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Can Sleep Apnea Cause Celiac Disease?

I know that the topic of this post may inflame a lot of readers out there, but please hear me out.

Celiac disease is a well-defined autoimmune condition that was originally described in children with chronic, severe gastrointestinal symptoms (diarrhea, cramping, abdominal pain and bloating). It’s known to exist in around 1/100 people in this country (97% don’t know they have it), and it’s responsible for various non-gastrointestinal symptoms, including a specific skin rash called dermatitis herpetiformis, migraines, ADHD, numbness, depression, chronic fatigue, and seizures. Others have reported a link between celiac disease and migraines, PCOS, and infertility. Only 1 out of 6 people have classic abdominal and gastrointestinal symptoms. For unexplainable reasons, the incidence has increased 4 time in the past 50 years.

The theory behind this widespread condition is that the in susceptible people, antibodies in the small intestines attack gluten, a common protein in wheat-based food. Humans don’t have the enzyme to digest gluten, so it passes harmlessly, but in people with celiac, an immune response is created which causes severe inflammation in the small intestines, leading to the classic symptoms. The only known effective cure is to avoid eating anything that contains wheat, in favor of alternatives such as rice, flax, oats, quinoa, teff, and buckwheat.

People who are eventually diagnosed and who go gluten free have remarkable success stories, with more awareness within the medical community and the lay public. One proposed explanation as to why this condition is so underdiagnosed in the US compared to other developed countries is that there’s no pharmaceutical drug that treats this condition, and that in other countries with centralized medical systems, prevention is stressed, rather than just treating the symptoms.

So far, pretty basic information, right?

Here’s my take on celiac disease: For the past few years, whenever I see patients with known celiac disease who come to see me for various ear, nose and throat symptoms, they all have various degrees of sleep-breathing problems. Almost invariably, they have small jaws, cold hands, can’t sleep on their backs, are tired all the time, and have at least one parent that snores heavily. If you look at the space behind the tongue, the airway is extremely narrow. I’ve always suspected that there’s a link between celiac disease and a sleep-breathing disorder such as upper airway resistance syndrome, but I’ve been waiting to accumulate enough studies and evidence before adding celiac disease to my sleep-breathing paradigm.

Various other gastrointestinal conditions have been linked to sleep-breathing problems such as irritable bowel syndrome, Chron’s and ulcerative colitis, so why not celiac? Remember that with upper airway resistance syndrome (UARS), repeated micro-obstructions and arousals prevents deep sleep, which causes a chronic low-grade physiologic stress response. Stress shuts down blood flow to the intestines, which leads to the food just sitting in your intestines without proper digestion and nutrient absorption. After a while, the food becomes an irritant, which causes an inflammatory reaction, creating antibodies in the process, and food being rapidly expelled in the form of diarrhea. Chronic low-grade stress heightens your nervous system and immune system, where your body tends to over-react to normal stimulants or irritants. Just like in the nose, not only will you have an allergic reaction, you’ll also have a nervous system reaction (since your gut has a lot of nerves).

It’s no surprise that every symptom that you see with celiac disease is also seen with upper airway resistance syndrome, including hypothyroidism, migraines, PCOS, dizziness, low blood pressure, and cold hands. There’s even anecdotal evidence that breastfeeding lessens the chance that you’ll develop celiac, which is consistent with what I’ve been saying about how bottlefeeding can increase your risk of upper airway resistance syndrome and obstructive sleep apnea.

I’m not discounting the significant strides made in celiac disease research. There needs to be more awareness and more screening to treat this all-too-common condition. However, even when people go on completely gluten-free diets, they continue to have many of the various other non-gastrointestinal symptoms, including chronic fatigue, migraines, and poor sleep. The way I see celiac is that it’s kind of like a bad allergy, where your main reaction occurs in the intestines. Removing gluten definitely can help, similar to removing a cat from your house if you’re strongly allergic. But ultimately, you’re not treating what’s making you allergic in the first place. Celiac is possibly one of the early signs of an underlying sleep-breathing disorder, just like hypertension, ADHD, depression and heart disease. In modern medicine, we only tend to treat the end result, rather than the cause.

If you have celiac disease, ask yourself the following:

1. Do you prefer to sleep on your side or stomach?

2. Are you tired, no matter how long you sleep?

3. Do you have cold hands or feet?

4. Do you get frequent sinus headaches or nasal congestion?

5. Do either of your parents snore heavily?

What’s your take on my theory? Please enter your feedback in the comments box below.

Sleep Apnea As A Cause For Erectile Dysfunction?

Believe it or not, there are tons of studies showing a strong link between obstructive sleep apnea and erectile dysfunction (ED). It’s not too surprising, since obstructive sleep apnea causes a stress response that upsets the relative balance that’s needed for proper sexual functioning. This applies to women as well as men.

Arousal is activated by the parasympathetic part of the involuntary nervous system. This is the rest and relaxation half of the autonomic nervous system. Orgasm is activated by the sympathetic nervous system, or the fight or flight half of your autonomic nervous system. It makes sense that if there’s too much physiologic stress from chronic long-term sleep deprivation, then by suppressing the parasympathetic nervous system, arousal won’t happen too readily.

A recent study out of Turkey showed that people with severe obstructive sleep apnea have a higher likelihood of having ED, and that treating this condition can significantly improve this condition, as well as obstructive sleep apnea. These results are not too revolutionary, but taken along with various past studies showing similar findings, it makes me wonder if everyone with ED should at least be screened.

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Commitment and Consistency: Sleep Apnea In The Medical Community

With all the studies linking untreated obstructive sleep apnea with heart disease, car accidents, high blood pressure, depression, stroke, and various other common medical conditions, it’s surprising to me that not more doctors are looking for or screening for a condition that exists in 24% of all men and 9% of all women. We screen routinely for conditions that occur in 1-2% of the population that are much less deadly, but with sleep apnea, there’s a mental block that keeps physicians from diagnosing 90% of the people who have it. 

 

Dr. Robert Cialdini, a social physchologist, in his classic book, Influence: The Psychology of Persuasion, describes this phenomenon as commitment and consistency. He states that once you’ve committed to a certain statement, truth, or paradigm, that your subsequent thoughts, words and actions will always be consistent with your original statements or actions. One simple example is an innocent lie that perpetuates more and more lies to cover up the original lie. 

 

In medicine, we have a number of fundamental beliefs, including the fact that germs can cause illness and disease, and that antimicrobial medications can cure these conditions. Only 200 years ago, bad humors and toxins in your blood was removed with blood-letting. If you proposed back then that an unseen germ can cause illness, you’ll be laughed at or even imprisoned for such a wild and ludicrous statement. Galileo was imprisoned under house arrest for his explanation of our sun-centered solar system. I’m sure that 100 years from now, we’ll look at what we’re doing now in medicine will also seem barbaric and primitive.

 

Western medicine has a clinical diagnosis for almost every ailment we can imagine. There are a number of overlapping features, but for the most part, conditions such as diabetes, heart disease, depression, cold hands, migraines or diarrhea are treated as independent diseases, with different options for treatment. Eastern medicine, on the other hand, proposes that there are only a small number of basic fundamental imbalances that can lead to a number of common symptoms.

 

Obstructive sleep apnea today is classified alongside thousands of other common and esoteric medical diagnoses, and so to propose that obstructive sleep apnea may be the root cause of a number other other conditions would be considered heresy. Knowing that most people with heart attacks will have obstructive sleep apnea, suddenly screening and treating for sleep apnea in every patient with heart disease will only confirm that if you treat sleep apnea first, then heart disease won’t happen as much. Not only does it bruise our delicate physician egos, it also affects the bottom line for the entire medical industry, which is based on waiting until things get really bad before treating it. To go this route would be to admit that the way we’re practicing medicine is fundamentally wrong, and that would also open up liability issues as well.

 

Physicians and the lay public are definitely more aware of obstructive sleep apnea, but to date, we’re still treating it as a separate condition, independent of other medical conditions, rather than looking at it from the big picture. Also, despite numerous studies showing that you don’t have to be overweight or even snore to have obstructive sleep apnea, most doctors still won’t consider obstructive sleep apnea unless you fit the typical profile.

 

What we need is a major paradigm shift in medicine. Unfortunately, I don’t see that happening anytime soon. Do you think I’m being too pessimistic by not giving the medical profession enough credit? Please enter your reaction to this blog by typing your comments in the box below.

Sleep Apnea Denial

Here’s a common situation that I see almost every day: A middle-aged, overweight man who snores, has high blood pressure, depression and low energy levels that comes in for a throat and sinus infection, not responding to oral antibiotics. He’s found not to have an infection at all, but inflammation of his throat and sinuses from laryngopharyngeal reflux disease, most likely due to his underlying possible sleep apnea. His problems are taken care of with conservative treatment, but when I mention the possibility of obstructive sleep apnea, he refuses or politely declines  to undergo a sleep study. Some agree to undergo the test, but delay and procrastinate, saying that they’re too busy.

 

When this situation happens, there are two possible explanations: The more common type of patient is one that truly believes that his or her sinus infection is causing all the symptoms. No matter how much I explain the importance of undergoing a sleep study (including the fact that his father died of a heart attack at age 45), this patient refuses to take this explanation seriously. Eventually, months or years later, they usually come around, but only after the condition worsens.

 

The other type of patient is one that’s already done all the research, and knows about sleep apnea. Usually, they’ll have a family or friend with known sleep apnea and has seen one of the treatment options. This person refuses to even undergo a sleep study, since all the available treatment options are not too appealing. If you don’t have a diagnosis, then there’s nothing to worry about. Except that their other chronic medical conditions continue, causing the person to repeatedly go back to their doctors for their general ailments or seeing a number of specialists for various other conditions. These patients are more difficult to convince, and usually, they’ll find and accept every other medical diagnosis (hypothyroidism, anemia, chronic fatigue syndrome, migraines, sinusitis, etc.) before being convinced of the fact that they have a sleep-breathing disorder that’s at the root of many of their medical ailments.

 

If you’re the type of person that I’ve just described, what will it take for me to convince you to take your sleep-breathing condition more seriously? Please enter your answer in the comments box below.

Sleep Apnea And Liver Disease

Here’s another "dot" that connects to the central concept of my sleep-breathing paradigm: That poor breathing and frequent obstructions and arousals can negatively affect EVERY organ or system in your body, and that all modern humans are susceptible to various degrees of breathing problems while sleeping. 

 

We’ve known for a long time that untreated obstructive sleep apnea can lead to hypertension, diabetes, obesity, heart disease, heart attack, or stroke. Recently there are even studies suggesting a link to inflammatory bowel diseases such as Chron’s disease and ulcerative colitis. I’ve written numerous blogs about the link between Alzheimer’s and sleep apnea. One study showed that creating hypoxic states in mice similar to what occurs in sleep apnea creates amyloid plaques in brain tissue. Now, there’s a study linking oxygen deprivation to chronic liver disease in mice.

 

Researchers showed that keeping mice in low oxygen levels for a week resulted in increased levels of fat and inflammation in the liver. Nonalcoholic steatohepatitis (NASH) is a common, often silent liver disease that occurs in up to 40% of the population. It’s like alcoholic liver disease (alcoholic steatohepatitis, or ASH), but occurs in people who drink little to no alcohol. NASH can be severe and lead to cirrhosis. 

 

Interestingly, we know that obesity predisposes to both fatty liver and obstructive sleep apnea. Alcohol also predisposes to obstructive sleep apnea by relaxing throat muscles, leading to more frequent obstructions and low oxygen states. In this particular study, the mice exposed to low oxygen were also less sensitive to insulin.

 

This study brings up an interesting question: are NASH and ASH the same condition, where alcohol aggravates more hypoxia by causing more frequent obstructions? If you’re obese, the chances that you’ll have obstructive sleep apnea are much higher, and if you add alcohol, it’ll add further to your risk of developing chronic liver disease.

 

If you have any type of chronic liver disease, do you snore, or suspect that you may have a sleep-breathing problem? Please enter your responses below in the comments box.

Sleep Apnea, Leptin, and Alzheimer’s Disease

One of my major goals on this website is to "connect the dots" between cutting edge health research findings within the context of my sleep-breathing paradigm.

 

Here’s another not-too-surprising study about Alzheimer’s: that high levels of leptin is associated with lower rates of Alzheimer’s disease. Leptin is a hormone that’s produced by fat cells which tells your brain that your stomach is full. Over 12 years of follow-up in 785 elderly people, those with the lowest level of leptin were about 4 times more likely to develop Alzheimer’s disease than people with highest levels.

 

The study authors speculate that further research on supplementation with leptin could lead to promising new treatment options for Alzheimer’s in the future. 

 

If you step back and look at this study through the lens of my sleep-breathing paradigm, it makes perfect sense. We know that having obstructive sleep apnea makes you much more susceptible to microscopic clots and strokes in the brain, and it makes your blood thicker and more prone to stagnation and clotting. People with untreated obstructive sleep apnea are found to have multiple areas of dead or nonfunctional brain tissue. The end result is the accumulation of amyloid plaques. 

 

We also know that the physiologic effects of obstructive sleep apnea causes your leptin levels to drop (in addition to lowered levels of thyroid hormone), making you more hungry and more prone to gaining weight. Weight gain, narrows your throat even further, aggravating even more obstructions and arousals, leading to even more clots. 

 

I guarantee that you’ll continue to see many more studies associating other biochemical markers to Alzheimer’s. There are probably thousands if not millions of events that occur in the inflammatory cascade that begins with simple breathing pauses while sleeping. It’s easy to link through research any two points within this cascade, but by doing so, you’re missing the forest entirely. 

 

Sleep Apnea Surgery: Sham or Science?

As a surgeon, it’s difficult for me to say that most surgical procedures that are performed for sleep apnea don’t work. But like everything else in life, it’s never black or white—there are always various shades of gray.

 

Many people (and surgeons) think of the upper airway as a simple tube that channels air into the lungs. What’s not appreciated enough is that this passageway from the tip of the nose to the vocal folds is highly dynamic, constantly changing, with multiple levels of partial to total obstruction. There are major areas of potential obstruction (nose, soft palate and tongue), but there are many other factors that can cause inflammation, swelling, or narrowing, in addition to these 3 major areas. These other factors can include weather changes, your emotions, what you just ate, sleep position, drugs and medications, and your weight.

 

But even if you consider the three major areas only, even then it’s not that well understood. Imagine a simple, long semi-collapsible tube connecting your nose to you windpipe. If there’s one area of obstruction, then opening up this area will help should help in most cases (for example, large tonsils). But let’s say that in addition to the tonsils, you also have nasal congestion due to a deviated nasal septum. Then by undergoing only a tonsillectomy, you may feel better initially, but over time, vacuum forces created in the throat by having a stuffy nose will aggravate soft palate and tongue collapse, leading to sleep apnea later in life. If you start with obstruction in the tongue area, soft palate and the nose, then opening up the soft palate obstruction only may work sometimes, but not all the time.

 

This is the reason for the 40% success rate of the uvulopalatopharyngoplasty procedure (UPPP). You can argue what the meaning of surgical success, but that’s for another discussion. So this leads to one of the most common questions that I get asked: Does the UPPP procedure work for sleep apnea? The answer is yes, but only in people who have obstruction purely in the soft palate area, especially if you have very large tonsils. This situation occurs only in about 40% of the time in adults. 

 

In young children, undergoing tonsillectomy only without soft palate surgery is found to "cure" sleep apnea in about 2/3 of patients. This makes sense, since tonsils tend to be relatively bigger in children. But what’s the reason for residual sleep apnea in the other 1/3 of children? The answer is for the same reasons as in adults: smaller jaws that lead to tongue collapse and nasal congestion. Even in the children who are considered initially "successful," a certain proportion will go on to slowly re-develop obstructive sleep apnea, due to their smaller jaw anatomy and predisposition for inflammation in the upper airways. The tongue becomes more of an issue later in adulthood as the voice box develops and descends down in the throat. 

 

So does sleep apnea surgery work? Like everything else in life, it depends. 

 

If you want more detailed information on the truth about sleep apnea surgery, sign up for my free report on the box to the right.

 

Did you ever undergo surgery for sleep apnea? Was it addressing one level or multiple levels? Please enter your response in the comments box below.

The Sleep Apnea Switch

What’s the best treatment for sleep apnea? Believe it or not, it’s not weight loss, CPAP, oral appliances, or even surgery. It’s your mind.

 

What I’m constantly amazed about is how some people are able to instantly turn on a switch in their minds, and decide that one way or another, they must be successful with sleep apnea treatment. Ultimately, a much more powerful motivator for achieving success is not my recommendation, or even then risk of not treating sleep apnea, but the person’s mindset. There has to be an important reason for succeeding beyond the medical consequences. Let me explain.

 

One close friend who’s in his late middle years was struggling with CPAP for his severe sleep apnea. Over time, many of his close friends succumbed to possible complications of sleep apnea: one had a stroke that left him blind, and another was incapacitated for weeks due to a blood clot that went to his lungs. He became determined to properly treat his sleep apnea, and is now doing well. 

 

I often see airline pilots, truck or bus drives for sleep apnea. What I’ve noticed is how well most are able to tolerate and benefit from CPAP compared with the rest of the population. When their jobs are on the line, there’s good motivation to get treated and be able to get back to work ASAP.

 

Another common situation is a newly diagnosed younger sleep apnea patient who happens to have a parent that snored heavily and died of a heart attack or stroke in their 40s. Clearly, he does not want to succumb to his father’s fate.

 

On the flip side, I have elderly patients that have severe sleep apnea (they stop breathing 75 times per hour), but since they feel fine, refuse any treatment. There’s no reason for them to even consider being attached to a machine every night. Eventually, they slowly come back to me many years later, as more and more of their friends die from heart attacks and strokes.

 

For some of these people, success comes easy, no matter which treatment option, and for others, it can be a challenge, trying multiple different options, but they all reach a point where they’re happy one way or another. Once you set a goal, supported by the right reasons behind it, you’ll get there, one way or another.

 

What’s your true motivation for addressing your sleep apnea? Please enter your reasons in the comments box below.

Which Comes First, Sleep Apnea or Stress?

Sleep apnea is a major cause of physiologic stress. External stress of any kind (especially the holiday season) only aggravates the internal, physiologic stress that I describe in people who don’t sleep well.

To help you better manage your stress this holiday season, I’ve invited Dr. Niloo Dardashti, an integrative psychologist and holistic healer for this month’s expert interview, and I hope you’ll dial in and join us.

During this free information-packed hour, you’ll learn:

- What’s the interaction between stress, sleep problems and heart disease?

- What are some techniques for quieting "inner chatter" when stress has its’ hold on us?

- How can I stop unwanted thoughts?

- Which comes first – the chicken or the egg – does lack of sleep cause stress, or does stress cause lack of sleep?

- How can stress be handled returning to work after holidays or vacations?

- What are Dr. Dardashti’s thoughts on ADHD, Adderall and stimulants, especially for someone who has both anxiety and sleep apnea?

- How can I quit smoking if I’m very stressed and exhausted?

- What’s the best way of controlling work related stress?

- How can one reduce stress during a very stressful situation, such as being stuck in a large crowd, for example?

- How can I deal with being short on cash?

Tuesday, December 15th, at 8PM Eastern.

Register here to receive the call-in details.

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