If you’ve ever felt like you’re waking up more tired than when you went to bed, you’re not alone. Sleep apnea affects millions of people, but it often flies under the radar and is under-diagnosed. So you might not even know you have it.
That being said, there’s also the assumption that all fat people have obstructive sleep apnea (OSA) because it’s considered an “ob*sity-related” condition. This stereotype is not only inaccurate but also deeply harmful, reinforcing stigma and antifat bias.
That’s why it’s so important to understand the facts about sleep apnea free from the weight of assumptions and blame. So let’s clear up the confusion and get straight to the facts
What is Sleep Apnea?
In simple terms, sleep apnea is a condition where your breathing repeatedly stops and starts while you sleep. It’s a big deal because these interruptions in your breathing can lead to serious health problems, like heart disease.
There are two types of interruptions:
👉Apnea: Your breathing completely stops.
👉Hypopnea: Your breathing continues, but your oxygen levels dip because you’re not getting enough air.
The terms get tricky, and we’re all guilty of using them interchangeably. But for today, let’s keep it simple — sleep apnea refers to both of these issues.
Sleep Apnea Goes By Many Names
It gets even more confusing with all the different names thrown around. You’ll hear sleep disordered breathing and obstructive sleep apnea used interchangeably. It’s not clear if there is a difference between the two, and I’m not sure even the experts agree on the correct terminology.
And here’s where it gets a little technical: Obstructive sleep apnea can be asymptomatic — meaning you may have it but not even know it. People with more severe forms, known as obstructive sleep apnea syndrome, are more likely to experience symptoms like excessive sleepiness.
A Relatively New Discovery
Sleep apnea is a relatively new condition in medical terms. We only really started understanding it in the 1970s, compared to older conditions like hypertension, which had been studied for centuries. While doctors were talking about high blood pressure in the 19th century, sleep apnea didn’t get much attention until the a few decades ago.
It was Dr. Christian Guilleminault, a pioneer in sleep medicine, who first documented the physiological effects of obstructive sleep apnea in his groundbreaking studies. These early studies suggested that repeated episodes of oxygen deprivation during sleep could place significant stress on the cardiovascular system.
In the 1980s, researchers began to identify more direct links between sleep apnea and conditions like hypertension, cardiac arrhythmias (irregular heatbeats), and heart disease. The Wisconsin Sleep Cohort Study was instrumental in providing large-scale data connecting OSA with cardiovascular risk factors, including high blood pressure and heart failure.
A landmark paper in the New England Journal of Medicine by T. Young et al. in 1993 formally established a strong association between sleep apnea and systemic hypertension, demonstrating that untreated sleep apnea significantly increases the risk of cardiovascular complications.
The Weight Debate
You’ve probably heard it before: being overweight increases the risk of sleep apnea. Yes, it’s true that higher weight is common in people diagnosed with sleep apnea. But thin people get sleep apnea too. In fact the average BMI in the HypnoLaus Study was 25.6.
Doctors are more likely to assume their higher weight patient has sleep apnea, which leads to more testing. This in turn leads to a higher rate of diagnosis. But what about the everyone else? How many doctors even consider sleep apnea as a possibility when a thin person is feeling tired all the time?
It’s no wonder that this bias is repeatedly being addressed, including a paper on the risk factors for obstructive sleep apnea in adults (Young, 2004). The authors are adamant that “symptoms should not be dismissed simply because the patient does not reflect the “Pickwickian” stereotype”. (If you don’t know which of Charles Dickens characters this author is referring to, I suggest you don’t google it).
Unpacking the Apnea-Hypopnea Index (AHI)
When you get a sleep study, one of the most important things we look at is the Apnea-Hypopnea Index, or AHI. This number tells us how many apneas (pauses in breathing) or hypopneas (partial blockages of the airway) occur in an hour of sleep. To break it down: the higher your AHI, the more severe your sleep apnea is.
Here’s how it works:
🌟Normal: Less than 5 apneas or hypopneas per hour
🌟Mild: 5 to 15
🌟Moderate: 15 to 30
🌟Severe: 30+
It’s a way to measure severity and guide treatment decisions, but let’s be clear: AHI is just a number. It doesn’t tell you everything about your health or what’s causing your symptoms.
Risk Factors: It's Not Just About Weight
A lot of people are quick to point to weight when they talk about sleep apnea. But let’s slow down and take a look at the whole picture, shall we. The truth is, several factors can increase your risk, including:
☑️Age: People over 60 are more likely to develop sleep apnea.
☑️Sex: It’s more common in men, although women are at higher risk post-menopause.
☑️Anatomy: Things like jaw structure and the shape of your upper airway can make you more prone.
☑️Family history: Like many conditions, sleep apnea tends to run in families, suggesting a genetic link.
☑️Ethnicity: Some studies show higher rates of sleep apnea among Asian populations compared to white populations.
☑️Nasal congestion: Conditions like rhinitis, sinusitis, and enlarged adenoids can impact the AHI.
And while weight can increase the likelihood of sleep apnea, it’s not the whole story. Research, like the Wisconsin Sleep Cohort study, shows that weight gain over time can increase the severity of sleep apnea. However, and this is the crucial part, association is not causation. Gaining weight doesn’t automatically cause sleep apnea. It’s just one piece of the puzzle.
There could be a number of reasons why weight gain is associated with an increased AHI. Weight cycling, weight stigma, increased stress, and poor access to medical care are just some of them. So let’s not go making assumptions, and also remember this: intentional weight loss is the number one risk factor for long term weight gain (Mann, 2007).
Symptoms: More Than Just Snoring
Not everyone with sleep apnea has symptoms. Some people may sleep through the night without realizing they have it. But for those who do, the most common are:
☑️Unrefreshed sleep: You wake up feeling like you’ve barely slept.
☑️Daytime sleepiness: If you’re feeling constantly tired or even dozing off during the day, your sleep apnea could be at play.
☑️Headaches: Especially morning headaches that fade after a few hours.
☑️Concentration and mood issues: Difficulty focusing, depression, irritability, and even hyperactivity can be linked to poor sleep quality caused by sleep apnea.
If you recognize these symptoms in yourself, it’s time to talk to your doctor. Sleep apnea is nothing to ignore, and the sooner you address it, the better. But remember – you might feel fine or you might be so used to the fatigue and waking up feeling unrefreshed that you don’t recognise an underlying issue. So if a partner mentions to you that your breathing is interrupted at night, it might be worth speaking to a doctor too.
Severe Sleep Apnea: The Case for Treatment
When it comes to sleep apnea, there’s no denying the impact it can have on health outcomes. The Wisconsin Sleep Cohort Study, which followed over 1,500 participants for up to 18 years, provides us with valuable insights (Young, 2008). The results showed that untreated severe sleep apnea significantly increases mortality risk.
For example, the risk of all-cause mortality tripled for those with severe sleep apnea was even higher when they excluded participants using CPAP therapy. When looking specifically at cardiovascular mortality, the risk was five times higher compared to those without sleep apnea.
Before you panic, remember this: these figures represent relative risks, not absolutes. If your baseline risk of dying from cardiovascular disease is very low, even a fivefold increase still keeps that risk relatively small.
It’s vital to consider the broader context rather than assuming the worst. For instance, survival rates remain high for those with mild or moderate sleep apnea and are significantly improved with CPAP therapy.
Looking Ahead: learn all about the Weight Inclusive Management of Sleep Apnea
join the masterclass
If you’d like to dive deeper into this topic, join me for my live masterclass, Thin People Also Get Sleep Apnea, where we’ll explore the topic in more detail without the stigma. I’ll answer your questions live on Tuesday, the 10th of December, at 2 p.m. UK time (GMT).
Don’t worry if you can’t make the live event, or the date has already past. You can catch up on the replay anytime.