# The impact of continuous positive airway pressure combined with lifestyle intervention on patients with obstructive sleep apnea: a multilevel meta-analysis

## TL;DR

Combining CPAP with lifestyle changes significantly improves sleep apnea, especially for those with severe cases or obesity.

## Contribution

This study provides moderate-quality evidence that lifestyle interventions enhance CPAP effectiveness in treating obstructive sleep apnea.

## Key findings

- CPAP plus lifestyle interventions reduced AHI by nearly 10 events per hour.
- Multi-component lifestyle interventions showed the greatest improvement in AHI.
- Greater benefits were observed in patients with moderate-to-severe OSA and those who lost at least 5 kg/m² in BMI.

## Abstract

Obstructive Sleep Apnea (OSA) is commonly managed with Continuous Positive Airway Pressure (CPAP), yet low adherence and insufficient metabolic improvements limit its effectiveness.

This study aimed to systematically assess the effect of CPAP combined with lifestyle interventions on OSA severity, as measured by the Apnea-Hypopnea Index (AHI), and to explore potential moderators.

This systematic review and meta-analysis followed the PRISMA 2020 guidelines. We identified randomized controlled trials (RCTs) in PubMed, Web of Science, the Cochrane Library, and Embase. Effect sizes were reported as mean differences (MD). Data were synthesized using multilevel random-effects models. Statistical heterogeneity was assessed with the I2 statistic and Cochran’s Q test. To identify potential moderators, we conducted sensitivity analyses, publication bias assessment, subgroup analyses, and meta-regression. The reliability of the evidence for each outcome was rigorously assessed using the GRADE framework.

Fourteen RCTs involving 1,623 patients were included. CPAP combined with lifestyle interventions significantly reduced AHI (MD = −9.99, 95% CI: −14.55 to −5.44, p < 0.001, GRADE: Moderate). Subgroup analyses showed greater benefits with multi-component lifestyle interventions (integrating diet, exercise, and behavioral strategies) (MD = −11.99, p < 0.001, GRADE: Moderate), intervention duration < 12 weeks (MD = −19.29, p < 0.001, GRADE: Low), moderate-to-severe OSA (MD = −11.55, p < 0.001, GRADE: Moderate), and BMI reduction of ≥ 5 kg/m2 (MD = −23.39, p < 0.001, GRADE: Low). Meta-regression analyses showed that most prespecified moderators were not statistically significant, whereas increasing age was associated with greater reductions in AHI (β = −1.12, p = 0.024).

Moderate-quality evidence indicates that CPAP combined with lifestyle interventions improves AHI in patients with OSA, particularly those with moderate-to-severe OSA, obesity, or receiving multi-component lifestyle interventions. The evidence is limited by high heterogeneity and risk of bias.

Systematic review registration: PROSPERO (CRD420251053389).