weight in relation to sleep apnea and the main things we look for when assisting physicians in the screening process for sleep apnea.

Yes, it is possible that if you are overweight, your chances of having sleep apnea increase, but the reasoning is what is important. 

Let’s say you have a larger neck; then there is likely going to be more tissue within your neck. When you’re in a very deep sleep, your body takes over your breathing, and you are in an unconscious state. 

The tissues and muscles within your neck relax, and it actually does not take much before your airway can become obstructed due to the excess tissue. This, however, would also apply to someone who is very muscular in the neck area or is not overweight but has a larger neck. 

Someone with a neck circumference of 17 inches or more would have a higher risk of testing positive for sleep apnea. However, when the neck is very small, this could also be an issue.

I have tested patients who were considered underweight or average, and they ended up presenting with severe sleep apnea. 

Yes, there may be less tissue, but there is also less space for the airway, so again when you’re relaxed in a deep sleep, it would be easy for the airway to be obstructed. 

I have also tested patients who weighed over 300 pounds but did not have sleep apnea or had a very mild case. So, it is not always determined by weight.

When talking about anatomy, we also should look at the genetic factor. If your parents or grandparents had sleep apnea, the chance that you have sleep apnea as well is higher. 

For example, if one of your parents had a recessed chin or a higher Mallampati score, this could also transfer over to you. Because sleep apnea is much more studied, and treatment is more readily available now, it is very important to get screened for sleep apnea if you have any of the typical signs and symptoms.

One of the most useful tools used to determine the risk of sleep apnea is not weight related at all, and it is called the Mallampati. The Mallampati can be used to help physicians determine if your oral cavity may be causing you to be more at risk for sleep apnea. 

This is a test that a healthcare professional can administer just by looking at the back of your throat when you open your mouth very wide and stick your tongue out as far as you can. 

There are four different classes of the Mallampati:

Class 1: Complete visualization of the Soft Palate and the Uvula

Class 2: Complete visualization of the Uvula

Class 3: Visualization of the base of the Uvula only

Class 4: The Soft Palate and the Uvula are not visible at all.

The higher the Class, the higher your risk of sleep apnea. When you have a Class 3 or 4 Mallampati, the chances of your upper airway obstructing increase by quite a bit.

When you are sleeping on your back especially, your tongue may relax to the point where it can fall to the back of your throat and cause an obstruction. 

Class 4 patients usually snore. Snoring is actually an indication that air is still passing through the airway. That said, snoring should not be viewed as a good thing as it can be disruptive to not only your sleep but your partner’s as well.

Snoring occurs when there is only a partial obstruction. Even with partial obstructions, which we call hypopnea, it can still lower your oxygen levels and cause stress to your heart, depending on how often and how long it occurs during the night.

A deviated septum is another example of upper airway obstruction. If you have a deviated septum, you may have issues breathing in your nose through one nostril, or when you lie down, you can’t breathe through your nose at all. 

This could be an issue because you’re not only dealing with the possibility that your tongue could fall back or the tissues in your neck could relax and block your airway, but you may not be able to breathe properly through your nose, as well. 

So, now you have multiple points of concern. Some people are born with a deviated septum, and others may have had some physical trauma that caused the deviation. A deviated septum would generally be repairable through surgery, depending on the deviation.

A general practitioner should be able to look up your nose to see if this may be an area of concern for you. You would then need to be referred to an Ear Nose Throat (ENT) specialist to help determine if surgery would be an option to repair/reconstruct your nose to help improve your breathing.

In some cases, an ENT specialist may remove a patient’s adenoids, tonsils, uvula, or perform extensive jaw surgery to help open the airway. This is not always effective because, unfortunately, some tissues, such as scar tissue or adenoids, though not tonsils, do grow back.

My stepfather is an example of someone who had his adenoids, tonsils, and uvula removed, which was a toll in itself. Because these tissues were removed when he was an adult, the healing process was a bit longer than if a child had had these procedures.

Even after the surgery, he is still required to use a CPAP machine. Because his oral space is quite small, and his Mallampati is 4, he instantly obstructs as soon as he falls asleep. He also has a larger neck, which does not help the situation, either. 

If a patient is recommended CPAP or BiPAP therapy or surgery as an option for the treatment of sleep apnea, I would always recommend trying the devices first. The surgery is invasive, and the healing process can be very uncomfortable. The success rate is also not very high.

Age and sex are also quite important in the sleep apnea diagnosis. Men are twice as likely to have sleep apnea than women. Many different factors are reviewed in studies when comparing men to women. 

Some of these factors include weight, hormones, breathing patterns, aging, and upper airway anatomy. Some women have no symptoms or risk factors when younger in life, but may still develop sleep apnea when they are older, especially in the menopausal period. 

Progesterone and estrogen can both enhance the female’s ability to counteract the upper airway collapsing during sleep. Progesterone helps prevent disturbances in sleep, which could lead to more regular breathing at night. 

Once we age, and these hormone levels decrease, the chances of obstructions and hypopneas may increase. This is why it’s important to get screened for sleep apnea as an older woman if she has any new symptoms that develop later in life.

As we age, our skin, tissues, muscles, etc., lose the tone and elasticity they used to have when we were younger. Things start to relax more, skin starts to sag, and the same happens to tissues inside our bodies. 

Some people are more likely to develop sleep apnea later in life because they are a class 2 or 3 Mallampati or their tissues in the neck do not have the same elasticity as before. 

The body changes as we age, so it’s important that we monitor any new symptoms that develop, as sleep apnea can affect your life negatively in many ways. It can also lead to many other health issues if left untreated.

Comorbidities can also be a major indicator of sleep apnea. If you are diagnosed with any condition that weakens the connective tissues or muscles, conditions that also weaken your heart or ability to breathe normally could make you more likely to be more at risk, as well.

Some of the most serious comorbidities for sleep apnea are stroke, heart disease, and diabetes. Cardiovascular, cerebrovascular, and respiratory comorbidities are very important for doctors to determine risk factors for sleep apnea. 

Atrial fibrillation, atrial flutter, excessive irritability, depression, and high blood pressure can often be related to sleep apnea, so it is important to follow up with your physician to get screened for sleep apnea to at least rule in or rule out the diagnosis.

As you can see, there are many different things we can look at when screening for sleep apnea, and weight is definitely not the most important factor when it comes to a physician’s screening process. 

Screening for sleep apnea is, of course, very important, but it is the testing that produces the actual results. Sleep apnea testing can consist of an at-home sleep study that you can complete in the comfort of your own home. Read the article talking about home sleep tests here. 

Polysomnography, an overnight sleep study, is usually completed at the hospital or a private clinic. It can be used to help physicians diagnose a multitude of sleep disorders, not only sleep apnea.

I hope this article has given you some insight into the misconceptions about weight in relation to the screening process for sleep apnea, as well as the many risk factors that should not be ignored.