August 21, 2010
If you wake up every morning needing to hack up lots of thick mucous, or have throat pain, hoarseness, or a chronic cough, you’re not alone. You may think it’s the beginning of a cold, but a cold doesn’t continue for weeks to months without progressing into the full-blown viral symptoms.
Instead, these symptoms are the beginnings of the most common throat problem sleep apnea sufferers face. And as I explain below, without understanding why this occurs, it can be one of the hardest problems to treat.
Beware of the “Vacuum Effect”
People with obstructive sleep apnea are more prone to breathing problems at night due to partial or total collapse of one or more areas of the entire upper airway, from the nose to the tongue. It’s usually worse when on your back, since the tongue can fall back more in this position. During deep sleep, your muscles naturally relax and you’ll be more susceptible to breathing stoppages.
Pressure sensors placed inside sleep apnea patients reveal that every time an apnea occurs, a tremendous vacuum effect is created inside the chest and throat, which literally suctions up your normal stomach juices into your esophagus and throat. This can happen occasionally, even for normal people, but if you happen to have a late meal or a snack just before bedtime, there will be even more stomach juices lingering in your stomach to come up into the throat. If you happened to drink a nightcap, the situation is even worse since alcohol is a strong muscle relaxant.
What comes up into your throat is not only acid, but also bile, digestive enzymes, and even bacteria. Washings of lung, sinus and ear contents have shown H. pylori, a common stomach bacteria, and pepsin, a major stomach digestive enzyme. So what comes up can cause severe irritation in your throat, provoking the mucous secreting glands of your throat to try to dilute these substances.
Although people generally attribute throat mucous to post-nasal drip, in most cases there’s nothing dripping down the back of the throat. It’s actually coming from your stomach. However, in some cases, since your stomach juices can reach your nose, it can cause nasal congestion and inflammation, which can aggravate tongue and soft palate collapse by creating a vacuum effect downstream. Ultimately, it’s a vicious cycle.
Chronic acid and other irritating substances lingering in your throat can have other detrimental effects. One recent study showed that chronic acid exposure can numb or deaden the protective chemoreceptors in your throat. These are sensors that detect any acid in the throat to prevent aspiration of your stomach contents into your lungs. If these chemoreceptors sense any acid in your throat, a feedback signal is sent to the brain, causing you to wake up so that you can swallow. This is what’s called a reflux arousal.
Treating Reflux For Good
So besides not eating late and avoiding alcohol close to bedtime, what else can you do?
I’m assuming that many of you that are reading this article are already being treated for obstructive sleep apnea, via either CPAP, oral appliances, or even with surgery. The problem is that no matter which option you choose, there will always be some degree of reflux. Taking acid reflux medications can help sometimes, but for the most part, these reflux medications don’t really do anything for reflux. All they do is to lower the acid content content before it comes up into your throat.
Other options include stimulating your stomach via natural remedies or prescription medications to empty your stomach much faster. One fascinating study showed that using a combination of pseudoephedrine (Sudafed) and a pro-motility agent (domperidone) eliminated snoring in most people. Unfortunately, we don’t have the equivalent of domperidone here in the US. Other similar medications are available, but have more serious side effects.
This is why eating early at least 3-4 hours of bedtime is so important whether or not you have obstructive sleep apnea. The same also applies to alcohol. If your nose is stuffy, talk with your doctor to find a way to breathe better through your nose. Make sure you’re sleeping in your preferred or optimal sleep position. Lastly, work with your sleep physician to fully optimize your sleep apnea treatment, no matter which option you choose.
August 21, 2010
You’ve gained some weight over the years and you’re just not sleeping well. Your husband says you’ve begun snoring. You know that your father has obstructive sleep apnea and is doing well with CPAP. You mention this to your doctor and she orders a sleep study. The sleep study comes back completely normal. Now what?
The Real Reason for Your Chronic Fatigue
Before you begin searching for other reasons for your chronic fatigue, don’t rule out a sleep-breathing problem too quickly, even if you don’t have obstructive sleep apnea. In fact, a sleep-breathing problem can cause if not aggravate conditions such as hypothyroidism, chronic fatigue syndrome, depression, insomnia, and even irritable bowel syndrome.
Sleep doctors have defined obstructive sleep apnea as having at least 5 apneas or hypopneas every hour on average. An apnea means you stop breathing completely for 10 seconds or longer. Hypopneas are similar 10 second or longer pauses but with restricted airflow. But what what happens if you stop breathing 25 times every hour but each episode lasts only a few seconds?
In the early 1990s, Dr. Christian Guilleminault of Stanford University looked at young, thin men and women who were tired all the time, no matter how long they slept. These people were found not to have obstructive sleep apnea after undergoing formal sleep studies. However when they placed thin pressure catheters in their chest and throat, they found the they had frequent episodes of partial obstruction which led to subtle, but significant limitation of nasal airflow, along with very negative vacuum pressures in the throat. Most of these minor episodes were not apneas or hypopneas, but still lead to an arousal—from deep to light sleep. What was happening was multiple partial obstructions and arousals that were not severe enough to be called apneas or hypopneas, but enough to wreak havoc on deep sleep quality.
It’s been shown that even very subtle levels of restricted breathing can lead to deep brain stimulation and arousals that prevents your ability to stay in deep sleep. These reflex signals to the brain can be so weak that it doesn’t even reach the outer layers of the brain where standard scalp electrodes can pick up these disturbances.
Blame It On Your Parents (And Your Jaws)
The fundamental problem in UARS is due to smaller upper airway anatomy, caused by having smaller jaws and dental crowding. The smaller the space behind the tongue, the more likely you’ll obstruct while breathing when on your back (due to gravity, the tongue can fall back), and when in deeper levels of sleep (when your muscles relax). This is why most people with UARS can’t, or prefer not to sleep on their backs. The problem is that you can still have breathing problems despite sleeping on your side or stomach, just not as bad as being on your back.
Lack of sleep and especially lack of deep sleep has been found to cause a whole host of physiologic changes. In general this happens due to chronic overstimulation of your sympathetic nervous system. This is the fight-or-flight half of your involuntary nervous system. Since your body thinks it’s under attack, it heightens your nervous system, making you en garde, edgy, hypersensitive or overreact to normal situations. This also leads to diversion of blood flow, energy and resources away from less essential body parts and organs, such as your digestive system, reproductive organs, skin, hands, feet, and other “end organs.”
Due to this “hypersensitivity,” the nose and sinuses can be overly sensitive, reacting to stimulants such as weather changes, chemicals, scents, and even allergies. Chronic stress that results from sleep deprivation also can heighten your immune system.
Is It Hormones or Your Breathing?
A number of other studies point out that UARS patients are more prone to have cold hands or feet, hypothyroidism, irritable bowel syndrome, depression, chronic fatigue, and various other “somatic” syndromes. I see this all the time in my practice. In fact, a recent study even showed that chronic long-term sleep deprivation caused significant lowering of the TSH and T4 levels, with women being much more susceptible to this effect compared with men.
With time, as people age, and especially as they gain weight, most people will progress into true obstructive sleep apnea. You’ll find that most younger, thinner people with UARS will have one or two parents with significant obstructive sleep apnea.
Now that you’re convinced that you may have this condition, what can you do about it? For the most part, it’s treated just like obstructive sleep apnea. You should start with all the conservative options first, such as weight loss (if you’re overweight), diet, exercise, improving your nasal breathing, and not eating late. If these options don’t work, then all the formal options for treating obstructive sleep apnea are possible including CPAP, oral appliances, and even surgery.
Unfortunately, if you don’t officially have a sleep apnea diagnosis based on a sleep study, then insurances generally won’t cover any of the treatments. The irony is that our health care system won’t treat or prevent diseases in the early stages, and would rather wait until it’s much more severe before covering for medical services.
If you think you may have upper airway resistance syndrome, you may be disappointed to find that the medical community in general will not be responsive to your queries. With a few exceptions, many sleep doctors are not convinced that UARS is even a legitimate condition, and would rather lump it into the spectrum of snoring to obstructive sleep apnea. Time after time, whenever I see patients who are told they don’t have obstructive sleep apnea and I treat the upper airway narrowing and inflammation, patients almost always feel better. Your best option is to continue to educate yourself and be persistent. Your first priority should be to be able to breathe better so that you can sleep better.
July 20, 2010
There are many resources available regarding tips for travel while on vacation, but one thing that can definitely ruin your vacation is poor sleep. You may never think that you will suffer from sleeping problem until it happens, and by then, it’s too late. Besides the various stresses of travel, including delayed flights, misplaced luggage, or traveling with children, the last thing you need is to lay down in your hotel bed, and start tossing and turning, unable to sleep.
On the other hand, you can go to sleep with no problems, but wake up feeling like you slept for only 3 hours. This can happen due to worrying about your lost luggage, persistent ear pain and hearing loss since getting off the plane, or an uncomfortable mattress or pillow. If you are a poor sleeper to begin with and especially if you normally can’t sleep on your back, then the following travel tips could prevent your vacation from turning into a disaster.
Tip #1. Keep your nose clear.
If you have a history of ear or sinus discomfort while flying, or if you have any degree of nasal congestion due to allergies or colds, then take preventive measures to open up your nasal breathing passageways to prevent ear, nose or sinus problems which can keep you up at night. Your ears and sinuses are connected to your nose through very narrow passageways. If you have any form of nasal congestion or inflammation, these passageways can become more narrow, and the rapid pressure changes during your flight (usually when descending) can aggravate more swelling and a partial blockage of your sinuses or ears. The middle ears are connected to the nose by the Eustachian tubes, which acts to equalize pressure between your nose and your ears every time you swallow. But when there’s swelling (due to colds, allergies, migraines, or acid reflux) around the Eustachian tubes in the back of the nose, this tube doesn’t work properly and your ears won’t equalize. Not breathing well through your nose can also prevent proper breathing at night, leading to poor sleep.
The simplest way of preventing ear, nose and sinus problems while flying is to decongest your nose using generous amounts of nasal saline (which is a mild decongestant), or over-the-counter decongestants, such as Sudafed tablets or Afrin nasal spray. If you have high blood pressure or are sensitive to Sudafed, it’s not a good idea to take. Afrin, on the hand, can only be used for 2-3 days if you have persistent ear fullness after the flight. For most people, taking a decongestant in the middle of the flight (before descending), should be enough. There are various ear “plugs” marketed for flying. They can be helpful for some people; if it works, keep using them.
Now that you've made it safely off the plane without any problems, you finally make it to your hotel at 9 PM and check in. You're really hungry and stop by the restaurant to grab a sandwich.
Tip #2: Don’t eat before bedtime.
Eating late before bedtime, while on vacation or at home, is the single most common habit that could potentially ruin a good night's sleep. On vacation, it’s tempting to eat later or binge at a great restaurant, but you’ll pay for it that night. For many people, if you have food in your stomach when you lay down, some of the stomach juices can regurgitate up into your throat, causing irritation and inflammation. This can wake you up more often, diminishing deep sleep quality. For people who snore or prefer to sleep on their sides or stomachs, they may actively suck up stomach juices into their throats while sleeping, worsening an already tenuous sleep situation. The general rule of thumb is to eat your last meal about 3-4 hours before bedtime. This also means no snacks before bedtime.
Tip #3. Avoid the Night Cap.
You've stopped your late night snacks, and so far so good. You make arrangements to meet your long-time friend at the hotel bar, but the earliest he can meet is at 10 PM. The two of you meet and decide to have a glass of wine. As you take your first sip, you remember the newspaper article that reported that red wine has an ingredient that could keep you young. Afterwards, you to back to your room to rejoin your wife, and you go to bed. The next morning, for some reason, you feel like you only slept for 3-4 hours. What happened?
There are numerous studies that tout red wines' beneficial health effects. But one aspect of red wine, and all other forms of alcohol, that could be detrimental to your health is its' relaxing effects on your throat muscles. If you already have a slightly narrowed upper airway passageways (like most people), sleeping on your back can cause mild collapse of your tongue backwards. But when you add deep sleep, since all your body's muscles relax the most, adding alcohol can tip you over the edge and cause you to stop breathing. You may wake up subconsciously, or completely awake. This is one of the main components of alcohol that promotes hangovers in some people.
The bottom line is that you should avoid drinking alcohol 3-4 hours before bedtime.
Tip #4. Take Your Own Pillow.
You've stopped your late night eating and drinking alcohol, and you are ready to go to sleep. You lie down to sleep, but something doesn't feel right. After a few minutes of tossing and turning and fluffing the pillow, you realize what the problem is: you miss your own pillow. Yours is much firmer, and the hotel's pillow is too soft. Thinking about your pillow is not something that most people consider before taking trips. You can't bring your own mattress, but you can bring your own pillow, if space allows. On car trips, I always bring my own memory foam, contoured pillow. A soft down pillow could easily fit into a decent sized suitcase.
Don't wait until you are ready to go to bed to find that the hotel's pillow isn't "just right." When you first arrive in your room, after you unpack, test drive your pillow. If it doesn't feel right, ask the concierge for a different type of pillow. Some may even have the memory foam contoured pillow that I like, and some Asian travelers may prefer a roll-like buckwheat-filled pillow.
If you like to sleep on your back, and feel less than refreshed in the morning, try sleeping on your side. If that's not possible, experiment with the roll-like pillow that I mentioned previously, or roll up a towel to just the right thickness. The reason this may help you sleep is that when your head is cocked back slightly when sleeping (unlike softer, down pillows that end up bending your head forward), the space behind the tongue opens up significantly, preventing frequent awakenings at night.
Tip #5. Don't Sleep In.
When you're on vacation, it's tempting to stay up late and sleep in in the morning. RESIST THE URGE. I've already covered in the past few lessons why it's important not to eat late, and why you must go to bed at a reasonable time to allot for your normal sleep duration. If you go to bed late and wake up later in the morning, you've shifted your sleep clock, which will make you want to go to bed later. Once you're back home, along with the clock shift from changing time zones, you'll be doubly affected: time zone shift and a sleep clock shift. This is why it's so hard to get anything done when you get back to work.
To make the most of your vacation, plan your sleep times accordingly so that you can maximize your fun during your waking hours. Spend time outside in the sun, walk, jog, cycle, swim, and relax! If possible, remember to give yourself a day or two to wind down after you come back before you go back to work.
Even if you don't suffer from any problems during your trip, many ear and sinus problems occur AFTER your return trip, usually aggravated by the return flight. You've had a great vacation, but now you're paying for it when you come home. If you had followed my advice during your vacation, you wouldn't have to see a doctor about your ear problem.
July 20, 2010
One of the most common excuses for not wanting to use CPAP is that “I travel a lot.” Even after I explain that many people travel just fine with their CPAP machines, some people are stll reluctant. With advances in technology and increased awareness by the lay public, government officials and medical professionals about the importance of using CPAP for obstructive sleep apnea, traveling with CPAP, although initially a challenge, can be done with relative ease. People use CPAP on planes, and even go camping with it. With the FAA’s recent ruling and instructions on carrying and using CPAP on airlines, it’s become even easier to travel with CPAP machine. I know there are various types of PAP devices, but for the sake of simplicity, I’ll call these devices the generic name, CPAP.
Flying with Your CPAP
The Federal Aviation Administration (FAA) recently ruled that airline passengers must be allowed to use respiratory assistive devices, such as a CPAP machine (Nondiscrimination on the Basis of Disability in Air Travel – May 13, 2009). However, don’t think that you’ll just breeze by security checkpoints at the airport. Here are some common tips that are recommended when you fly with your CPAP machine:
1. Never check your CPAP machine.
2. Always have with you a prescription for your CPAP machine and your latest sleep study. You never know if your unit gets lost or stolen, or breaks down.
3. Attach a medical equipment tag, identifying the contents as such.
4. Let the TSA security agent know that you have a CPAP machine. Remove it from the back and have it scanned separately.
5. Request that security agents change gloves and wipe down the table before inspecting your machine. Wrap your device in a clear bag while being scanned to prevent contamination with germs and other chemicals.
6. Keep a record of the model and serial number in hand, just in case.
7. If you’re going to use your CPAP machine in-flight, check beforehand if there’s an outlet next to your seat, and if you have the right adaptor.
8. If the flight attendant says something about your CPAP being another carry-on, let him or her know that it’s a CPAP machine and under the Americans with Disability Act, it’s not counted as an added carry-on.
9. Consider having your doctor give you a letter describing the need for your CPAP machine.
10. Most CPAP units will automatically convert to the correct local voltage. Check with your instruction manual or manufacturer to confirm this. You may, however, need a plug adaptor, as well as an extension cord, in case your outlet is far away.
Tips On Water
Many people are so focused on the logistics of their machines, that sometimes they forget about distilled water. Make sure you have plenty of distilled water available if you’re going to use it on the plane, or at your final destination.
If you’re not going to use your CPAP device on the plane, then make sure you empty and dry the water chamber before flying (check out expedia for available flights!). If you’re planning on using your CPAP device on-board, there are two options to be able to pass large amounts of fluids past TSA security checkpoints: Have your doctor prescribe distilled water in a pharmaceutical grade bottle. A 500 mL bottle should hold about 16 oz. Another option is to purchase papFLASK, which is designed to pass through security checkpoints with ease.
For whatever reason you don’t have distilled water available, using bottled or even tap water is OK, but try to find distilled water as soon as reasonably possible. Mineral deposits in tap water can build up within the PAP machine and can cause damage if it continues long-term.
Camping or Backing Up with CPAP
For travel to areas that don’t have electricity, or in case you have a blackout, there are numerous battery options available. Each manufacturer will usually have a back up battery recommendations and adaptors.
For more extended periods, various people have written about using a 12 volt deep cycle marine battery with a sine wave inverter. There are numerous other battery options so do your research. Different manufacturers have different voltage needs, so also check with your manufacturer. Since a humidifier uses a lot of energy, most people recommend not using the humidifier if you’re only camping for a few days. There’s lots more information about batteries in CPAP support sites such as sleepguide.com, cpaptalk.com, talkaboutsleep.com, or apneasupport.com.
Have A Back Up Plan
Some patients carry around their oral appliances with them whenever they travel, either using it in place of their CPAP machines or just in case the device breaks. Some people use both the oral appliance and their CPAP machines simultaneously. If you’ve never tried an oral appliance and you’re interested in an alternative option, it may be worth giving it a try now before you need to travel for long extended periods.
No More Excuses
With advances in technology and more acceptance by the medical community as well as the lay public, there’s basically no reason (unless it’s psychological) you can’t travel with a CPAP machine. With knowledge and some flexibility and creativity, anyone can travel with CPAP, even in the more remote areas of the world. There have even been descriptions of solar power being used to recharge batteries used for CPAP. If you travel frequently to the same location, consider purchasing a second unit. Prices for middle of the road CPAP models are in the $300 to $700 range.
The first major challenge is in finding a way to make CPAP work for you. The second major challenge is in un-tethering your machine from your bedroom. Many people are living vibrant and normal lives, despite having to use their CPAP machines while traveling. Or is it because they are using their CPAP machines regularly while traveling? You decide.
June 30, 2010
Learn the Insider Secrets of Highly Successful CPAP Users…
Get your FREE access to the audio replay and mp3 download of this interview with Aurelio Henriquez who has extensive experience helping patients with sleep apnea succeed in using their CPAP machine.
Since 2002, Aurelio has helped hundreds of CPAP users overcome their struggles while he was with the NY Methodist Sleep Disordered Center as a Polysomnographic technologist and then later as the technical lab director for the Columbia University Sleep Disorder Center.
• What to expect when you first try CPAP in the lab
• How to avoid the #1 mistake every new CPAP user makes
• Where to get the best CPAP equipment for the best price
• What one thing you MUST do BEFORE using CPAP to dramatically increase your chance of success
• What makes some people fail and some to succeed on CPAP and how you can be successful
June 8, 2010
Over the past year, ever since the birth of our third son, Brennan, I've been more tired than usual. Not too unexpected when you have a newborn, right? Add to this having to help my wife tend to the needs of our two older boys, who are 7 and 10. But even now when Brennan is sleeping well through the night, and I'm sleeping about 7 hours every night, I'm still more tired than I used to be, despite running 3 times per week, and being as fit as ever. Could I be going through male menopause?
The Facts of Male Menopause
I wrote last month about how mothers can suffer from poor sleep due to the effects of menopause on sleep quality, but what about fathers? You may have heard about male menopause, or more precisely, andropause. It's not that well known, and even if it happens, it's so slow and insidious that most men don't realize it's happening.
Well, it turns out that men go through a similar transition during the mid-life years. Not only does testosterone slowly drop, but thyroid levels as well. Our traditional medical culture and even holistic and alternative doctors sometimes argue that aging is a deficiency of certain hormones, vitamins or minerals, and that replacement using synthetic or natural supplements is the answer. But is that the only answer?
Most people think that this is a natural part of aging, along with the typical memory loss, balding, wrinkles and lowered energy and stamina. But what if I told you that I routinely see even young to middle aged men who complain about hot flashes, night sweats, mood swings, insomnia and irritability—or all the prevailing symptoms of menopause?
Aging As A Consequence of Poor Sleep
In my book, Sleep, Interrupted, I describe a sleep-breathing paradigm where all modern humans are on a continuum, where we're all susceptible to sleep-breathing problems to various degrees.
As you age, it's expected that overall, you'll keep moving up this continuum to the point where sleep breathing problems become much more serious as in obstructive sleep apnea. Not only do we sag and bulge on the outside as we get older, it also happens on the inside, including your upper airway. And as your airway becomes narrower, the more trouble you'll have breathing while sleeping, and this in turn will make you wake up more and obstruct more.
Women experience more dramatic changes in hormone levels (particularly progesterone) that affect upper airway patency, but levels of testosterone and even small amounts of progesterone can also influence upper airway muscle tone in men as well; Not to mention the typical weight gain that occurs in the middle years, leading to even more narrowing of the upper airway. Adding any degree of inflammation to the upper airway (such as from a cold, allergies, or reflux) can cause more frequent obstructions and arousals. Poor sleep efficiency leads to weight gain, and weight gain narrows the throat.
Sleep Apnea And Aging
It's a given that as you age, your upper airway begins to narrow gradually, aggravated intermittently with additional narrowing from inflammation. This is also why men begin to develop cardiovascular disease as they get older. Women are somewhat protected before menopause, but afterwards, they begin to catch up when it comes to rates of heart disease. As you slowly move up the sleep-breathing continuum, your risk of developing obstructive sleep apnea increases, and once it begins, a vicious cycle begins, where poor sleep aggravates weight gain, and weight gain aggravates poor sleep.
Poor sleep (by causing a physiologic form of stress) also causes major hormonal changes by lowering your thyroid levels, as well as your reproductive hormones. So naturally, if you test for thyroid or testosterone levels, it may come back on the low side. Not too unexpectedly, supplementing with replacement hormones helps in some cases, but not all the time.
We know that untreated obstructive sleep apnea (OSA) can aggravate or cause routine medical conditions such as diabetes, high blood pressure, depression/anxiety, heart disease, heart attack and stroke. Your risk of car accidents also increases anywhere from 3 to 10 times normal if you have OSA. Add to this all the other common expected conditions that you may experience as you get older: frequent bathroom trips, balding, erectile dysfunction, hearing loss, and even Alzheimer's.
Taken at face value these seemingly disparate symptoms of old age aren’t all that unexpected. However, if you look at them from the perspective of my sleep breathing paradigm, you’ll begin to see how it’s your breathing and not necessarily your age that’s making you feel sick and tired.
Too Many Bathroom Trip—Risky For Your Health
It's been shown that going to the bathroom frequently at night is not because you're making too much urine, but because you stop breathing and you think you have to go to the bathroom. One recent study showed that going to the bathroom two or more times per night increases your chances of dying by 50%. There have even been many anecdotal reports of hair regrowth after definitive treatment for sleep apnea. Erectile dysfunction (ED) is a very well-known complication of sleep apnea. Having ED can predict the presence of sleep apnea in the majority of patients.
Brain Damage From Poor Breathing While Asleep
Untreated sleep apnea also increases your chances of microscopic strokes and small vessel blockages in multiple, critical areas of the brain. One recent study showed that sleep apnea patients have 20% smaller brain volume in the Mammary bodies. Another showed smaller brain tissue densities in critical areas of the brain that controls memory, executive function, breathing and respiration. Untreated sleep apnea patients have much more viscous (thick) blood that can stagnate and clot in small vessels in the brain. One area that's particularly sensitive are the small vessels that supply the high-frequency sensing areas of the inner ear.
All these issues begin when you're young, but begin to manifest in your middle years, progressing to full-blown medical complications when you reach your 60’s and 70’s. As you can see, how narrow you upper breathing passageways are determines how quickly you age or how often you become sick. Now that I'm in my mid-40s, if I don't get at least 7 hours of sleep, or if I eat later than usual, I definitely feel worse the next day. This is why it's important to do everything possible to breathe well at night while sleeping, in addition to a healthy lifestyle that includes a good diet, regular exercise and smart decisions when it comes to your sleep.
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.
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.
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.
April 21, 2010
Looking back at my teen years at Stuyvesant High School in the mid 1980s, it's amazing what I was able to accomplish: Beside the rigors of academics, I was in the symphonic band, orchestra, jazz band, captain of the track team, and a major science geek, entering and placing in various prestigious competitions, including reaching the semi-finals of the Westinghouse Science Talent Search (now renamed Intel). I also remember having the hardest time getting up in the mornings, since I had to commute over an hour by public transportation to get to school. Many of my friends had to travel much further and had even more impressive activities.
Late To Bed, Early To Rise
It's almost a given that if you have a teenager, he or she will be sleepy, especially in the morning. Various experts describe teens' hectic schedules as a major cause of their sleepiness. One particular explanation is that teens' sleep cycles are shifted later into the night, going to bed later and waking up later. But because most of our schools begin at 8AM, teens have to get up hours before their normal wake times. But can there be an alternative explanation to why their sleep times are shifted and why they have trouble getting up in the morning? Is their delayed sleep time a natural part of their development, or is it an artificial product of modern society?
My sleep-breathing paradigm proposes that all modern humans are susceptible to breathing problems while sleeping due to our smaller jaws. Coupled with this paradigm, there are also various developmental and anatomic changes that teens undergo that can explain why teens are so sleep deprived, and why paradoxically, they can be extremely active and productive during the day.
In my book, Sleep, Interrupted, I describe a phenomenon where due to a major change in modern humans' diets along with the invention of bottle-feeding, our jaws are getting smaller with more dental crowding. Another variable that compounds this problem is that we're able to talk and communicate—this make our tongue prone to collapse, especially when on our backs and in deep sleep (due to muscle relaxation).
Growing Up Can Cause Sleep Problems
Throughout life, there are various accelerated periods of growth or change with our voice boxes as it relates to our upper airways. This first period occurs between 4-6 months, when the voice box separates away from the soft palate, creating a uniquely human area in the throat called the oropharynx. The oropharynx is the space that's behind your tongue, between the tonsils and below the soft palate. Humans infants, who are born able to breathe and suckle at the same time, have to relearn this process during this timeframe. Interestingly, this is also the period of time when SIDS (sudden infant death syndrome) peaks.
The Tonsil Dilemma
During ages 3 to 6, childrens' tonsils grow significantly larger, and not too surprisingly, this is also the time period in which tonsils are most frequently removed, especially for snoring and obstructive sleep apnea. Once tonsils (and adenoids) are removed, most children do well, but recently, we're realizing that this is not necessarily the case.
The problem is that removing tonsils and adenoids only addresses part of the problem—it doesn't address the smaller jaws that these children have. Having smaller jaws means that the tongue can fall back easier and cause more of a vacuum effect in the throat that suctions up normal stomach juices into the throat, causing the tonsils to become even larger. This creates more obstructions, preventing the jaws from widening and developing more fully. This is why rapid palatal expansion alone was found to be equivalent to tonsillectomy, and doing both gave additive results.
Let's say that your child's large tonsils were removed, but the jaws never fully developed properly. Most young teens will eventually need braces to correct for crowded teeth. Unfortunately, most orthodontics is focused on straightening teeth, rather than enlarging the airway.
As your child goes through puberty, an obvious thing also happens: his or her voice becomes lower. One major consequence of a deepening voice is that the voice box has to drop in the neck. This opens up the oropharynx even further, creating even more space for the tongue to fall back. This process continues into early adulthood, where the voice box settles in its' final location (it's been shown that the voice box continues to drop an additional 1/2 vertebral body length slowly even up to age 70).
Delayed Sleep or Deficient Sleep?
As your teen undergoes this transition, by definition, sleep quality diminishes, with various consequences, both good and bad. Because they're not able to sleep efficiently, it's hard to get out of bed in the morning. To compensate for their fatigue, they tend to participate in numerous activities throughout the day, including sometimes very physical sports. I've also commented in my book about a possible connection between mild sleep deprivation and creativity promotion, since your senses are heightened. After a full days worth of school and after-school activities, they'll have dinner and then have another few hours of homework to tackle.
With this schedule, it's not surprising that most teens don't get to bed before 11 or 12 PM, if not later. If you add to this all the media distractions like the computer, phones and television, they'll get even less sleep. Eventually, they crash, and are forced to wake up earlier than they want to to begin the next day. When I was is high school, I didn't have that much homework, so I usually went to bed at a reasonable time, around 9 to 10 PM. These days, I'm sure that teens probably go to bed much later than this. Their minds are so wired at night that it's difficult to go to bed earlier. In essence bad sleep hygiene such as this can lead to delayed sleep times, similar to many adults with delayed sleep phase syndrome.
An Explanation For The Freshman 10
If one or both parents snore or have documented obstructive sleep apnea, the teen has a higher risk of having sleep apnea as well, or developing it later in life. For some reason, sleep apnea in teens is not seen too often. But I'm willing to bet that it's a major problem that's not being addressed. Similar to the natural anatomic changes that occur during menopause, adolescence is a period of change in the sleep-breathing status that can cause paradoxical patterns of moodiness and irritability, along with intense creativity and productivity.
Notice that the incidence of depression and anxiety also begins to spike in the late teens and early adulthood. Imagine taking a teen out of his protected home environment with regular, healthy meals and place him suddenly in college where he'll binge in the cafeteria, stay up late, and even drink alcohol.
All this can lead to, or aggravate underlying sleep-breathing problems. Since inefficient sleep causes weight gain, and weight gain can narrow the throat, all this is not surprising. Perhaps the freshman 10 weight gain is an expected consequence of this expected life transition (an anatomic transition) that can unmask any underlying sleep-breathing problems.