Sleep Apnea, Statins, & Stroke: A Travesty?
May 28, 2010
The standard of care after stroke these days is to give high-dose statins (cholesterol lowering drugs), in order to prevent a second stroke. Researchers reported that although rates of statin therapy after stoke are improving (from 75 to 85%), more needs to be done to encourage doctors to prescribe statins to everyone who suffers a stroke. This recommendation was based on the SPARCL trial, which showed that loading up on high doses of statins after an initial stroke lowered the rate of repeat strokes. If you actually read through the details, it shows that the absolute drop was 2.2% over 5 years, and 16% relative risk reduction. But despite the finding that Lipitor actually increased the risk of hemorrhagic stroke, the investigators still recommended starting statin therapy soon after a stroke or TIA.
Despite the well-intentioned recommendations by medical researchers, they're completely missing the boat. This situation reminds me of Dr. Mercola's video, The Town of Allopath. You should definitely watch this video. In summary, the town of Allopath (pun intended) had too many traffic accidents at an intersection without traffic lights. An expert was brought in from the Motor Division (MD) to determine the cause of these accidents. A town meeting was convened, and the expert proudly announced the cause of all the accidents: tire skid marks. With great enthusiasm, they decide to cover up the skid marks with Teflon, thinking that if you prevent skidding, then you won't have any more accidents. You can imagine what happens next.
In the same way, elevated LDL cholesterol levels is only a sign of conditions that predisposes you to having a stroke. Having sleep apnea can cause liver dysfunction and altered lipid metabolism. We also know that most stroke patients have sleep apnea, and that having sleep apnea increases your chances of stroke by 2-3 times normal. I would think that screening for obstructive sleep apnea and treating it is a much more effective way of preventing second strokes.
What do you think about my recommendation? Am I going too far, or not far enough? Please enter your comments in the text box below.
Ask Dr. Park: Sleep Meeting 2010 Update
May 28, 2010
Sleep Meeting 2010 Update
Register below to get the replay of this FREE teleseminar about the latest in innovations and news from the SLEEP 2010 meeting in San Antonio, where all the top sleep researchers gather for their annual convention.
It's my roundup of the latest in sleep apnea treatments as well as to answer your specific questions about the topics that I report on.
More Hip Fractures With Sleep Apnea?
May 25, 2010
The FDA recently warned that chronic use of PPIs (Prilosec, Nexium, Prevacid, Protonix, etc.) can increase your risk of hip, wrist, and spine fractures. This is interesting news because most people with sleep apnea have reflux. Laryngopharyngeal reflux disease (LPRD) is probably one of the most common conditions seen by an ENT doctor like myself. In our field we like to give twice daily dosing for weeks to months. Also note that these reflux medications don't really prevent acid reflux.
Do you have sleep apnea and take one of the above mentioned medications?
Please enter your response in the box below.
Proven Weight Loss Strategies for Sleep Apnea Sufferers
May 21, 2010
My wife just commented to me that just by eating dinner about one hour earlier than usual for the past few weeks, she's automatically lost about 2-3 pounds. We normally eat about 3 hours before bedtime, but by the time we finish dinner and have fruit for dessert, it's about two and a half hours before we go to bed at 10PM. Even our children now seem less tired and more alert during the day. Although we decided to make this change to increase our sleep quality, my wife's weight loss was an unexpected side effect. So how does this apply to sleep apnea sufferers?
The Sleep Apnea Stereotype
At almost every sleep apnea lecture that I've seen in my career, the speaker almost always puts up a picture of Joe the fat boy from Dickens' The Pickwick Papers. If you read any scientific study about obstructive sleep apnea, it almost always starts with, "…typically seen in middle aged or older obese men who snore heavily with large necks."
Although described 30 or so years ago in these stereotypical men, now we know that it can occur even in young, thin women who don't snore. But many overweight people, especially as they get older, will snore or have obstructive sleep apnea. It's estimated that overall, about 24% of men and 9% of women will have it, but by the time you reach your 70 to 80s, the incidence about 55%. Being overweight is still a major risk factor for development of obstructive sleep apnea. If you're overweight and have sleep apnea, then it's much harder to lose weight than if you didn't have sleep apnea. Let me explain why.
How Hormones Affect Your Appetite
It's been proven that poor sleep (quality or quantity) can promote weight gain through various mechanisms. Leptin is one major hormone that provides information about energy status to your brain—essentially, it tells your brain that you have enough energy. Low levels of leptin causes hunger. Normally, leptin increases after you eat, but sleep deprivation lowers this hormone, making you hungry. As leptin drops, your cortisol levels will also increase. As I've mentioned numerous times in my book, Sleep, Interrupted, poor sleep efficiency cause a low-grade physiologic stress reaction that increases your cortisol levels. This hormone also makes you more hungry. Other studies have shown that not only will you be more hungry, you'll tend to crave fattier, sugary, high carb foods.
You can imagine how once this process starts, it's a vicious cycle: Poor sleep makes you more hungry, so you eat more or snack close to bedtime. More frequent obstructions causes your stomach juices to be suctioned up into your throat, causing more inflammation and swelling. These juices can then go into your nose and lungs, causing further inflammation and swelling. Weight gain then narrows your throat further, aggravating sleep apnea, which makes you sleep less efficiently.
First Steps Toward Losing Weight
So what can you do if you have sleep apnea and are overweight? Is it hopeless?
Fortunately, there are steps that you can take that if followed properly, can not only help most people lose pounds, but also sleep better in the process. The first and most important thing is to eat as early as possible before bedtime. I know I keep repeating this, but you'll be surprised by how many people continue to eat late or snack just before bedtime. Three to four hours is the general recommendation to avoid eating before going to bed. The only thing you can have is water within this timeframe. The same goes for any kind of alcohol, since alcohol relaxes your throat muscles, aggravating obstructions and arousals.
The second most important thing to do is to make sure that you can breathe well through your nose. If your nose is stuffy, the challenge is in figuring out what's causing your nasal congestion, since there are a number of different reasons. In many cases, there's more than one reason. This is a huge topic that I cover in my Ask Dr. Park teleseminar called Un-Stuff Your Stuffy Nose. I also have various articles and blogs about this issue on my website at doctorstevenpark.com.
Needless to say, you also have to eat healthy and exercise regularly. I'll leave the specific recommendations for other respective experts in this area. One thing to point out, though, is that if you lift weights or engage in any activity that bulks up your upper chest and neck muscles, remember that your upper airway is unprotected, and that that any degree of neck muscle enlargement and press in on your upper airway. This is why many bodybuilders and weightlifters snore.
Eating earlier helps to reduce inflammation and swelling in your throat, and better nasal breathing lessens the vacuum effect that's created in the throat when you breathe in while sleeping. These two steps alone (along with eating healthy and regular exercise) will help many people, but to various degrees. For some, making these conservative changes alone may be enough, but with others, they will need some form of formal treatment for their obstructive sleep apnea. I won't get into the treatment options for sleep apnea since that's a HUGE topic in itself. For more information about sleep apnea treatment, I have lots of practical information on my website or you can find one comprehensive resource by reading my book, Sleep. Interrupted.
Sleep More, Lose Weight
Lastly, most people in general are sleep deprived. Lack of sleep, in addition to inefficient sleep due to sleep-breathing problems, can also cause similar weight promoting issues. A great example is when Glamour magazine asked women volunteers to try to get consistently 7.5 hours of sleep every night for 10 weeks. Many women lost anywhere from 6 to 15 pounds, all just by sleeping more. Studies have shown that lack of sleep (5 hours or less) per night is a major risk factor for significant weight gain.
So whether or not you are overweight, the recommendations outlined above will help you to breathe better and sleep better. Even if you are thin and don't have obstructive sleep apnea, following these recommendations can the onset of sleep-breathing problems and ultimately lessen the risks that can go along with obstructive sleep apnea. If you are overweight, this is the first step toward losing unwanted pounds.
Why Mothers Are So Tired
May 21, 2010
Mother's Day has come and gone, and despite the short respite that many mothers received from their loved ones, most mothers are in a constant state of exhaustion. There are many explanations for why this is so, including the demands of modern society, family, career, and so on. But as many fathers will argue, these are the same issues and challenges they face. For women however, there are a number of internal, or physiologic factors that can not only contribute to but sometimes cause women, more so than men, in general to be tired all the time.
Blame It On Hormones…Or Your Anatomy?
We all know about hormonal issues, which has been blamed for everything from PMS and menopause to infertility issues. But one relatively unknown fact that most doctors don't know about is that progesterone is an upper airway muscle dilator. Essentially, it stimulates the tongue, giving it more muscle tone. How is this relevant to how much energy you have?
Modern humans have a number of anatomic issues that makes us predisposed to breathing pauses at night, especially when in deep sleep, due to muscle relaxation. Since our voice boxes are lower in the neck beneath the tongue, our tongues can fall back easily due to gravity, especially when on our backs. Add REM sleep (the dreaming stage) along with muscle relaxation, and the more likely you may stop breathing.
Modern humans are thought to have shrinking jaws with dental crowding due to a major shift in our diets. We went from eating completely off the land (ripping, shredding, grinding, chewing) to eating soft, mushy foods with relatively little nutritional value. Bottle-feeding (another modern, Western invention) is also thought to aggravate dental crowding and malocclusion. The smaller the jaws, the less room there is for the normal-sized tongue, which predisposes it to breathing obstruction at night.
So the less progesterone you have, the more likely your tongue will relax and obstruct your breathing, causing you to wake up and turn over. This condition prevents you from staying in deep sleep. Most people with this condition will naturally like to sleep on their sides or stomachs to compensate.
Life Changes That Aggravate Deep Sleep Deprivation
There are a number of life changes in a woman's life that promote more frequent obstructions and arousals, leading to increased fatigue and tiredness. During a woman's monthly periods, estrogen and progesterone cycles up and down. The week before she has her period, progesterone drops, leading to a temporary state of deep sleep deprivation, leading to a low-grade state of physiologic stress. This also causes a heightening of the involuntary nervous system, leading to heightened senses, irritability and moodiness.
During pregnancy, progesterone naturally increases significantly. As women gain 20 to 40 pounds during pregnancy, they would be expected to develop sleep apnea, but most don't. One major reason is that progesterone helps to protect the upper airway, by tensing the tongue, despite the added throat narrowing from weight gain. But once mom delivers, progesterone drops, and she's left with all the weight. This only adds to the chronic fatigue, depression and problems with weight loss in the post-partum period for most women.
Similarly, long before menopause begins, progesterone begins to slowly drop beginning the late 30s and early 40s. This leads to a slow and gradual lessening of the woman's sleep efficiency. Later on as the drop intensifies, the relative changes in the involuntary nervous system causes the typical symptoms of menopause such as night sweats, hot flashes, mood swings, weight gain and irritability. Once the hormonal changes stabilize, the symptoms get better.
The Effect of Estrogen Dominance
Like everything else in life, balance is key. The relative proportions between estrogen and progesterone has a huge impact on a woman's sleep quality. With the advances in science, medicine, and industrialization, this delicate balance between these two hormones has been significantly altered.
One major shift comes from oral contraceptives. Despite the potential benefits of birth control pills, having excess estrogen of any type can suppress progesterone levels or functional status. Synthetic variants of estrogen are much more powerful than what the body normally makes. There are various combinations of synthetic and bio-identical estrogens and progesterones that are used, but it's safe to say that the overall relative balance is never perfect.
In addition, many of the byproducts of industrialization produces chemicals that can mimic estrogen. Up until recently, Bisphenol-A (or BPA) has been used in plastics that are found in most plastics, including baby bottles. BPA and many other chemicals are though to leech into our environment, acting as endocrine disruptors. There are various reports of earlier onset of puberty and breast development (premature thelarche) in young girls compared with even 10 years ago.
Blame It on Stress
One of the major consequences of inefficient sleep is a physiologic form of stress. Your body thinks it's under attack all the time. This causes hormonal and neurologic changes that not only increases cortisol, it also heightens your involuntary nervous system. It also makes you more hungry in general, with cravings for fatty, sugary or high-carb foods. This can lead to weight gain, which is hard to get rid of since you're not sleeping well.
Your body also doesn't care where stress comes from. Modern life is full of stresses including family and career obligations, along with the typical financial and health considerations. Any degree of external stress whether it's physical, psychological or emotional stress, can also aggravate any internal stress that's going on.
This is why you should do whatever you can do to help your mother feel loved and more relaxed. Mothers have lots of reasons to feel stressed, sleep deprived, and just plain tired all the time. Now you know the reason why.
Seizures, Brain Density, and Sleep Apnea
May 21, 2010
I've written in the past about how untreated obstructive sleep apnea can lower your seizure thresholds. Here's a study looking at children with seizures, that showed that they had lower white matter brain volume. There have been numerous past studies showing that untreated obstructive sleep apnea leads to reductions in brain volume and density, and even a higher incidence of small strokes through critical areas of the brain. I wonder if the parents of these children snores. Something else to think about.
Raynaud’s and Sleep Apnea
May 20, 2010
There was an interesting Q&A article on Raynaud's in the New York Times. This is what I responded with:
Notice how almost everyone one of you with Raynaud's can't (or prefer not to) sleep on your back. The reason for this is that due to smaller jaw structures and narrowing of your upper airway, you literally can't breathe properly when you sleep. When normally on your back, your tongue fall back partially due to gravity. But if you have a smaller mouth, the tongue takes up relatively more space and falls back a bit more completely. This becomes a problem when when you're in deep sleep, since all your muscles (including your throat muscles) begin to relax. In this situation, you'll stop breathing and wake up to turn over to your side or stomach. This is something that began when you were a child, and most people compensate by normally sleeping only on their sides or stomach.
Problems occur when you're suddenly forced to sleep on your back, such as from an injury or after undergoing an operation
Despite being able to compensate by avoiding the back position, it's usually not good enough. By definition, you won't be able to achieve deep, efficient sleep, which causes a low-grade physiologic stress response. This activates the sympathetic (fight or flight) nervous system which tends to constrict blood flow and nervous innervation to low-priority organs and body parts, such as your hands, feet, skin, digestive and reproductive organs. This is also why Raynaud's is also associated with autoimmune conditions.
Chronic low-grade physiologic stress over-activates your immune system, resulting in your body attacking its' own tissues. Not only is your immune system over-reactive, but your nervous system is also overly activated, leading you to be en garde, edgy, and hypersensitive in general. These symptoms are seen often in people with upper airway resistance syndrome.
Inefficient sleep leads to chronic fatigue issues. But most people compensate by staying active during the day, or participating regularly in intense physical activity.
Typically, most people with Raynaud's improve as they get older. But as you gain weight, many of you will begin to develop obstructive sleep apnea. Notice how one or both of your parents may snore heavily and have have cardiovascular disease. If you don't gain weight, then your Raynaud's may last longer.
This is also why anything that helps to calm your nervous system (meditation, yoga, acupuncture, biofeedback, etc.) can help your symptoms. It also explains why when the breathing problem is taken care of definitively, Raynaud's symptoms can improve.
Snoring Article in Parade Magazine
May 18, 2010
Here's a funny account of a writer's adventures in dealing with his major snoring problem. It was published in this past weekend's Parade Magazine. AJ Jacobs is a New York Times best-selling author (The Year of Living Biblically, The Guinea Pig Diaries), who came to see me to take care of his snoring problem, as well to chronicle his journey throughout the process.
What do you think?
Biden’s Stroke: Could It Be From Sleep Apnea?
May 14, 2010
Recent reports that Vice President Joe Biden's son Beau, attorney general of Delaware, suffered a small stroke brings up awareness of strokes in younger adults. Beau Biden is 41. Various reports and news articles go over all the routine risk factors for stroke, but surprisingly, never mention obstructive sleep apnea as a major risk factor. The Bidens have a history of cardiovascular disease, so this is not surprising.
It's been shown that untreated sleep apnea can increase your risk of stroke by up to 3 times normal. Stroke patients are found to have obstructive sleep apnea in up to 80% of the time. We know that about 24% of men and 9% of women have at least some degree of obstructive sleep apnea, which increases significantly as you get older. Knowing all this, it's puzzling why doctors aren't routinely screening people with strokes for sleep apnea.
What do you think about my proposal? Should all stroke patients be screened for sleep apnea? Even better, should everyone with cardiovascular disease be screened for sleep apnea?
Car Accidents and Sleep Apnea: A New Perspective
May 13, 2010
It's commonly known that if you have obstructive sleep apnea, your risk of getting into a car accident is anywhere from 3 to 10 times normal. But if you don't have sleep apnea, can injuries from a car accident lead to obstructive sleep apnea? In certain situations, yes.
Just yesterday, I saw two patients in a row who came in for various ear, nose and throat complaints, including headache, ear fullness, nasal congestion, sinus pain and pressure. It turns out the both got into major car accidents many months to years ago, and ever since then has not been able to sleep as deeply or efficiently as they normally did. It turns out that both of these women naturally preferred to sleep on their sides or stomach. Both attributed their poor sleep to various neck and back pain. As a result, they ended up sleeping on their backs.
I talk about how most modern human's jaws are smaller than what they used to be hundreds of years ago, and as a result of dental crowding, the tongue takes up relatively too much space. This makes the tongue more susceptible to falling back and blocking your breathing at night, especially when you're in deep sleep, due to muscle relaxation. Most people with these issues naturally prefer to sleep on their sides or stomachs, but when they are forced to sleep on their backs for whatever reason, their sleep efficiency drops significantly. We know that in many people with severe obstructive sleep apnea, sleeping on their sides can eliminate apneas almost entirely.
More frequent obstructions and arousals not only cause poor quality sleep, but it also creates a vacuum effect in the throat that suctions up your normal stomach juices into your throat, which can then go into your ears and nose.
This situation applies not only with car accidents, but any type of injury that prevents you from sleeping in your preferred sleep position. I also see it happening during pregnancy, surgical procedures, or sleeping next to a new bed-partner. More recently, women are starting to sleep more on their backs after reading in magazines that they should avoid stomach or side sleeping since it can cause facial wrinkles. Really bad advice. Since back sleeping lessens your sleep quality, you'll develop even more facial wrinkles.
Did you used to sleep on your stomach or your side, but had to switch to your back due to an injury?
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