L E T T E R S TO T H E E D I TO R
pii: jc-00237-15 http://dx.doi.org/10.5664/jcsm.5032
Obstructive Sleep Apnea is Not Associated with an Increased Risk of Osteoporosis: a Systematic Review and Meta-Analysis Sikarin Upala, MD, MS1,2; Anawin Sanguankeo, MD1,2; Soontharee Congrete, MD1
1 Department of Internal Medicine, Bassett Medical Center and Columbia University College of Physicians and Surgeons, Cooperstown, NY; 2Department of Preventive and Social Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Thailand
W
e read the article written by Chakhtoura et al.1 with interest. The authors reviewed potential mechanisms of bone loss and osteoporosis in patients with obstructive sleep apnea (OSA). However, the authors did not perform systematic review on all articles related to this topic. We completed a systematic review and meta-analysis of published observational studies evaluating obstructive sleep apnea and incidence of osteoporosis compared with non-apnea individuals. Reviews, case reports, letters, commentaries, abstracts, and unpublished studies were excluded. OSA was diagnosed by having polysomnography measured. Individuals who had osteoporosis at baseline were excluded. We performed a systematic search from the Cochrane Central Register of Controlled Trials, PubMed/MEDLINE, and EMBASE databases until May 2015. We estimated the pooled risk ratio (RR) of osteoporosis comparing between OSA and non-OSA groups using a random effects model in the Review Manager 5.3 software from The Cochrane Collaboration. We also reported the pooled mean difference (MD) of a bone mineral density (BMD) measured by T-score at femur between OSA and non-OSA groups. The heterogeneity of effect size estimates across these studies was quantified using the I2 statistic and Q statistic. A total of 9 articles underwent full-length review. Data from five cohort studies2–6 involving 113,137 participants were extracted and included in the meta-analysis. The analysis on risk of osteoporosis revealed that the pooled RR in participants with obstructive sleep apnea compared with controls was 1.37 (95 % confidence interval [CI]: 0.71–2.62, p = 0.34). The statistical between-study heterogeneity was high with an I2 of 92%. In the analysis of BMD measured by T-score at femur, the pooled MD was −0.03 (95% CI: −0.19 to 0.14, p = 0.76, I2 = 56%). Although previous studies had demonstrated that severe OSA was associated with increased bone resorption,7 our analysis did not find a significant association of osteoporosis and OSA, or a difference in bone loss between the two groups. This may be explained by a potential mechanism that higher body weight in patients with OSA is beneficial to bone because of the positive effect of mechanical loading conferred by body weight on bone formation.8–10
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A major limitation of our study was the small number of studies that met our inclusion criteria. Another limitation is that the results analyzed were from observational studies, which might be confounded by unadjusted factors such as age, gender, BMI, medication, and comorbidities, all of which might affect the risk of osteoporosis. In conclusion, this is the first systematic review and metaanalysis of published observational studies to evaluate the association between obstructive sleep apnea and risk of having osteoporosis. Further controlled studies with adjusted effects for age, sex, or BMI are needed to accurately investigate the relationship between osteoporosis and OSA.
CITATION Upala S, Sanguankeo A, Congrete S. Obstructive sleep apnea is not associated with an increased risk of osteoporosis: a systematic review and meta-analysis. J Clin Sleep Med 2015;11(9):1069–1070.
REFERENCES 1. Chakhtoura M, Nasrallah M, Chami H. Bone loss in obesity and obstructive sleep apnea: a review of literature. J Clin Sleep Med 2015;11:575–80. 2. Wang TY, Lo YL, Chou PC, et al. Associated bone mineral density and obstructive sleep apnea in chronic obstructive pulmonary disease. Int J Chron Obstruct Pulmon Dis 2015;10:231–7. 3. Chen YL, Weng SF, Shen YC, et al. Obstructive sleep apnea and risk of osteoporosis: a population-based cohort study in Taiwan. J Clin Endocrinol Metab 2014;99:2441–7. 4. Yen CM, Kuo CL, Lin MC, et al. Sleep disorders increase the risk of osteoporosis: a nationwide population-based cohort study. Sleep Med 2014;15:1339–44. 5. Sforza E, Thomas T, Barthelemy JC, Collet P, Roche F. Obstructive sleep apnea is associated with preserved bone mineral density in healthy elderly subjects. Sleep 2013;36:1509–15. 6. Schiza SE, Bouloukaki I, Mermigkis C. Bone mineral density in patients with obstructive sleep apnea syndrome. Sleep Breath 2013;17:17–8. 7. Tomiyama H, Okazaki R, Inoue D, et al. Link between obstructive sleep apnea and increased bone resorption in men. Osteoporos Int 2008;19:1185–92. 8. Reid IR. Relationships among body mass, its components, and bone. Bone 2002;31:547–55. 9. Felson DT, Zhang Y, Hannan MT, Anderson JJ. Effects of weight and body mass index on bone mineral density in men and women: the Framingham study. J Bone Miner Res 1993;8:567–73. 10. Mariani S, Fiore D, Varone L, et al. Obstructive sleep apnea and bone mineral density in obese patients. Diabetes Metab Syndr Obes 2012;5:395–401.
Journal of Clinical Sleep Medicine, Vol. 11, No. 9, 2015
S Upala, A Sanguankeo and S Congrete
SUBMISSION & CORRESPONDENCE INFORMATION
DISCLOSURE STATEMENT
Submitted for publication June, 2015 Accepted for publication June, 2015 Address correspondence to: Anawin Sanguankeo, MD, Department of Internal Medicine, Bassett Medical Center, 1 Atwell Road, Cooperstown, NY 13326; Tel: (607) 547-4805; Fax: (607) 547-6612; Email: [email protected]
Journal of Clinical Sleep Medicine, Vol. 11, No. 9, 2015
The authors have indicated no financial conflicts of interest.
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pii: jc-00237-15 http://dx.doi.org/10.5664/jcsm.5032
Obstructive Sleep Apnea is Not Associated with an Increased Risk of Osteoporosis: a Systematic Review and Meta-Analysis Sikarin Upala, MD, MS1,2; Anawin Sanguankeo, MD1,2; Soontharee Congrete, MD1
1 Department of Internal Medicine, Bassett Medical Center and Columbia University College of Physicians and Surgeons, Cooperstown, NY; 2Department of Preventive and Social Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Thailand
W
e read the article written by Chakhtoura et al.1 with interest. The authors reviewed potential mechanisms of bone loss and osteoporosis in patients with obstructive sleep apnea (OSA). However, the authors did not perform systematic review on all articles related to this topic. We completed a systematic review and meta-analysis of published observational studies evaluating obstructive sleep apnea and incidence of osteoporosis compared with non-apnea individuals. Reviews, case reports, letters, commentaries, abstracts, and unpublished studies were excluded. OSA was diagnosed by having polysomnography measured. Individuals who had osteoporosis at baseline were excluded. We performed a systematic search from the Cochrane Central Register of Controlled Trials, PubMed/MEDLINE, and EMBASE databases until May 2015. We estimated the pooled risk ratio (RR) of osteoporosis comparing between OSA and non-OSA groups using a random effects model in the Review Manager 5.3 software from The Cochrane Collaboration. We also reported the pooled mean difference (MD) of a bone mineral density (BMD) measured by T-score at femur between OSA and non-OSA groups. The heterogeneity of effect size estimates across these studies was quantified using the I2 statistic and Q statistic. A total of 9 articles underwent full-length review. Data from five cohort studies2–6 involving 113,137 participants were extracted and included in the meta-analysis. The analysis on risk of osteoporosis revealed that the pooled RR in participants with obstructive sleep apnea compared with controls was 1.37 (95 % confidence interval [CI]: 0.71–2.62, p = 0.34). The statistical between-study heterogeneity was high with an I2 of 92%. In the analysis of BMD measured by T-score at femur, the pooled MD was −0.03 (95% CI: −0.19 to 0.14, p = 0.76, I2 = 56%). Although previous studies had demonstrated that severe OSA was associated with increased bone resorption,7 our analysis did not find a significant association of osteoporosis and OSA, or a difference in bone loss between the two groups. This may be explained by a potential mechanism that higher body weight in patients with OSA is beneficial to bone because of the positive effect of mechanical loading conferred by body weight on bone formation.8–10
1069
A major limitation of our study was the small number of studies that met our inclusion criteria. Another limitation is that the results analyzed were from observational studies, which might be confounded by unadjusted factors such as age, gender, BMI, medication, and comorbidities, all of which might affect the risk of osteoporosis. In conclusion, this is the first systematic review and metaanalysis of published observational studies to evaluate the association between obstructive sleep apnea and risk of having osteoporosis. Further controlled studies with adjusted effects for age, sex, or BMI are needed to accurately investigate the relationship between osteoporosis and OSA.
CITATION Upala S, Sanguankeo A, Congrete S. Obstructive sleep apnea is not associated with an increased risk of osteoporosis: a systematic review and meta-analysis. J Clin Sleep Med 2015;11(9):1069–1070.
REFERENCES 1. Chakhtoura M, Nasrallah M, Chami H. Bone loss in obesity and obstructive sleep apnea: a review of literature. J Clin Sleep Med 2015;11:575–80. 2. Wang TY, Lo YL, Chou PC, et al. Associated bone mineral density and obstructive sleep apnea in chronic obstructive pulmonary disease. Int J Chron Obstruct Pulmon Dis 2015;10:231–7. 3. Chen YL, Weng SF, Shen YC, et al. Obstructive sleep apnea and risk of osteoporosis: a population-based cohort study in Taiwan. J Clin Endocrinol Metab 2014;99:2441–7. 4. Yen CM, Kuo CL, Lin MC, et al. Sleep disorders increase the risk of osteoporosis: a nationwide population-based cohort study. Sleep Med 2014;15:1339–44. 5. Sforza E, Thomas T, Barthelemy JC, Collet P, Roche F. Obstructive sleep apnea is associated with preserved bone mineral density in healthy elderly subjects. Sleep 2013;36:1509–15. 6. Schiza SE, Bouloukaki I, Mermigkis C. Bone mineral density in patients with obstructive sleep apnea syndrome. Sleep Breath 2013;17:17–8. 7. Tomiyama H, Okazaki R, Inoue D, et al. Link between obstructive sleep apnea and increased bone resorption in men. Osteoporos Int 2008;19:1185–92. 8. Reid IR. Relationships among body mass, its components, and bone. Bone 2002;31:547–55. 9. Felson DT, Zhang Y, Hannan MT, Anderson JJ. Effects of weight and body mass index on bone mineral density in men and women: the Framingham study. J Bone Miner Res 1993;8:567–73. 10. Mariani S, Fiore D, Varone L, et al. Obstructive sleep apnea and bone mineral density in obese patients. Diabetes Metab Syndr Obes 2012;5:395–401.
Journal of Clinical Sleep Medicine, Vol. 11, No. 9, 2015
S Upala, A Sanguankeo and S Congrete
SUBMISSION & CORRESPONDENCE INFORMATION
DISCLOSURE STATEMENT
Submitted for publication June, 2015 Accepted for publication June, 2015 Address correspondence to: Anawin Sanguankeo, MD, Department of Internal Medicine, Bassett Medical Center, 1 Atwell Road, Cooperstown, NY 13326; Tel: (607) 547-4805; Fax: (607) 547-6612; Email: [email protected]
Journal of Clinical Sleep Medicine, Vol. 11, No. 9, 2015
The authors have indicated no financial conflicts of interest.
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