November 17, 2014 by Steven Park
I’m in the process of completely overhauling my website, and I need your help with the logo design. I’ve whittled the design down to 6 candidates. Will you please help me choose your favorite design? I would also appreciate your feedback and comments as to why you like or dislike the designs. This poll is being undertaken by my publisher, who will report the results to me. I will then publish the final results.
The logo and Web site redesign is just the start. I’m just about to begin working with an editor to go through the manuscript for my second book, “The Total Sleep Apnea Solution: Dr. Park’s Complete Guide to Getting the Sleep You Need and the Life You Want.” This is still a working title, so I’ll send out another poll about the title as the book publishing process continues.
Thanks for taking time to help me with the start of a very important project.
Please click here to take the poll to choose your favorite logo.
November 12, 2014 by Steven Park
A psychologist colleague of mine once told me that at the hospital where he works, many of his patients are on antipsychotic and antidepressant medications. A significant number of these patients will go on to gain significant weight, snore heavily, and end up dying of heart attacks or strokes. While this is purely anecdotal, based on what we know about the side effects of commonly prescribed prescription medications, it’s not too far fetched for the following reason: Any medication that causes weight gain can potentially aggravate or uncover obstructive sleep apnea.
I’ve written extensively in the past how obstructive sleep apnea is mainly a structural problem with narrow jaws and upper airways, but if you add fat in the throat due to being overweight, it just makes things much worse. Here are 7 commonly prescribed prescription medications that can aggravate obstructive sleep apnea due to their ability to put on weight:
1. Many of the antidepressants, especially the tricyclic antidepressants (TCAs) are known to stimulate appetite. Two examples of brand names are Pamelor and Elavil. The newer class of antidepressants called selective serotonin repute inhibitors (SSRIs) don’t generally cause weight gain, except for Paxil. One interesting known side effect of these type of medications is that they suppress REM sleep. Perhaps by limiting REM sleep, you’re prevented from having as much apneas since you’re kept out of REM sleep. This can be one way that these medications may help with depression. However, there’s a cost to not getting enough REM sleep: Your nervous system gets more excitable, with lowered pain thresholds, and you’ll have more problems with learning and memory.
2. Depakote (valproic acid) is a common mood stabilizer to treat bipolar disease and seizures. It’s also used to prevent migraines. One study found that 44% of women and 24% of men gained about 11 pounds on average over one year.
3. Atypical anti-psychotics (Risperdal, Seroquel, Zyprexa, Abilify, and others) are known to cause significant weight gain (7% or more in original body weight) in up to 30% of patients. There’s also some evidence that these medications may also cause insulin resistance and potentially lead to diabetes. A study published in Obesity found that men who took Zyprexa for only 2 weeks increased their food intake by 17%. Another study published in the Journal of the American Medical Association reported that 10 to 36% of children and teens became overweight or obese after 12 weeks taking atypical antipsychotics for the first time.
4. Prednisone, one of many corticosteroids to control inflammation, is one of the most commonly prescribed medications. Chronic, long-term use is given for asthma, inflammatory bowel disease, rheumatoid arthritis, and various other autoimmune conditions. One study found that 70% of people on chronic steroid use reported significant weight gain.
5. Antihistamines such as Allegra and Zyrtec, are also associated with being overweight. This study found that patients on these medications were 55% more likely to be overweight compared to those not taking the medications.
6. Insulin. You’d think that with better sugar control, there would be weight loss, but the findings are the reverse. Here’s a study showing that insulin alone promotes weight gain.
7. The older beta-blockers such as atenolol, metoprolol and propranolol are also associated with significant weight gain. One possible mechanism is that any drug that lowers sympathetic activity will block the brain pathway that stimulates melatonin. Light stimulates receptors in the eye that stimulate nerves in the suprachiasmatic nucleus (near the optic nerve), which then connects to the thalamus then drops down to the spinal cord, connecting with the superior cervical ganglion, and then back up to the pineal gland, which makes melatonin. Light suppresses melatonin, whereas darkness enhances melatonin. Since the superior cervical ganglion is part of the sympathetic nervous system, taking beta-blockers can potentially alter melatonin production.
As I was doing research for this blog post, I kept getting led down more rabbit holes with studies detailing potentially serious side effects with all these medications. I only listed 7 medications, but there are many more. It’s clear that most if not all prescription medications will have various side effects, with many causing sleep or weight disturbances. This is something that all physician must think about when prescribing any of these medications.
If you started taking any of the above mentioned medications, did you notice any significant weight gain?
November 5, 2014 by Steven Park
Asthma is the third most common chronic disease amongst children, and the third most common reason for admission to the hospital. The CDC estimates that 7.1 million children suffer from this condition, costing over $50 billion a year. A new study from the University of Chicago found that children who undergo tonsillectomy had 37% reduced hospitalizations and 26% less visits to the emergency room. They compared about 13,000 children with asthma who underwent adenotonsillectomy to 27,000 who didn’t undergo the procedure. This finding builds on previous smaller-scale studies finding similar results. A Fox News article summarizing the findings concludes with a standard disclaimer that since this was a retrospective study, causation can’t be linked, and that large-scale prospective studies are needed.
What the paper doesn’t address is the possible reason why removing tonsils may help asthma. I’ve described in the past about the strong association between large tonsils, obstructive sleep apnea and reflux. Every time a child stops breathing, a vacuum force is created in the chest and throat, with normal stomach juices coming up into the throat. What comes up not only includes acid, but also bile, digestive enzymes, and bacteria. In fact, one recent study found pepsin (a stomach enzyme) in the lungs in the vast majority of children and teens with chronic lung disease. There are also numerous reports of pepsin being found in chronic ear and sinus infection fluid.
While tonsillectomy is not a completely benign surgical procedure, this study adds to the multiple potential benefits that improved breathing and sleep can have on your child’s health.
For the parents out there, did you notice any improvements in your child’s asthma symptoms after tonsil surgery?
October 16, 2014 by Steven Park
One of the most common complaints by my patients with obstructive sleep apnea (OSA) is memory loss. Judith is a 55 year old woman who used to have a sharp memory, but now is having trouble with names and losing her keys all the time. Things got much worse when she gained more weight, which worsened her snoring. She was eventually placed on CPAP for her moderate obstructive sleep apnea, and is now happy to report that while her memory is not back to normal, it is much improved.
At a recent Airway Dentistry conference I went to last month, the most memorable topic was given by Dr. Ronald Harper, Distinguished Professor of Neurobiology at the David Geffen School of Medicine at UCLA. I’ve been following his work over many years, but his presentation only confirmed my suspicion that there can be significant brain damage with untreated obstructive sleep apnea. Based on various high-tech MRI technology, specific known areas of the brain can be damaged with repeated episodes of apneas and low oxygen levels. Note that the word “damage” can mean low functioning, or dead brain cells. Here are 5 particular areas of brain damage from untreated obstructive sleep apnea with their specific symptoms:
1. The right insular cortex. This is the area of the brain that regulates sympathetic control of the autonomic nervous system. If the insular cortex is damaged, baroreflex control is affected. The insula also controls nerve endings that relate to pain. Both OSA and sleep apnea patients are found to have insular cortex injury.
2. The vetrolateral medulla (VLM). This area of the brain controls breathing and blood pressure regulation. Injury to this area blunts and delays heart rate responses to sudden pressure changes. One sided VLM injury leads to an asymmetric response to blood pressure challenge, which can potentially cause heart rhythm problems.
3. The cerebellum is the area of the brain that helps adjust blood pressure control and motor coordination, including breathing. Damage to this area prevents the ability to coordinate vascular and motor activity.
4. The hippocampus is found to be significantly smaller in people with obstructive sleep apnea. This area of the brain processes short and long-term memory and spatial navigation. One study found that hippocampal damage can be partially reversed after a period of CPAP. The hippocampus is also one of the first areas to be damaged in Alzheimer’s disease.
5. Mammary bodies are important for memory recall, as well as for memory for certain smells. These structures are much smaller in patients with OSA, and almost nonexistent in patients with heart failure. The hippocampus and mammary bodies are also found to be damaged in chronic alcoholism.
If OSA can damage critical areas of the brain that regulates breathing, balance, memory, and the autonomic nervous system, the implications are enormous. For example, heart failure is thought to lead to central sleep apnea. Is it possible that untreated obstructive sleep apnea can damage breathing and reflex centers in the brain that can lead to heart failure? What proportion of Alzheimer’s disease is actually undiagnosed OSA? The possibilities are endless. As they say at the end of every scientific journal article, more studies are needed.
If you have both OSA and memory problems, did your memory improve at all after being treated? Please tell your story below.
(Take a look at the references below to take a look at the various photos and figures. The figure above is from the Macey 2002 paper)
Canessa, N., Castronovo, V., Cappa, S. F., Aloia, M. S., Marelli, S., Falini, A., et al. (2011). Obstructive Sleep Apnea: Brain Structural Changes and Neurocognitive Function before and after Treatment. American Journal of Respiratory and Critical Care Medicine, 183(10), 1419–1426
Henderson, L. A., Woo, M. A., Macey, P. M., Macey, K. E., Frysinger, R. C., Alger, J. R., et al. (2003). Neural responses during Valsalva maneuvers in obstructive sleep apnea syndrome. Journal of Applied Physiology (Bethesda, Md. : 1985), 94(3), 1063–1074.
Kumar, R., Chavez, A. S., Macey, P. M., Woo, M. A., Yan-Go, F. L., & Harper, R. M. (2012). Altered global and regional brain mean diffusivity in patients with obstructive sleep apnea. Journal of Neuroscience Research, 90(10), 2043–2052.
Macey, P. M., Henderson, L. A., Macey, K. E., Alger, J. R., Frysinger, R. C., Woo, M. A., et al. (2002). Brain Morphology Associated with Obstructive Sleep Apnea. American Journal of Respiratory and Critical Care Medicine, 166(10), 1382–1387.
Macey, P. M., Kumar, R., Woo, M. A., Valladares, E. M., Yan-Go, F. L., & Harper, R. M. (2008). Brain structural changes in obstructive sleep apnea. Sleep, 31(7), 967–977.
Lal, C., Strange, C., & Bachman, D. (2012). Neurocognitive impairment in obstructive sleep apnea. CHEST Journal, 141(6), 1601–1610.
October 7, 2014 by Steven Park
Over the years, I’ve witnessed countless stories about patients with obstructive sleep apnea who undergo nightmare experiences while undergoing treatment. Oftentimes, the insurance issues can be worse than any medical issues. In his book, The Midnight Stranglers: A Personal Quest For Healthcare Transparency, Aiden Hill chronicles his painful journey from first being diagnosed with obstructive sleep apnea to his ordeal as a consultant helping California residents obtain health care coverage.
- Basic concepts of obstructive sleep apnea and consequence of non-treatment are covered. It’s not taken to be medical advice, but is well-written from a lay-person’s perspective.
- He describes the current flawed state of affairs with our health care system, likening it to Dr. Jekyll and Mr. Hyde. There can be a dark consequence to any good intention.
- With ongoing changes to our health care system, he emphasizes the importance of taking a pro-active approach before undergoing any type of treatment. Even then, you’re likely to get hit with an unexpected bill, despite putting in your due diligence. Expect to spend hours, days or even years dealing with the aftermath. I’ve experienced this personally numerous times.
- The problems that he encountered with insurances companies, doctors, hospitals, and government entities are all governed by the basic rule: “Protect the asset.”
- I completely agree that full financial transparency is needed before undergoing any medical transaction.
October 3, 2014 by Steven Park
When I first wrote my book, Sleep, Interrupted in 2008, I had a question mark in my diagram linking obstructive sleep apnea to possible cancer. Since that time, there have been a number of studies making that link stronger, and I am now more comfortable in removing that question mark. One of the basic hallmarks of obstructive sleep apnea is repeated episodes of low oxygen levels (intermittent hypoxia) due to obstructed breathing at night. If you google “intermittent hypoxia and cancer” you’ll see about 460,000 search results, of which 33,000 are scholarly articles. Low oxygen levels are strongly associated with cancer progression.
In a recent review article on this subject, Dr. David Gozal and colleagues published a paper titled, Sleep apnea awakens cancer: A unifying immunological hypothesis. They hypothesized that intermittent hypoxia and sleep fragmentation can promote changes in the tumor microenvironment, leading to a weakened immune system and tumor growth enhancement.
It’s important to remember that intermittent hypoxia not only can enhance cancer development, it can also in theory enhance benign tumor growth as well. One of many possible explanation is the concept of increased levels of vascular endothelial growth factor, which enhances more blood vessel growth, so that more nutrients (via blood) can reach the oxygen starved tissues. Initially, it may only cause localized enlargement of the soft tissues. Imagine if you continue to have intermittent hypoxia, and let’s say that you have a gene that makes you more susceptible to cancer. If you add additional lifestyle habits such as smoking and drinking alcohol, then one mutation can potentially lead cancer.
To date there hasn’t been any particular cancer that’s strongly associated with obstructive sleep apnea. However, one large-scale population study found that your chances of dying from cancer increases almost 5 times if you have untreated severe obstructive sleep apnea. Another study found a 2.5 times increased risk of having cancer and 3.4 times higher risk of dying from cancer with untreated moderate to severe obstructive sleep apnea.
Notice that the most common types of cancer happen in the “low priority” organs when you’re under stress. These areas include the gastrointestinal system, the reproductive organs, hands, feet, and the skin. In general, the core, central areas take priority. Any form of physiologic or emotional stress diverts blood flow and nervous system activation away from low priority to high priority areas. Rarely do you hear about cancer in the brain, heart or muscles, which are considered high priority.
This is another example of how sleep connects the dots between almost every known chronic health condition. Unfortunately, cutting edge cancer research focuses mainly on the molecular, genetic, and biochemical aspects without looking at the big picture. Without addressing proper sleep and breathing, even the best cancer treatments can give possibly suboptimal results.
If you have a diagnosis of obstructive sleep apnea, do you have a cancer history in your family?
September 24, 2014 by Steven Park
Oftentimes, I recommend a referral to a dentist to treat obstructive sleep apnea. Most patients will ask me, “How is a dentist going to help me?” My answer is that since obstructive sleep apnea is mainly a problem from small jaws and crooked teeth, they have a variety of different ways of helping you to breathe better and sleep better.
I just came back from presenting at an Airway Dentistry conference in Laguna Hills, CA. It was definitely one of the most exciting and rewarding conferences I have ever attended. All the speakers and the attendees are at the forefront of not only potentially better treatment, but also better prevention of obstructive sleep apnea.
The most common way dentists can treat obstructive sleep apnea is by making a retainer-like appliance that pulls your lower jaw forward. Since the muscle that attaches the base of your tongue connects to the lower jaw, moving the jaw forward will pull the tongue forward. This option works well for most people and is usually better tolerated than CPAP. However, because it’s a device that sits in your mouth, protruding your lower jaw, it can sometimes cause problems like profuse salivation, jaw pain and shifting teeth. It uses the upper teeth as a lever to pull the lower teeth forward, so the upper teeth can shift back to various degrees. Fortunately, this is unusual, and can be adjusted for by your dentist. In many cases, people don’t mind because sleep is so much improved.
Now there are a newer generations of dental appliances that work not by pulling forward your lower jaw, but by expanding your jaw wider and more forward, all without surgery. Granted, it can take much more time, similar to braces. However, it’s different from braces in that rather just straightening teeth, the entire jaw structure is significantly expanded, opening up the airway.
The downside to these newer options is that because they are so new, not too many dentists know about it, and it’s not generally covered by insurance. It’s also important to remember that there hasn’t been large-scale studies on obstructive sleep apnea treatment effectiveness. Hopefully, studies will be forthcoming. Currently, most dental appliances that are FDA approved for obstructive sleep apnea are the advancement devices.
Up to date dentists are also incorporating orofacial myologists who train your tongue and throat muscles properly. Since your tongue is your most important orthodontic appliance, how it’s used (along with the lips and throat muscle) can have a profound effect on the eventual size of your jaws and your upper airway.
I challenge everyone reading this post to find out how much they know your dentist knows about obstructive sleep apnea. Does he or she appreciate how important the teeth are in relation to your upper airway? Does your orthodontist still remove teeth before applying braces for your child? If not, at the risk of possibly offending your dentist, please direct them to the American Academy of Physiologic Medicine and Dentistry, and the American Academy of Dental Sleep Medicine.
What has your experience been with your dentist? How well are they versed in the importance of the airway?
September 17, 2014 by Steven Park
Many women look forward to a radiant, flawless glow that’s expected to come with pregnancy. However, despite the upbeat exterior, many pregnant women suffer from depression, with potentially serious medical consequences for the mother and the baby.
This paper reviews outcomes of pregnancy when mothers have depression. What they found was that having depression during pregnancy is significantly associated with higher rates of pre-term delivery, low birth weights, pre-eclampsia, and spontaneous abortion. In children born to depressed mothers, higher rates of emotional and behavioral problems were seen.
The prevailing theory is that increased stress hormones can potentially cause complications in the mother and the baby. However, it’s interesting that these same complications are very similar to complications of untreated obstructive sleep apnea. We know that poor breathing during sleep (which leads to inefficient sleep) can lead to increased levels of physiologic stress. Added weight gain and snoring are known and normal consequence of pregnancy.
With about 20 to 30% of pregnant women suffering from depression, it’s important to screen for depression. Better yet, perhaps doctors should routinely screen for obstructive sleep apnea in all pregnant women. Of course this paper doesn’t discuss depression that can happen after delivery (postpartum depression).
For the mothers that are reading this, did you suffer from depression during pregnancy, and if so, do you currently snore?
August 28, 2014 by Steven Park
Podcast #002 Show Notes
Reader Question: Do those anti-snoring devices that you see advertised really work?
Sleep Tip of the Day: How to minimize light pollution in your bedroom.
Resources mentioned in podcast:
Finding Connor Deegan video
American Academy of Physiologic Medicine & Dentistry (AAPMD.org)
Ride of the Zombies Charity Bike Ride
Subscribe in iTunes @ doctorstevenpark.com/itunes. Thanks for reviewing my podcast and rating me.
Listen to the MP3 file here. (Right click to download)
August 26, 2014 by Steven Park
You may be sick of hearing about ADHD (attention deficit hyperactivity disorder) in children, but it’s a real problem with potentially devastating consequences. Here’s an article I wrote for Respiratory Care & Sleep Medicine on how poor sleep is often neglected when diagnosing and treating ADHD. Stay tuned for an upcoming podcast interview with Ms. Valerie Deegan, who helped to create a moving video about her son’s severe ADHD.