CoChat
Sign Up
Cited by 3Pharmacology and Obesity TreatmentObstructive Sleep Apnea ResearchDiabetes Treatment and Management

Receipt of Glucagon-Like Peptide-1 Receptor Agonists Among Rural Patients with Obstructive Sleep Apnea and Excess Weight

Leonhard, Aristotle G, Josey, Kevin, Castaneda, Jason M, Chee, Mark, Duan, Kevin I, Nadeem, Hasan, Plumley, Robert, Triplette, Matthew +4 more·2026·Annals of the American Thoracic Society
DOI 10.1093/annalsats/aaoag047PMC PMC13307129
Open this paper in CoChat — free account

Abstract

Rationale: Successful weight loss is difficult for those with obstructive sleep apnea (OSA), and gaps in weight management care are more pronounced in rural areas. Glucagon-Like Peptide-1 Receptor Agonists (GLP-1RAs) are promising agents to improve the effectiveness of weight management care in patients with OSA and excess weight living in rural areas.

Integrity signals

Registry

Crossref · 10.1093/annalsats/aaoag047

Cites

41 of 41 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

19 of 34 cited sources checked · 8 supported · 1 flagged · accuracy not yet measured

  • Premisecitation

    GLP-1RAs allow most patients to achieve clinically meaningful weight loss.

    “These medications allow most patients to achieve clinically meaningful weight loss, improve severity of OSA, and improve cardiometabolic comorbidities.13,14”
    Quote in the paperSubstantial claim2 of 2 sources checked
    • cites [13] Blackman, 2016, Effect of liraglutide 3.0 mg in individuals with obesity and moderate or severe obstructive sleep apnea: the SCALE sleep apnea randomized clinical trial, Int J Obes (Lond) source

      The Results section (Body weight and related end points; page unavailable) reports that 46.3% of liraglutide-treated participants lost at least 5% of baseline weight at week 32—fewer than most. The trial also studied one GLP-1 receptor agonist in participants with obesity and moderate or severe OSA, not the drug class across patients generally. (LLM, conf=0.87)

      Checked by a reasoning model — may be wrong.

      Experimental — accuracy not yet measured
    • cites [14] Malhotra, 2024, Tirzepatide for the treatment of obstructive sleep apnea and obesity, N Engl J Med source

      The ‘Change in PROs and Cardiovascular Risk Factors’ section (page unavailable) reports significant body-weight reductions in both trials, and Table 2 (page unavailable) reports a 17.7% estimated reduction for one tirzepatide group. The paper does not establish that most individual patients achieved clinically meaningful weight loss, and its trials tested tirzepatide in adults with obesity and moderate-to-severe OSA rather than GLP-1 receptor agonists generally. (LLM, conf=0.84)

      Experimental — accuracy not yet measured
  • Premisecitation

    Gaps in weight management care are more pronounced in rural areas.

    “gaps in weight management care are particularly pronounced in rural areas.”
    • Also stated in: § Rationale: · plain
      “gaps in weight management care are more pronounced in rural areas.”
    Quote in the paperSubstantial claim1 of 2 sources checked
    • cites [9] Thomas, 2024 source

      The Key Drivers and Conclusion section (page not provided) says rural areas often have less accessible medical care and reports higher obesity rates. It does not specifically compare gaps in weight-management care between rural and urban areas, so the claim is more specific than the source supports. (LLM, conf=0.82)

      Experimental — accuracy not yet measured
    • cites [10] Krishna, 2010, Diabetes burden and access to preventive care in the rural United States, J Rural Health Off J Am Rural Health Assoc Natl Rural Health Care Assoc source
  • Premisecitation

    Patients with obstructive sleep apnea lose less weight than their peers.

    “Patients with OSA lose less weight than their peers, even though studies suggest that patients with OSA may demonstrate greater engagement with lifestyle-based weight management programs.7,8”
    Quote in the paperSubstantial claim2 of 2 sources checked
    • cites [7] Kline, 2018, Bidirectional relationships between weight change and sleep apnea in a behavioral weight loss intervention, Mayo Clin Proc source
    • cites [8] Littman, 2012, Evaluation of a weight management program for veterans, Prev Chronic Dis source

      The Results > Reach section reports that veterans with sleep apnea were more likely to participate in the weight-management program. The Discussion says participants with more comorbidities were less likely to lose at least 5% of their weight, but it does not establish that patients with sleep apnea specifically lost less weight than their peers. (LLM, conf=0.85)

      Experimental — accuracy not yet measured
  • Premisecitation

    Rural Americans are less likely to receive healthcare to address obesity-related burdens.

    “Over 46 million Americans live in rural areas and carry a disproportionate burden of obesity-related comorbidities but are less likely to receive healthcare to address these burdens.9,10”
    Quote in the paperSubstantial claim1 of 2 sources checked
    • cites [9] Thomas, 2024 source

      The Key Drivers and Conclusion section says rural areas often have limited medical treatment and less accessible healthcare options, and separately reports higher obesity rates. It does not establish that rural Americans are less likely to receive care specifically for obesity-related burdens; that part is more specific than the source supports. (LLM, conf=0.84)

      Experimental — accuracy not yet measured
    • cites [10] Krishna, 2010, Diabetes burden and access to preventive care in the rural United States, J Rural Health Off J Am Rural Health Assoc Natl Rural Health Care Assoc source
  • Premisecitation

    Rural patients with obstructive sleep apnea receive fewer weight management services than urban peers.

    “We previously have shown that rural patients with OSA receive fewer weight management services (lifestyle programs, nutrition consults, pharmacotherapy, and bariatric surgery) in comparison to urban peers”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites [12] Leonhard, 2025, Receipt of weight management services among patients with OSA and obesity, CHEST Pulm. source
  • May combine two claims. 11
  • Classified as probably not a substantial claim. 9

  • May combine two claims.

    Premisecitation

    Many patients treated with GLP-1RAs achieve clinically meaningful weight loss and improvements in cardiometabolic health.

    “Many patients treated with GLP-1RAs achieve clinically meaningful weight loss while simultaneously demonstrating improvements in cardiometabolic health.45,46”
    Quote in the paperSubstantial claim1 of 2 sources checked
    • cites [45] Wilding, 2021, Once-weekly semaglutide in adults with overweight or obesity, N Engl J Med source
    • cites [46] Jastreboff, 2022, Tirzepatide once weekly for the treatment of obesity, N Engl J Med source

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Rural Americans carry a disproportionate burden of obesity-related comorbidities.

    “Over 46 million Americans live in rural areas and carry a disproportionate burden of obesity-related comorbidities but are less likely to receive healthcare to address these burdens.9,10”
    Quote in the paperNot a substantial claim1 of 2 sources checked
    • cites [9] Thomas, 2024 source
    • cites [10] Krishna, 2010, Diabetes burden and access to preventive care in the rural United States, J Rural Health Off J Am Rural Health Assoc Natl Rural Health Care Assoc source

  • Classified as probably not a substantial claim.

    Premisecitation

    Early evidence in type II diabetes suggests lower GLP-1RA uptake among rural patients compared with urban patients.

    “Early evidence in the management of type II diabetes mellitus suggests lower uptake for GLP-1RAs among patients in rural areas compared with urban peers.17”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites [17] Chen, 2024, Geographic variation and racial disparities in adoption of newer glucose-lowering drugs with cardiovascular benefits among US Medicare beneficiaries with type 2 diabetes, PLoS One source

      The Results (page unavailable) report that urban Medicare beneficiaries with type 2 diabetes were slightly more likely than rural beneficiaries to initiate a newer glucose-lowering drug. The Methods define that outcome as filling a prescription for either a GLP-1 receptor agonist or an SGLT2 inhibitor, so the reported rural–urban difference does not establish lower uptake of GLP-1 receptor agonists specifically. (LLM, conf=0.86)

      Experimental — accuracy not yet measured

  • May combine two claims.

    Premisecitation

    Pharmacotherapy and bariatric surgery can augment weight loss but are rarely received by patients with obstructive sleep apnea.

    “While options such as pharmacotherapy and bariatric surgery can augment weight loss, they are rarely received by patients with OSA.12”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites [12] Leonhard, 2025, Receipt of weight management services among patients with OSA and obesity, CHEST Pulm. source

  • Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing).

    Premisecitation

    Access is a multidimensional concept including geographic, temporal, financial, digital, and cultural domains.

    “As described by Fortney et. al., access is a multidimensional concept including geographic, temporal, financial, digital, and cultural domains, and barriers to care can be considered within these areas.42”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [42] Fortney, 2011, A re-conceptualization of access for 21st century healthcare, J Gen Intern Med source

  • May combine two claims.

    Premisecitation

    GLP-1RAs have relatively few laboratory and clinical monitoring requirements and few contraindications.

    “In addition, GLP-1RAs have relatively few requirements for laboratory and clinical monitoring, as well as few contraindications, providing a potentially effective and scalable option to improve the effectiveness of weight management care for patients with OSA living in rural areas.15,16”
    Quote in the paperSubstantial claim1 of 2 sources checked
    • cites [15] Ghusn, 2024, Glucagon-like receptor-1 agonists for obesity: weight loss outcomes, tolerability, side effects, and risks, Obes Pillars source

      The Discussion: clinical expert identifies a history of medullary thyroid cancer as a reason treatment may be unsuitable and recommends medical assessment and professional supervision. The Abstract Conclusion calls for vigilant monitoring. Neither passage establishes that laboratory or clinical monitoring requirements are relatively few, or that contraindications are few (searched: laboratory and clinical monitoring requirements; contraindications). (LLM, conf=0.72)

      Experimental — accuracy not yet measured
    • cites [16] Latif, 2025

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductcitation

    A directed acyclic graph was constructed to define a priori assumptions about covariate relationships with exposure and outcome.

    “We then constructed a directed acyclic graph (DAG) to clearly define our a priori assumptions regarding covariate relationships with the exposure and outcome variables (Figure 1).29,30”
    Quote in the paperNot a substantial claim2 of 2 sources checked
    • cites [29] Lederer, 2019, Control of confounding and reporting of results in causal inference studies. Guidance for authors from editors of respiratory, sleep, and critical care journals, Ann Am Thorac Soc source
    • cites [30] Textor, 2016, Robust causal inference using directed acyclic graphs: the R package ‘dagitty’, Int J Epidemiol source

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    Rural areas had a lower proportion of Hispanic patients (5.2% vs 13.2%) than urban areas.

    “Rural areas also had a lower proportion of patients of Hispanic ethnicity (5.2% in rural areas vs. 13.2% in urban areas).”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    Drive time and drive distance to primary and specialty care were greater in rural areas than in urban areas.

    “As expected, the drive time and drive distance to primary and specialty care were greater in rural areas as compared to urban areas (Table 1).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    In diabetes-stratified analysis, 15.6% of patients with diabetes and 3.0% of patients without diabetes were prescribed a GLP-1RA.

    “In sensitivity analyses stratified by diabetes diagnosis, we found that 15.6% of patients with diabetes (n=27,184) were prescribed a GLP-1RA in comparison to 3.0% of those without diabetes (n=41,496).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Rural areas had a higher proportion of white patients (78.2% vs 56.9%) and a lower proportion of Black patients (13.0% vs 31.6%) than urban areas.

    “Rural populations had a higher proportion of patients that were identified as white (78.2% in rural areas vs. 56.9% in urban areas) and lower proportion of patients identified as Black (13.0% in rural areas vs. 31.6% in urban areas).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Among the cohort, 26.0% lived in a rural area and 74.0% lived in an urban area.

    “Of these, 17,880 (26.0%) lived in a rural area, and 50,800 (74.0%) lived in an urban area.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    The Veterans Health Administration is the largest integrated health care system in the United States and has national geographic reach including representative rural areas.

    “The VHA is the largest integrated health care system in the United States with a national geographic reach including representative rural areas.55,56”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [55] Administration UD of VA Veterans Health

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

    • cites [56] Bureau UC

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • May combine two claims.

    Interpretationown data

    GLP-1RA use among this population remained low overall despite increasing over time.

    “Although the use of GLP-1RA agents increased across the time period of the cohort, usage overall remained low.”
    • Also stated in: § Discussion/Conclusions: · plain
      “Though this proportion increased over the years of the study population, the receipt of these effective medications remained low at ~15% overall in patients that entered the cohort in 2023.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Study design and conductown data

    Age, female proportion, and comorbidities were largely balanced between rural and urban groups, with standardized mean differences below 0.2.

    “Age, female proportion, and comorbidities were largely balanced between rural and urban areas with standardized mean differences <0.2.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S2 (checkable).

    Interpretationreasoning

    Measurable variables such as drive time, drive distance, and rurality alone do not encompass all aspects of access.

    “Measurable variables such as drive time, drive distance, and rurality alone do not encompass all aspects of access.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Study design and conductown data

    All analyses adjusted for clustering by VA Medical Center using a random intercept.

    “In all analyses, patient’s VA Medical Center (defined as the medical center of the qualifying sleep study) was adjusted by a random intercept to account for clustering of practice patterns.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given

    Staged analyses were performed to assess the impacts of confounding as outlined in the directed acyclic graph.

    “We performed a series of staged analyses to assess the impacts of confounding as outlined in our DAG.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Study design and conductown data

    The study sample has a disproportionate number of patients with male sex and is not representative of the U.S. population at large.

    “First, while the VHA has national reach of services, there is a disproportionate sample of patients with male sex, which is not representative of the U.S. population at large.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Study design and conductnone given

    The Veterans Health Administration has universal coverage of enrollees regardless of location, which limits confounding by insurance status and coverage.

    “The VHA also has universal coverage of enrollees regardless of location, limiting confounding by insurance status and coverage.”
    Quote in the paperSubstantial claim
20 of 20

  • The authors state this as an assumption.

    Drive distance and drive time to primary and specialty care are mediators of the effect of rurality on GLP-1RA receipt.

    “We performed a causal mediation analysis hypothesizing that patient’s drive distance and drive time to nearest VA primary care center are mediating variables. We also examined the mediating effects attributable to drive distance and drive time to nearest specialty care center.”

  • The paper relies on this without support.

    There is no unmeasured confounding of the exposure-outcome, exposure-mediator, and mediator-outcome relationships in the mediation analysis.

    “We then constructed a directed acyclic graph (DAG) to clearly define our a priori assumptions regarding covariate relationships with the exposure and outcome variables (Figure 1).29,30”

  • The paper relies on this without support.

    Rural residence has a causal effect on GLP-1RA receipt that can be decomposed into direct and indirect effects.

    “We performed a causal mediation analysis”
    “From these regressions, we estimated the total effect, average direct effect, and average causal mediation (indirect) effect.35”

  • The paper relies on this without support.

    Drive time and drive distance accurately measure geographic access to care.

    “We also included geographic determinants of access to care, defined as drive time and drive distance to primary care and specialty care.”
4 of 4

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

Each contradiction between two passages listed here was confirmed by an independent check.

  • Overall sample size differs between Results and Discussion

    Minor

    The paper reports 68,680 patients in the Results section, but later says 68,862 patients were included in the sample. These two totals cannot both be correct for the same cohort.

  • Sample size differs in the limitations section

    Minor

    The limitations section gives a sample size of 68,862, whereas the results report 68,680 patients meeting the inclusion criteria.

2 of 2

Cites

Flagged first, then by citations

Research works printed but not linked: 7

  1. Culbreath, 2019, VIReC Corporate Data Warehouse (CDW) Domain Descriptions
  2. Veterans Health Administration Office of Rural Health, 2023, Fact Sheet: How to Define Rurality
  3. National Academies of Sciences, Engineering, and Medicine; Division of Behavioral and Social Sciences and Education; Board on Human-Systems Integration; Division on Engineering and Physical Sciences; Board on Infrastructure and the Constructed Environment; Committee on Facilities Staffing Requirements for Veterans Health Administration., 2019, Facilities Staffing Require­ments for the Veterans Health Administration-Resource Planning and Methodology for the Future
  4. Brundisini, 2013, Chronic disease patients’ experiences with accessing health care in rural and remote areas: a systematic review and qualitative meta-synthesis, Ont Health Technol Assess Ser, 13, 1
  5. Administration UD of VA Veterans Health, VA.gov | Veterans Affairs
  6. Bureau UC, Veterans in Rural America: 2011-2015
  7. Rogers, MOVE! Weight Management Program | Veterans Affairs

Cited by

Sorted by citations

Related

Authors
Leonhard, A. G., Josey, K., Castaneda, J. M., Chee, M., Duan, K. I., Nadeem, H., Plumley, R., Triplette, M., Smith, N. L., Au, D. H., Feemster, L. C., & Donovan, L. M.
Affiliations
  • University of Washington (US)
  • Colorado School of Public Health (US)
  • University of British Columbia (CA)
  • VA Puget Sound Health Care System (US)
  • United States Department of Veterans Affairs (US)
Corresponding author
Leonhard, Aristotle G
ORCID
Venue
Annals of the American Thoracic Society
Publisher
Oxford University Press (OUP)
Published
2026-03-03
Volume
23
Issue
7
Pages
1087-1096
ISSN
2325-6621 (ISSN-L)
DOI
10.1093/annalsats/aaoag047
PMC
PMC13307129
OpenAlex
W7133501054
Cited by
3
References
37
Citations by year
2026: 3
FWCI
12.62
Type
journal article
Language
en
Open access
closed
Licence
academic.oup.com/pages/standard-publication-reuse-rights (vor)
Locations
  • Annals of the American Thoracic Society (publishedVersion)
  • PubMed (publishedVersion)
Funders
  • NIH/NHLBI (5T32 HL007287-45, 1F32HL179793-01)
  • American Thoracic Society through the ATS Academic Sleep Pulmonary Integrated REsearch/Clinical
Topics
  • Health Sciences › Medicine › Pharmacology › Pharmacology and Obesity Treatment
  • Health Sciences › Medicine › Physiology › Obstructive Sleep Apnea Research
  • Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes Treatment and Management
Keywords
GLP-1 receptor agonists, obstructive sleep apnea, overweight, obesity, urban-rural differences, health care access, weight loss, veterans
MeSH terms
Glucagon-Like Peptide-1 Receptor Agonists, Aged, Female, Humans, Male, Middle Aged, Rural Population, United States, Weight Loss, Body Mass Index, Sleep Apnea, Obstructive, Overweight

About these checks

Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.

Claims read under definition version 3 (extract-v3) on 2026-09-28.

Classified by jev-1.13-20260917 (gold-guideline-v0.2) on 2026-09-28.

Cited sources are checked by gpt-6-sol.

Statistics and arithmetic are recomputed, not judged.

Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.

What counts as a claim ›How we measure confidence ›How we check this ›

Are you an author, or do you see a problem with this page? Request a review