Obstructive Sleep Apnea Is Not an Independent Determinant of Testosterone in Men

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B M Clarke and others Testosterone is dependent on 183:1 31–39 Clinical Study obesity not OSA

Obstructive sleep apnea is not an independent determinant of testosterone in men

Brigette Marie Clarke1,2, Andrew D Vincent3, Sean Martin2,3, Robert Adams2,4, Sarah Appleton2,3,4, Andrew Vakulin4,5, David Jesudason1,2,6 and Gary Allen Wittert1,2,3

1Department of Endocrinology and Metabolism, Royal Adelaide Hospital, Adelaide, South Australia, Australia, 2School of Medicine, The University of Adelaide, Adelaide, South Australia, Australia, 3Freemason Foundation Centre for Men’s Health, University of Adelaide, Adelaide, South Australia, Australia, 4Adelaide Institute for Sleep Health: A Flinders Centre of Research Excellence, College of Medicine and Public Health, Flinders University, Bedford Park, Correspondence South Australia, Australia, 5NeuroSleep – NHMRC Centre of Research Excellence, Woolcock Institute of Medical should be addressed Research, University of Sydney, Sydney, New South Wales, Australia, and 6Department of Endocrinology and to G A Wittert Diabetes, Queen Elizabeth Hospital, Woodville, South Australia, Australia Email [email protected]

Abstract

Objective: Obstructive sleep apnea (OSA) is generally considered to lower serum testosterone concentration in men, although data supporting this as a direct effect are limited. The aim of this study was to determine the relationship between the presence and severity of OSA and testosterone in a community-based cohort of men aged over 40 years. Design and methods: Anthropometry, polysomnography and biomedical information were collected from enrolled, consenting men from the prospective, longitudinal MAILES study cohort. Fasting morning blood samples (n = 1869) were drawn between 2010 and 2012 for measurement of testosterone using liquid chromatography mass spectrometry. Home polysomnography was completed in 861 men between 2010 and 2012. The final analysis sample consisted of 623 men aged 41–86 years. The effect of OSA on testosterone were analyzed using linear regression models controlling for potential confounders (age, BMI and sex hormone binding globulin (SHBG)). European Journal of Endocrinology Results: The mean (s.d.) cohort characteristics were: age 59.0 (10.2) years, testosterone 16.8 (5.3) nmol/L, SHBG 32.9 (13.1) nmol/L, BMI 28.6 (4.2) kg/m2 and apnoea hypopnoea index (AHI) 14.9 (13.7). OSA was present in 51.5%. There was an inverse relationship between AHI and testosterone (P = 0.01), which was lost after covariate adjustment. Conclusions: These data suggest that obesity, rather than OSA per se, determine testosterone concentration. This accords with the graded effect of weight loss, but limited effect of continuous positive airway pressure to increase testosterone, and highlights the importance of managing obesity in men with low testosterone concentration, particularly in the context of OSA.

European Journal of Endocrinology (2020) 183, 31–39

Introduction

Obstructive sleep apnea (OSA) is characterised by the condition, the prevalence of OSA rises with increasing recurrent interruption of breathing during sleep due to a obesity. In patients being evaluated for bariatric surgery, collapse of the upper airways. Recent data from different 71% of individuals with a BMI between 35–40 kg/m2 were countries reveal it to be a common disorder, with a diagnosed with OSA on polysomnography, with the figure reported prevalence around 50% in middle-aged and older rising to 95% among those with class 3 obesity and a BMI men (1, 2). Although not an exclusively obesity-related >60 kg/m2 (3). These findings were supported by a recent

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-19-0978 European Journal of Endocrinology https://eje.bioscientifica.com underwent polysomnography.underwent Atotalof238menwere From thisgroup,arandomly selectedsample( OSA diagnosis(75.2%)initially agreedtoparticipate( a sleepstudy. Overall, 1087of1445withoutaprevious with OSAasleepstudy?’ were invited toundergo reporting ‘No’ whenasked ‘Have you ever beendiagnosed identify menwithapriordiagnosisofOSA.Subjects completed byMAILES study participants ( 2012. 2010 andFebruary sleep assessments(M4)completedbetweenSeptember between 2007 and 2010 (time point codes M2, M3) and assessments, includingfastingbloodsamplescompleted current studywerecollectedfromfollow-upbiomedical purpose andnatureofthestudy. Dataforanalysis inthe written informedconsentafterfullexplanationofthe (approval number:2010054).Allparticipantsprovided number: 020305)andNorthWest AdelaideHealthService Committees oftheRoyalAdelaideHospital(approval The studywasapprovedbytheHumanResearch Ethics the community, aged 35 years or more atenrolment. described ( and Stress(MAILES)Study, ashaspreviouslybeen The MenAndrogenInflammationLifestyleEnvironment Study participantsandprotocol Subjects andmethods sleep study( half ofwhomwererandomlyinvitedtoundergoahome cohort ofmiddle-agedandelderlymen,approximately a comprehensivelycharacterizedcommunitydwelling severity ofOSAandserumtestosteroneconcentrationin examined the relationship between the presenceand clinical view that OSA causes low testosterone levels, we circumference ( non-significant afteradjustmentforeitherBMIorwaist concentration andOSA;however, thisassociationbecame detected arelationshipbetweenlowtestosterone 7 limited orabsentcovariatesinthedataanalyses( studydesign,smallsamplesizesand by observational Interpretation of many of thesestudies has been hampered reported in some ( and serum testosterone concentration in men has been associated withanincreaseinOSAprevalence( systematic reviewthatfoundrisingBMItobeafactor , Clinical Study 8 ). Thelargeststudycohortstudyingthisassociation A computer-assisted telephone interview was A computer-assistedtelephoneinterview Given thediscrepantdataandstillwidelyheld An inverserelationshipbetweenthepresenceofOSA 12 12 ), includesrandomlyselectedmenfrom ). 9 ). 5 , 6 , 7 , 8 ) but not all studies ( B MClarkeandothers n ,2) to =1,629) 4 9 ). , 10 n =861) , 5 12 11 , 6 ). ). , binding globulin;HPG,hypothalamic pituitarygonadal. hypopnea index;BMI,bodymass index;SHBG,sexhormone obstructive sleepapnoea;PSG, polysomnography;AHI,apnea study; CATI,computerassisted telephoneinterview;OSA, androgen inflammationlifestyle environmentandstress Participant flowchartforstudyanalysiscohort.MAILES,men Figure 1 to routinemethodology. andobesitywere Overweight kilograms permetresquaredwascalculatedaccording to methodsaspreviouslydescribed( to the nearest 0.1 kg and 0.1 cm, respectively, according Weight, heightandwaistcircumference wererecorded were recordedatthetimeofsleepstudycompletion. Anthropometric measuresandcurrentmedications Anthropometry analysis areoutlinedin to 86 years. The methods of population selection for the The final analysis group consisted of 623 men, aged 41 measurement values(BMI,AHIortestosterone)( presence ofactivemalignancy( testosterone concentration,SHBGorsleep( ( (HPG)disease known hypothalamic-pituitary-gonadal subsequently excludedfromthedataanalysisdueto 30 kg/m defined bythestandardBMIthresholds25and obesity notOSA Testosterone isdependenton n

= 43), pre-existinguseofmedicationsknowntoaffect 2 , respectively. Fig. 1 Downloaded fromBioscientifica.com at09/30/202103:22:52PM . n

= 20) or missing primary 20) ormissingprimary 183 :1 13 ). BMIin n n =99). =76), 32 via freeaccess

European Journal of Endocrinology testosterone concentrations wereassessedusing Associations betweenbaseline covariatesandmeasured Statistical analysis (SAPathology,laboratory Adelaide,Australia). immunoassay andHPLC,respectively, inaNATA certified (HbA1c) weremeasuredusingtwo-sitechemiluminescent binding globulin(SHBG)andglycatedhaemoglobin 11.1% at1.66nmol/Land4%8.17nmol/L.Sexhormone for thetestosteroneassaywere10.2%at0.43nmol/L, SCIEX) ( quadruple massspectrometer(AppliedBiosystems/MDS − in the morning following an overnight fast and stored at Blood plasma samples werecollected by venepuncture Assays data. from oximetry of oxygendesaturationevents desaturation index(ODI),describingtheaveragenumber oxygen desaturationbelow90%(TST90)and American Academy criteria ( equivalent toanAHIoftenevents/husingthealternate Study ( sleep-disordered breathingintheWisconsin SleepCohort based onanAHIcutoffoffiveevents/h,asusedtodefine our cohorthasbeenpreviouslydescribed( ≥ as follows:mild:AHI10–19;moderate:20–29andsevere: Classification ofSleepDisorders(ICSD-2)andclassified presence ofOSA,withseveritybasedontheInternational hypopnea index (AHI) a thoracic andabdominalexcursions,inconjunctionwith greater than50%reductioninnasalpressureorboth Medicine criteria( according tothe2007AmericanAcademyofSleep manually by asingleexperienced sleep technician position. andbody thoracic andabdominaleffort,oximetry electrooculogram, electromyogram,nasalpressure, Thornton, CO,USA)formeasurementofEEG, polysomnography (EmblettaX100,EmblaSystems, staff tocomplete8-channelin-homeunattended Participants werevisitedintheirhomesbytrained Polysomnography 80 30 perh.Therationaleforselectingthesethresholdsin ≥ Clinical Study 3% oxygendesaturationorarousalonEEG.Anapnea ° All homepolysomnographyreportswerescored C. Total testosteronewasassayedbyAPI-5000 triple- 16 18 ), havingbeendeterminedtobeapproximately ). Theinter-assaycoefficientsofvariation(CV) 14 ). Hypopneasweredefinedasa ≥ 10 per h was used to define the 17 ). The total sleep time with ≥ 3% perh,wereextracted B MClarkeandothers 15 ) andwas as linearcontinuouspredictors,withtotaltestosterone each ofthesemodels,themeasuresOSAincludedwere and finallyallthreeofthesefactorsplusage(model3).In combination oflogSHBG,BMIandstudyarm(model2) adjustment includedlogSHBG(model1),secondlyfora arousal index.Foreachlinearregressionmodel,covariate for eachofthesleepparametersAHI,ODI,TST90and concentration, linear regression analyses were constructed 16.3–20.2 andQ4: concentration quartiles (Q1: these analysessubjectsweredividedbytestosterone measures (AHI,arousalindex,TST90andODI).For triglycerides), endocrine(SHGB)andpolysomnography waist circumference), metabolicmorbidities(diabetesand caffeine and smoking), measures of adiposity (BMI and of shiftwork), average consumption habits (alcohol, general demographics(age,maritalstatusandyears Jonckheere’s trendtests.Baselinecovariatesincluded analyses wereconductedusing Rversion3.5.0. analyses significance isset at 0.05 (two-sided). Statistical in menwithminimalvariation intestosterone.Inall outcome these parametersmayhave had ontheprimary completed todeterminethe effectthatvariationwithin evaluated. Asubsequentsubgroupsensitivityanalysiswas and M2BMImeasurementsfromM4were in testosterone concentrations between time points M1 individual subjects overthe study period.Correlations of bothtotaltestosteroneconcentrationandOSAwithin undertaken inordertoevaluatetheassumptionofstability a single time point, post-hoc stability analyses were presented. Moderate: 20 categories (noOSA:AHI AHI, forwhichstandardthresholdsbasedonOSAseverity divided into quartiles. The exception in this model being continuous measures werereplaced with thesemeasures linear estimatesofthefinalmodels(model3),OSA OSA measuresandtotaltestosterone.To presentnon- to assessthepresenceofnon-linearassociationsbetween continuous modelsandthenon-linearwereused of freedom.Log-likelihoodratioteststhenestedlinear extended usingrestrictedcubicsplineswithfourdegrees 95% CIand coefficent described,wereportthestandardizedestimate, distributions werenotundulyviolated.Foreachmodel distributions ensuredthatassumptionsconcerningerror being logtransformed.Examinationofresidual obesity notOSA Testosterone isdependenton As datacollectionwassequentialratherthanfrom To evaluatetheeffectofOSAontestosterone Each ofthemultiplyadjustedmodels(model3)were P -value. < AHI > 20.2). ≤

30 and Severe AHI: Downloaded fromBioscientifica.com at09/30/202103:22:52PM ≤

10; mildOSA:10 ≤ https://eje.bioscientifica.com 13.1, Q2:13.1–16.3, Q3: 183 :1 < > AHI 0 are 30) ≤ 33 20; via freeaccess European Journal of Endocrinology https://eje.bioscientifica.com index; SHBG,sexhormonebindingglobulin; StD,standarddrinks;TG,triglycerides;TST90,totalsleep time withoxygensaturationbelow90%. AHI, apneahypopneaindex;FAMAS, FloreyAdelaideMaleAgingStudycohort;NWAHS,NorthWest HealthStudycohort;ODI,oxygendesaturation by M2,M3andM4. Testosterone quartiledivisionswere asfollows:Q1: ODI (1/h) TST90 (min) Arousal Index(1/h) AHI (1/h) Polysomnography (M4) SHBG (M2) Endocrine Yes, TG No, TG High triglycerides(M2) Diabetes No diabetes Diabetes (M2) Metabolic Morbidities Waist circumference(cm) BMI Adiposity (M4) Current Past Never Smoking history Coffee, cups/day Alcohol, StD/day Lifestyle (M2) 3 ormoreyears less than3years None Shift work,years(M3) Single Partner Marital Status(M4) Age (M4) Demographics FAMAS NWAHS Cohort Table 1 severe: 11%. was as follows: mild: 26%, moderate: 14% and category any severitywas51%.ThebreakdownbyOSA 2.4% and8.0%,respectively. TheprevalenceofOSA of 6.0 mmol/L, 8.0 mmol/L and 10.0 mmol/L were 0.3%, testosterone concentrationmeasuredbelowthethresholds 16.8 (5.3)nmol/L.Theproportionofindividualswith ranged from4.5to38.5nmol/L,withamean( (Range: 17.2–46.7kg/m ( The mean( Results 10 Clinical Study ) years,withanaverage( Patient characteristicsbytotaltestosteronequartiles. ≤ > 1.7 mmol/L 1.7 mmol/L s . d . ) ageofthe623menanalyzedwas59 2 ). Testosterone concentration s . d . 28.6 (4.2) 12.2 (12.5) 16.2 (40.6) 18.1 (7.8) 14.9 (13.7) 32.9 (13.1) 226 (36%) 397 (64%) 141 (23%) 471 (77%) 102 (11.7) 101 (16%) 270 (44%) 248 (40%) 211 (34%) 105 (17%) 302 (49%) 120 (19%) 502 (81%) 361 (58%) 262 (42%) ) BMIof28.2(4.2)kg/m 1.8 (1.6) 1.7 (3.7) B MClarkeandothers 59 (10.2) n = 623 All ≤ 13.1, Q2:13.1–16.3,Q3:16.3–20.2,Q4: 106.6 (11) 14.8 (14.7) 21.4 (45.9) 19.2 (8.8) 17.2 (15.5) 23.6 (8.4) 30.5 (4.3) 61.3 (9.8) 131 (83%) 1.7 (1.5) 1.7 (5.5) 80 (51%) 77 (49%) 60 (39%) 93 (61%) 13 (8%) 80 (51%) 64 (41%) 65 (42%) 22 (14%) 67 (44%) 26 (17%) 97 (62%) 60 (38%) n = 157 Q1 s . d . ) of 2

102.8 (11.8) not arousalindex( with AHI, ODI (both after adjustmentforSHBGtherewerenegativeassociations between totaltestosteronelevelsandAHI( ODI ( hypertriglyceridemia, SHBG,TST90(all measures ofadiposity, thepresenceofeitherdiabetesor associations betweentestosteronelevelsandboth quartiles areprovidedin parameters accordingtomeasuredtotaltestosterone comorbidities, hormonal,anthropomorphicandsleep 11.7 (9.6) 18.2 (50.9) 17.5 (7.5) 14.6 (11.6) 57.2 (9.8) obesity notOSA Testosterone isdependenton 106 (68%) 120 (77%) 126 (80%) 102 (65%) 1.8 (1.5) 1.9 (3.1) 55 (35%) 30 (9.6) 51 (32%) 36 (23%) 29 (4.2) 33 (21%) 65 (42%) 58 (37%) 48 (31%) 35 (22%) 74 (47%) 31 (20%) n = 157 In thelinearregressionmodelsoflogtestosterone, The distributionofdemographic,lifestyle, Q2 P

= 0.0002). Aweaknegativeassociationwasapparent > 20.2 nmol/L.Timepointsfordatacollection areannotated 101.2 (10.8) 11.6 (13.6) 17.9 (7.8) 14.1 (14.5) 34.4 (10.8) 59.2 (9.7) 124 (83%) 125 (82%) 1.8 (1.8) 1.5 (2.4) 68 (44%) 16 (34.9) 59 (39%) 94 (61%) 25 (17%) 28 (3.6) 27 (18%) 61 (40%) 64 (42%) 47 (31%) 23 (15%) 81 (54%) 28 (18%) 85 (56%) n = 153 P Q3

= P 0.08). Afteradditionaladjustment

= Downloaded fromBioscientifica.com at09/30/202103:22:52PM 0.01) and TST90 ( Table 1 10.5 (11.2) 17.7 (7.1) 13.8 (12.6) 43.9 (13.8) 97.5 (11.6) 58.5 (11.3) 120 (77%) 134 (87%) 120 (77%) 9.3 (25.1) 1.9 (1.6) 1.6 (3.1) 79 (51%) 36 (23%) 20 (13%) 27 (3.9) 28 (18%) 64 (42%) 62 (40%) 51 (33%) 25 (16%) 80 (51%) 35 (23%) 77 (49%) n = 156 Q4 . Therewerestrong 183 :1 P P P

< .08, but =0.0008), =0.04). .01 and 0.0001) < < < < < < P 0.0002 0.0001 0.39 0.04 0.0001 0.0001 0.0001 0.0001 0.0001 0.37 0.66 0.32 0.08 0.24 0.08 0.008 -value 34 via freeaccess European Journal of Endocrinology cohort to include only men in whom changes of less than Fig.1).However,0.72) (Supplementary restrictionofthe there was some variability in total testosterone (correlation stableovertime(correlation,0.95),though remained very Tablewith negligbleOSA(Supplementary 2). ( transformed totaltestosteronehigherinmenwithmild vs severe)indicatedaninvertedU-shapewithlog- the four-level discretised version (none, mild, moderate log SHBGandstudy).ReplacingcontinuousAHIwith that isexplainedbythefourcovariatesalone(age,BMI, of logtestosteronewasexplained,ascomparedto53.8% the modelwithnon-linearAHI,54.6%ofvariation ( evidence for non-linear associations with either ODI linear association with AHI ( using log-likelihoodratiotestsindicatedaweaknon- cubic splinesandcomparinglinearvsnon-linearmodels end ofthisarticle). 1, seesectionon positively associated(all associated withlogtestosterone,whileSHBGwasstrongly these analyses,BMIandagewerebothstronglynegatively after furtheradjustmentforage( testosterone andanyofthefourOSAmeasuresremained significant. Nodetectable linear associations between between testosterone and TST90 remained weakly testosterone and either AHI or ODI, though the association there werenodetectablelinearassociationsbetween (FAMAS) vsNorthWest AdelaideHealthStudy(NWAHS)), for BMI andstudy (Florey Adelaide Male Aging Study P P Clinical Study ( TST90 =0.17), = 0.04) or moderate ( The post-hocstabilityanalysesdemonstratedthatBMI Extending thesemultivariablemodelswithrestricted P supplementary materials supplementary

= 0.99) orarousalindex( P

= P 0.03) OSA as compared to men

0.0001, Supplementary Table0.0001, Supplementary P B MClarkeandothers

= Fig. 2 0.04). There was no and givenatthe Table 2 P .2. In =0.92). ). In of diagnosedOSA. screened forsleepstudyparticipationreportingahistory in thecommunity, evident by only 11% ofour population appears that OSA remains significantly under-diagnosed oxygen desaturation, as measured by the TST90, was also with mildtomoderateOSA.Increasedtotaldurationof there is no evidence of differences in testosterone levels This modelassumeslinearity, andunderthisassumption AHI afteradjustmentforconfoundingbyageandBMI. confirms thereisnoassociationbetweentestosteroneand estimates fortheAHIM3model( Tablefor BMI.Supplementary 1reportstheparameter AHI and ODI, the association was lost with adjustment severe sleepdisorderedbreathingasmeasuredbyboth lower measuredtotaltestosteroneconcentrationandmore older men. Though there was a linear association between concentration incommunitydwellingmiddle-agedand is notanindependentdeterminantofserumtestosterone of middle-agedandoldermeninrecentyears( This rateissimilartothosereportedinotherpopulations ofOSA. community dwellingmenwithnoknownhistory of morethan50%foundinourstudypopulation OSA is acommon disorder, with an overall prevalence Discussion Tablethe smallersamplesize(Supplementary 3). cohort, thoughwideningofCIsisnoted,inkeepingwith were almostunchangedfromtheanalysesinfull associations between total testosterone and OSA measures ( 25% in total testosterone were observed obesity notOSA Testosterone isdependenton The mainfindingsfromourresultssuggestthatOSA with oxygensaturationbelow90%. desaturation index;TST90,total sleeptime AHI, apneahypopneaindex;ODI, oxygen for logSHBG,BMI,studyarmand age. BMI andstudyarm.Model3:adjustment SHBG. Model2:adjustmentforlogSHBG, represented. Model1:adjustmentforlog adjustment forcovariatesare testosterone concentration,after different OSAparameterson(log) estimates and95%CIsfortheeffectof covariates. Thelinearregressionmodel concentration, afteradjustmentfor Effect ofOSAparametersontestosterone Figure 2 Downloaded fromBioscientifica.com at09/30/202103:22:52PM https://eje.bioscientifica.com Table 2 183 :1 ) infulland n 6) the =466), 1 , 2 35 ). It via freeaccess European Journal of Endocrinology https://eje.bioscientifica.com AHI, apneahypopneaindex;ODI,oxygendesaturationTST90,totalsleeptimewithsaturationbelow90%. vs NWAHS)and(model3)logSHBG,age,BMIstudy.Standardizedcoefficientsarereported. For eachmeasureofobstructivesleepapnea,threemodelsareconstructedadjustingfor(model1)logSHBG,2)BMIandstudy(FAMAS Arousals TST90 ODI testosterone concentration is not improved by treatment observed. rising BMIwithlowertestosterone concentrationwasstill in Barrett-Connor’s cohort,thoughasimilartrend of across eachofourtestosteronequartileswashigherthan dL) (4%comparedwith9%).Notably, the meanBMI testosterone concentrationbelow8.7nmol/L(250ng/ 73 years)andhadproportionallyfewermenwithalow on average15yearsyounger(59comparedwith to Barrett-Connor’s cohort, our patient population was are attenuatedafteradjustmentforBMI.Incomparison measures ofOSAincludingAHI,thoughtheseassociations relationship betweentestosteroneandpolysomnography elderly communitydwellingmen( the findingsbyBarrett-Connor’s studyofmorethan1300 middle-aged andoldermen,withoutcomessimilarto results from a large sample of community dwelling and hypoxia may also contribute. We have reported effects ofobesityandaging,thoughsleepfragmentation altered gonadal function in this population was due to the causefor of OSA,theauthorsconcludedthatprimary between lowertestosterone and thecategorical presence Luboshitzky ( is also worth noting that though the two small studies by of objectiveevaluation of OSA in all patients studied ( when evaluatingtherelationshipwithOSA( ( account forotherfactorsthatmayinfluencetestosterone 7 populations, withcohortsoflessthan100subjects( all ofthesestudieshave been limitedbysmallstudy presence ofOSAthatisindependentBMI.However, relationship betweentestosteroneconcentrationandthe toourresults,findinganegative outcomes contrary after adjustmentforage. after adjustmentforBMI,theassociationwasagainlost though the relationship remained borderline significant associated withlowertestosteroneconcentration;and AHI Table 2 5 , ), failuretoadjustfortheeffectofBMIontestosterone Clinical Study 8 , Several past observational studieshavereported Several pastobservational Our dataarealsosupported by evidenceshowingthat 10 , Linear regressionsoflogtotaltestosteroneonAHI,ODI,TST90andarousalindex. 11 − − − − 0.019 ( 0.035 ( 0.027 ( 0.026 ( ). Otherlimitationsincludefailuretoclearly 10 , Coef (95%CI) 11 − − − − 0.039, 0.0019) 0.056, 0.048, 0.047, ) foundpersistenceoftherelationship Model 1 − − − 0.015) 0.0063) 0.0055) B MClarkeandothers 9 ); Thereisaninverse 0.08 0.0008 0.01 0.01 P -value 6 ) andalack − − 0.00083 ( − 0.0085 ( 0.0019 ( 0.022 ( 8 5 Coef (95%CI) ). It , − − − − 6 0.028, 0.011) 0.041, 0.02, 0.021) 0.022, 0.018) , Model 2 adjusted for the change in body mass over the treatment Theoutcomeinthisstudywasalsonot the intervention. rise inSHBGconjunctionwithtestosteroneduring there wasnochangeinmeasuredfreetestosteroneduetoa in 43menwithsevereOSA( testosterone after3monthsofnasalCPAP treatment,used 25 irrespective of treatment duration ( pressure(CPAP),of OSAwithcontinuouspositiveairway there was a very highdegreeofpositivecorrelation there wasavery measure of adiposity in our study for statistical evaluation, analyses. Though we have selectively employed BMI as the parameters, including AHI, ODI, TST90 and arousals in the utilised avariety of differentobjective polysomnography and reliablediagnosticmethodinallparticipants evaluated sleepdisorderedbreathingusingavalidated representative of thebroader community. We have number ofsubjectswithbaselinecharacteristics men, intheabsenceofconcurrentobesity. hypothesis thatOSAismorecommoninhypogonadal can determine,thereisnoevidencetosupportaconverse to thedegreeofweightlossachieved( with themagnitudeofimprovementinTproportional been consistentlydemonstratedinresponsetoweightloss, contrast, improvementintestosteroneconcentrationhas findings in support of this conclusion ( due toinsufficientormissingkeydata,allstillreported three publishedstudiesexcludedfromthemeta-analysis has noinfluenceontestosteroneconcentration( this topicalsoconcludedthat,inmenwithOSA,CPAP testosterone concentration ( CPAP didnotresultinasignificantrisethemeasured month ofactivenasalCPAP treatmentascomparedtosham with lowertestosteroneconcentrationsatbaseline,1 in onlyasinglestudy;thoughmoresevereOSAcorrelated CPAP ontestosterone concentration has beenevaluated ( whichreachedborderlinesignificance the intervention period, withameanweightlossof1.4kgreportedduring obesity notOSA Testosterone isdependenton − P

0.0026) = ). Onlyasinglestudyhasreportedanincreaseintotal

0.06). Placebo-controlled evaluation of the effect of A strengthofourstudyistheinclusionalarge P 0.39 0.94 0.03 0.85 -value − 0.0047 ( 0.0045 ( 0.014 ( 0.014 ( Downloaded fromBioscientifica.com at09/30/202103:22:52PM 27 Coef (95%CI) 26 − − − ). Arecentmeta-analysis of − 0.013, 0.023) 0.0049, 0.033) 0.0047, 0.033) ). However, inthisreport 0.023, 0.014) 19 Model 3 183 , 20 30 :1 , 19 ). Asfaraswe 21 , , 25 22 , 28 0.61 0.63 0.15 0.14 P , 29 -value 23 ). The ). By , 36 24 via freeaccess , European Journal of Endocrinology had moresevereOSAtohave cometoclinicalattention. from theanalysis.Itispossible thattheseindividuals individuals withpre-existing obstructivesleepapnoea for sleepparameters). difference inassessmenttimes(M2fortestosterone,M4 associations intheoverallcohortareunaffectedby supporting theassumptionthatOSA-testosterone remains essentiallyunchanged.Thisprovidesevidence analysis measured testosterone,theresultofprimary those individuals whom showedminimal variability in analysis to only Furthermore, on restriction of the primary similar orgreaterstabilityovertheperiodofinterest. to assumethattestosteronemeasurementswouldhave months, comparedwith5years),thusitisalsoreasonable was significantlyshorter(median20months,IQR5 betweenM2andM4 M1 andM2thetimeinterval period. Testosterone levelswererelativelystablebetween OSA magnitudewouldalsobestableoverthissame that itisareasonableassumptionthemeasuresof stability ofBMIbetweentimepointM2andM4supports From theseanalyses,weconcludethatthehighlevelof stability analyses of testosteronemeasurements and BMI. limitations oftheavailabledata,weperformedpost-hoc between theseparameters.To addressthisissuewithinthe of thesleepstudy(M4),confoundingrelationship measurement usedintheanalysis(M2)andtime measured testosteronebetweenthetimeof it isnotpossibletodefinitivelyexcludeachangein was notremeasuredatthetimeofsleepstudy, M3 and M4, respectively. As testosterone concentration indicated intherelevanttablesbycodesM1,M2, transparency, the timing of data collection has been cross-sectional analysisfromasingletimepoint.For of assessmentswasnotidentical,thedataisatrue collection ofdataatdifferenttimepoints;asthetiming concentration. Afurtherlimitationisthestepwise BMI inmediatingtheeffectofOSAontotaltestosterone the data,thoughthisisinsufficienttoprovecausalityof design, meaningthatassociationsmaybedrawnfrom did notparticipateinthesleepstudy( to obesityorsleepsymptomsbetweenthosewhodidand which didnotfindanysignificantdifferencesinrelation also previouslyreportedananalysisofself-selectionbias, alter theOSA-testosteroneassociationsfound.We have an alternativeparameterofadipositywouldsignificantly shown), suchthatitisunlikelysubstitutingBMIfor between alladipositymeasuresrecorded(resultsnot Clinical Study We acknowledge that our study design excluded The main limitation of our study is its observational B MClarkeandothers 31 ). concentration independentofchangeinweight.With of OSAwithCPAP doesnotimprovetestosterone the evidence,asdiscussed,indicatingthattreatment of aproportionindividualstreatedforOSA,though diagnosed OSAwouldalsoresultintheincorporation mild OSA only. The inclusion of individuals with pre- study designresultedinaskewtowardsthedetectionof diagnosed inthecommunityandlesslikelythatour this seemstosupportthepropositionthatOSAisunder- diagnostic criteriafollowingsleepstudy. Incombination, still detectedinhalfofallindividualswhomettheOSA a pre-existingdiagnosis,moderateorsevereOSAwas study completion,anddespitetheexclusionthosewith when compared to the diagnosis rates following sleep was uncommoninthescreenedpopulation,particularly concentration. However, apre-existingdiagnosisofOSA OSA, obscuringtherelationshipwithtestosterone have resultedinabiastowardsthedetectionofmilder In suchaninstance,theirexclusionfromanalysismay from theResMedFoundation.Theother authorshavenothingtodisclose. support funding of recipient a is A R Care. Health Besins and Bayer from Watchers, Weight Lilly, Eli fees speaking as well as Pharmaceuticals, Lawley and Foundation Bayer, ResMed from support research of recipient a and Practice Clinical and Research Obesity of Editor-in-Chief the is W A G Declaration ofinterest EJE-19-0978 at paper the of version online the to linked is This Supplementary materials irrespective ofwhetherCPAP isinstitutedornot. in menwithOSA,particularlyiftestosteroneisdecreased, findings highlighttheimportanceofaddressingobesity objective measuresofOSA( weight loss can increase testosterone ( in testosterone concentration though, in contrast, with CPAP cannotbeexpectedtoleadanimprovement of obesity. Fromaclinicalstandpoint,treatmentofOSA consequence ofcomorbidOSAandratherreflecttheeffect concentrations, inthecontextofobesity, arenotthe support totheargumentthatlowserumtestosterone OSA ontestosteroneconcentration. there isnoeffect,apositiveeffectornegativeof consistent with any of three different outcomes, that for covariates, remain large, and thereforecouldbe measured byAHI,ontestosteroneafteradjustment acknowledge thattheCIsofdirectOSAeffect,as respect totheresultsobtained,itisalsoimportant obesity notOSA Testosterone isdependenton Overall the findings from ourstudy lend further . Downloaded fromBioscientifica.com at09/30/202103:22:52PM 32 , 33 https://eje.bioscientifica.com ). Taken together, these 183 https://doi.org/10.1530/ 30 :1 ) and improve 37 via freeaccess European Journal of Endocrinology https://eje.bioscientifica.com References for theirinvaluablecontributions. families their and participants the to extended also are Thanks machines. polysomnography the of use the for USA) (Colorado, Inc. 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