In this podcast, I have a fascinating discussion with Dr. Ronald M. Harper, Professor of Neurobiology at the University of California, Los Angeles. Dr. Harper shares some profound insights about why brain damage goes hand in hand with obstructive sleep apnea. In this interview, you’ll learn:
- Why Obstructive Sleep Apnea (or OSA) can cause brain damage but how this brain damage can further perpetuate sleep apnea
- Eye-opening insights about why OSA is so often associated with memory loss, brain fog, balance issues, hypertension, and even diabetes
- Besides traditional OSA treatment options, which simple exercise method can help reduce OSA severity.
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Brain Morphology Associated with Obstructive Sleep Apnea
Brain Structural Changes in Obstructive Sleep Apnea
Sex Differences in White Matter Alterations Accompanying Obstructive Sleep Apnea
Blood-Brain Barrier Leakiness in Obstructive Sleep Apnea
Obstructive Sleep Apnea: Brain Structural Changes and Neurocognitive Function before and after Treatment
In this podcast, Kathy and I will reveal “Everything You Wanted to Know About Nasal Surgery.” Topics include:
1. Septoplasty: Why packs are not needed
2. Turbinoplasty: How much removal is enough?
3. Nostril surgery: Why it’s better than Breathe Right strips
4. Sinus surgery: Myths and misconceptions
5. Reconstructive surgery: When you may need this.
The Truth About Sleep Apnea Surgery
Un-Stuff Your Stuffy Nose e-book
How to Find a Good Sleep Apnea Surgeon
Weight loss is probably one of the most common New Year’s resolutions that people make this time of the year. Some people succeed, but most do not.
Getting quality sleep, maintaining an ideal weight, and eating a healthy diet are like legs of a three-legged stool. Having one shorter leg or a loose leg can topple you over as you try to sit down. Similarly, poor sleep quality can also derail your New Year’s resolution to lose weight this year. Poor sleep can mean not enough sleep as well as fragmented, unrefreshing sleep due to any reason.
Coincidentally, two studies were published this month in the Sleep journal regarding sleep apnea and weight loss. Investigators studying veterans enrolled in a weight loss program found that those with sleep disordered breathing experienced significantly less weight loss at 6 months compared to those without sleep disordered breathing.
Another study found that only people with obstructive sleep apnea who had small facial skeleton volumes had any significant drops in the apnea hypopnea index (AHI) when losing significant weight, compared to those with moderate or large sized volumes. What this implies is that the smaller your facial skeletal volume (small mouth), the more likely any degree of weight loss can lower your AHI. It’s been shown that about a 10% weight loss lowers the AHI about 26% on average.
In addition to treating your sleep-related breathing disorder, you also have to change your mindset and habits to lose weight effectively and also to keep it off. To help you on this journey, I recommend you listen to these three past teleseminars:
Tara Marie Segundo on The Most Overlooked Solution for Weight Loss
- The #1 reason why most people can’t lose weight
- Her proprietary 5 Key Success Principles for losing weight and keeping it off
- How to strategically achieve your weight loss goals like the pros do
- How to lose weight without counting calories and depriving yourself
Tara Marie Segundo on Answers to Your Top 10 fitness Questions
- What #1 mistake prevents people from sticking with their exercise regimen and what you can do to avoid this
- How you can get fit in just 10 minutes a day
- Tips on overcoming the diet “blahs”
Alyse Levin on What to Eat When You’re Sick and Tired
- When to eat and when not to eat
- How to stay motivated to eat right and to lose weight
- Foods that can help you breathe better and sleep better
- Why some “good foods” can be bad for you
- Best low sugar, high power snacks to take with you when you’re On-The-Go
- Tips on what to order and where to go when you’re eating out
- How to read nutrition labels like a Pro
- How to control your blood sugar level if you’re at risk for diabetes with food and not with medications
You can also access all my past telesemianrs and podcasts here, or on iTunes.
In this podcast, Kathy and I will discuss the 7 myths about nasal surgery, & when to do surgery
1. Nasal trauma causes a deviated septum
2. Septoplasty will treat snoring or sleep apnea
3. Septoplasty will change my nose externally or have bruising
4. Will need packing inside the nose
5. Rhinoplasty – what it means, and what to watch out for
6. Does a deviated septum (or shrunken turbinates) come back after surgery?
7. Turbinate surgery causes empty nose syndrome.
And when to consider nasal surgery.
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“I keep Waking up every 2 hours in a sweat, with my heart racing and feeling very hot. I also keep having to go to the bathroom every time I wake up.”
This quote was from Doris, a 51 year-old woman who came to see me not for her menopausal symptoms, but for her severe snoring that was keeping her husband awake. It turned out that Doris had gained about 10 pounds over the past year, and she was also having some signs of menopause: occasional hot flashes, and increasing fatigue. Her mother began have similar symptoms at this age as well.
There are many good explanations for menopause, but one mechanism that’s related to sleep and breathing has to do with progesterone. This is one of the two female hormones (along with estrogen) that cycles every month, dropping just before a woman’s menses. During pregnancy, progesterone stays high, and drops after delivery. However, during menopause, it declines slowly over many years.
One of the interesting aspects of progesterone is that it’s an upper airway muscle stimulant. It’s been found to increase genioglossus (tongue) muscle activity and tension. In one study, post-menopausal women had lower levels of tongue muscle tone, but after progesterone was given, muscle tone went up significantly. This may explain why menopausal women tend to sleep better after taking progesterone.
With the natural progression of menopause and all its’ expected consequences, it’s not surprising that with added weight and lowered progesterone levels can add to the progression of obstructive sleep apnea. This may also be the reason why menopausal women almost catch up with men with heart disease. As I’ve stated before, poor sleep can aggravate weight gain, and weight gain can aggravate more sleep apnea, which leads to worse sleep.
In addition, notice how some of the features of menopause mirror symptoms of obstructive sleep apnea: frequent awakenings with a racing heart, night sweats, irritability and nighttime urination. In fact, I have seen some young men in their 20s later diagnosed with sleep apnea, and who obviously can’t be going through menopause, still come to see me complaining of these same symptoms.
In addition, having obstructive sleep apnea may also be a risk factor for some women who develop early menopause. Chronic stress states brought on by repeated episodes of choking at night can lower your reproductive hormone levels. This explains why there are a number of studies showing fertility issues in people with obstructive sleep apnea.
Granted, not all women going through menopause will develop sleep apnea. My guess is that the more susceptible you are (overweight, anatomy from your parents, smaller jaw structures, etc.), the more likely you’ll develop sleep apnea after menopause. Many of the symptoms of sleep apnea and menopause can overlap as well (weight gain, hot flashes, night sweats, mood swings and irritability). This may be one more compelling reason for women to get evaluated for sleep apnea if they suffer from common symptoms of menopause.
If you’re a post-menopausal woman with obstructive sleep apnea, who kind of symptoms did you have while undergoing menopause? Please enter your responses in the text box below.
Oftentimes in social situations, whenever people discover that I’m a sleep doctor, every other person will tell me about their spouses’ snoring problems or insomnia issues, but invariably, someone will tell me, “I’m a great sleeper!” However, when pressed further, I’ll get these comments from these great sleepers:
1. I sleep like a log.
2. I can sleep for 10 to 12 hours.
3. I can fall asleep anywhere, anytime.
Any time I hear any of these comments, I’ll take it at face value. But whenever I see someone with a very narrow face with dental crowding, I’m thinking that their sleep quality is not what it should be. When asked further, almost everyone prefer to sleep on their side or tummy. They’ll also have various health issues, like anxiety, headaches, TMJ, chronic pain issues, fatigue, or digestive problems. Almost invariably, one or both parents will snore heavily.
Normal sleep should work on a rhythm. You should be able to fall asleep within 10 to 20 minutes when you want to, and you should be able to wake up after 7-8 hours feeling refreshed. People who have problems breathing at night tend to sleep very well subjectively, but objectively, it’s very fragmented. Falling asleep too easily during the day is also not a good thing.
When people say that they sleep like a log for 12 hours, that’s a red flag. It’s also not normal to fall asleep anytime, anywhere during the day. Studies have shown higher rates of depression, angina, diabetes, and cancer for excessively long sleepers. There’s even a study showing a higher rate of dying if you sleep longer than 8 hours (or less than 4) compared with people who sleep 6 to 7 hours per night.
Most people with these issues compensate in various ways. Many will exercise intensely, getting quite good at their sport. Others will fill up with coffee or take stimulating supplements.
Do you have no problem falling asleep anywhere, anytime? Can you sleep for 10 to 12 hours, and still not feel refreshed? If so, what do you to to stay alert or active during the day?
With the development of the overnight sleep study by sleep researchers, sleep medicine was born in the mid 1900s. The term polysomnogram refers to multiple variables that are measured during sleep. Determining sleep stages by analyzing brain waves and eye movements was a monumental step for medicine in general. Tomes of research and incredible insights have been discovered through what’s found during sleep studies. So why am I saying that sleep studies are useless?
Take for example, Jenny, who is a young, thin woman to came to see me for her severe fatigue, anxiety, and headaches. She also has trouble staying asleep, waking up every 2 hours to go to the bathroom. Her father has a history of sleep apnea, so her sleep physician ordered a sleep study for Jenny, which came back as being normal. Her AHI (apnea hypopnea index) was 0.5, which was well below a level of 5 that’s needed for a sleep apnea diagnosis. The final interpretation stated that there was no evidence of obstructive sleep apnea or sleep-related breathing disorders. She was eventually offered treatment for insomnia.
When I saw Jenny, it was clear that she had a major sleep-breathing problem. She had a tiny mouth, with severe crowding of her upper airway. She eventually underwent nasal surgery to address her nasal congestion, during which time endoscopy under anesthesia showed severe tongue collapse with each breath in. The space behind her tongue was no more than 1-2 mm, and obstructed completely with each inhalation. Furthermore, her epiglottis, a cartilaginous flap that sits behind the tongue above the voice-box, fell back completely with each breath in.
It’s now considered standard of care to undergo a sleep study if you may be at risk for obstructive sleep apnea. There are very specific criteria to qualify for a sleep apnea diagnosis. As mentioned previously, you need to have at least 5 apneas or hypopnea every hour on average to be eligible for a sleep apnea diagnosis. Each episode has to last more than 10 seconds. Jenny’s problem was that when she obstructed, she woke up too quickly.
I see patients daily who don’t officially meet the formal criteria for sleep apnea based on sleep studies, but stop breathing 20 to 30 times every hour. Oftentimes, these more subtle obstructions don’t lead to any drops in oxygen levels, but can cause repeated partial arousals from deep to light sleep. Imagine never being able to stay in deep sleep for more than 1-2 minutes the entire night.
The main reason why I still order sleep studies is because you need a sleep apnea diagnosis for insurance carriers to cover any type of treatment. If you come in below 5, you’re out of luck, no matter how many times you stop breathing. Regardless of whether or not you have a formal diagnosis of sleep apnea, my philosophy is to treat the patient and the anatomy, not the numbers. In an upcoming post, I will describe my protocol for treating people who are in this dilemma, called upper airway resistance syndrome.
If you can’t sleep and were told you don’t have sleep apnea after testing, what did your sleep doctor recommend?
Almost routinely, I see patients who repeatedly stop breathing at night but don’t have any significant apneas on sleep studies. Jennifer was told by her husband that she choked multiple times at night with frequent arousals. But her apnea hypopnea index (AHI) on her in-lab sleep study was 1.0, well below the 5.0 threshold needed for an obstructive sleep apnea diagnosis. She underwent every possible test, including an MRI to rule out a brain tumor, but everything came back normal.
Eventually, drug induced sleep endoscopy (DISE) revealed severe tongue base and soft palate obstruction. Essentially, people with upper airway resistance syndrome (UARS) obstruct often but wake up to light sleep too quickly, less than the 10 seconds that are needed to be scored as an apnea or hypopnea.
Here are 5 reasons why UARS is harder to treat than obstructive sleep apnea:
1. If your AHI is less than 5, you’re told by sleep doctors that you don’t have sleep apnea. Your severe fatigue and various other conditions are often blamed on hormonal (pre-menstrual, menopause), neurologic (multiple sclerosis), infectious (Lyme, mononucleosis), rheumatologic (chronic fatigue, fibromyalgia), food/environmental allergies, mold sensitivities, or nutritional/vitamin deficiencies. As a result, treatment for a sleep-breathing problems is not even considered.
2. If you’ve already been diagnosed with one of the above conditions in #1, then it’s very unlikely that you or your doctor will consider an alternative explanation, especially if you’ve already invested so much time, energy and resources.
3. If your doctor wants to treat you for UARS with continuous positive airway pressure (CPAP) or a dental appliance (that pulls your tongue forward), insurance won’t usually cover it, since your AHI is less than 5.
4. Most people with upper airway resistance syndrome also have various degrees of nasal congestion. Having a small mouth with dental crowding also leads to narrow nasal passageways, making it more likely that you’ll have a deviated nasal septum, enlarged or over-reactive turbinates, or flimsy nostrils. Having a stuffy nose will prevent you from being able to use CPAP or dental appliances.
5. UARS is a structural problem caused by smaller-than-normal jaw structures, leading to narrowed air-passageways that lead to severe breathing problems at night. All the truly effective solutions involve using gadgets, devices or surgery. With few exceptions that can lead to temporary relief, you can’t treat it with a pill.
The most common manifestations of UARS are severe chronic fatigue and exhaustion (not sleepiness), anxiety/depression, headaches, nasal congestion, TMJ problems, cold hands/feet, low blood pressure, diarrhea/constipation/bloating, frequent nighttime urination, and hypothyroidism. The typical exam findings include a high arched hard palate, narrow dental arches, crooked teeth, bite problems, head forward posture, and a relatively large tongue (due to a small mouth).
If you fit some or all of the features described above, you may have upper airway resistance syndrome. For a more detailed description of UARS, you can read an article by clicking here. Please note that you can have UARS and various other conditions. But not being able to breathe and sleep properly can significantly aggravate any other condition that you already have. In addition, you can have obstructive sleep apnea and UARS overlap to various degrees.
Unfortunately, many mainstream sleep physicians will be resistant to acknowledging that UARS exists. If you do your research, you should be able to find a sleep physician that will be willing to treat your UARS even if you don’t have sleep apnea. Other specialists such as otolaryngologists and dentists may be more receptive to UARS, but even then, they are in the minority. A good place to start looking is to listen to some of my past expert interviews, particularly the episodes with Doctors Guilleminault, Krakow, Gold, Lawler, Palmer, Silkman, Belfor and Singh.
In this episode, I answer 13 of your questions that I get through my blog, email, and contact me page. This is completely live and unscripted. I have no ideal what Kathy will ask me. See below for a list of the questions.
1. How much do you charge for a office visit or procedure?
2. How can I make an appointment to see you?
3. Various questions about specific medical issues.
4. What’s the difference between upper airway resistance syndrome (UARS) and obstructive sleep apnea (OSA)?
5. Will sleeping pills work for upper airway resistance syndrome?
6. Does sleep apnea cause brain damage?
7. Are apneas more damaging on the brain than hypopneas?
8. What’s the relationship between depression and sleep apnea?
9. How do dental extractions affect sleep apnea?
10. Can nasal surgery cause sleep apnea later in life?
11. What’s the link between reflux and sleep apnea?
12. Can sleep apnea cause dizziness?
13. What questions should I be asking my doctor?
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Here’s a very good story about one of my past guest interviewees, Dr. Avram Gold. Sleep Review Magazine published an interesting article that reviews Dr. Gold’s controversial work on functional somatic syndromes (depression, anxiety, chronic fatigue syndrome, fibromyalgia, insomnia, Raynaud’s syndrome, RLS, hypothyroidism, IBS, etc.) and upper airway resistance syndrome.
It’s a fascinating discussion about how patients with “mild” or no obstructive sleep apnea (OSA) can often be worse off than OSA. My sleep-breathing paradigm is completely in agreement with Dr. Gold’s basic premise, that frequent partial resistance to breathing at night with repeated arousals from deep sleep can cause or aggravate many of the the conditions listed above. What I describe has more anatomy-based descriptors, due to the fact that modern Western humans have shrinking jaws, leading to more narrow upper airways.
I, too have had patient with many of the various functional somatic syndromes feel significantly better or get better completely after treating their narrowed upper airway anatomy, using CPAP, dental appliances, or surgery. In fact, most of these patients had no significant apneas or very mild levels of OSA on sleep studies. In all cases, upper airway evaluation using a flexible camera showed very narrowed airways.
If you have or had any of the above conditions improve or resolve completely by using CPAP, dental devices or surgery, please tell us your story in the box below.
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