The Truth About Acid Reflux Medications

 

My First Apnea?

Dr. Mack Jones suggested that I get tested for sleep apnea in response to my last post about feeling depressed all last week from what I thought was the gloomy weather. He may have a point here. Last week, as I was dozing off to sleep, my wife did mention that I stopped breathing suddenly and started breathing again after a short snort. I vaguely remember it happening. It was also a time when my nose was a little stuffy. Technically, this wasn’t an apnea, since it lasted only a brief second or two. On a sleep study, it would be classified as a respiratory event related arousal (RERA).

 

Having just passed my 42nd birthday, I’ve come to terms with the fact that this was bound to happen eventually. I’ve said again and again that all modern humans are susceptible to breathing problems while sleeping, and I’m no exception. The only comfort I take is the fact that I did undergo a sleep study many years ago to see what it was like, and it revealed an AHI of 1, which is considered "within normal limits."  It did show that I had some mild disruptions in my deep sleep stages. I suspect it may creep up slowly as I get older. Fortunately, my weight has not changed—if anything, it’s gone down since I began running regularly. 

 

More recently, I’ve been sleeping well, and my energy level is pretty good, despite that fact that our 5 month old has been up at night repeatedly due to teething.

 

There’s now even more reason for me to follow the advice I give to my patients: don’t eat late, exercise regularly, keep your nose clear, and don’t sleep on your back. The one thing I’ll have to work on is to try sleeping more on my side since that brief obstructive episode happened while I was on my back. I’ll keep you posted.

Under The Weather Or Depressed?

For whatever reason, until today, I’ve been feeling really run down with no energy or motivation to do anything. My sleep’s been OK, but I felt more tired than usual. My ability to focus and concentrate was definitely affected, and my wife even called my mood "morose." Ouch. I hope my bad mood didn’t rub off on my three boys.

The reason for bringing this up is that today, I feel great all of a sudden. The only difference that I can think of is that the sun shined in New York City for the first time in days, maybe even over one week. We’ve had either rain or overcast weather most of June. 

I realize now that I was probably suffering from a mild case of seasonal affective disorder (SAD), which affects susceptible people who either don’t get enough sunlight or during the winter season, when there’s much less sunlight. I didn’t think I could have this, but I guess things change as you get older.

For prolonged cases of SAD, bright light therapy is one way to treating this condition. Another way is to spend more time outdoors, even with the overcast skies. 

How many of you were also under the weather this past week?

 

Sleep Your Way To Better Creativity

There’s a common phrase that’s used when people are searching for creative answers: "Let’s sleep on it." A new study that was summarized in the New York Times shows that this is literally true. By sleeping more, we now know that you’ll be more creative. However, this study revealed that the type of sleep stage was more important than the length of time in sleep. In particular, researchers found that napping which included time in REM sleep lead to significantly better in word association test scores. REM sleep (rapid eye movement) is the sleep stage when you’re dreaming. 

 

Although napping without REM sleep resulted in slightly better test scores, naps that included REM sleep resulted in close to a 40% improvement over pre-nap scores.

 

This study is interesting in that we know that most of our REM sleep is in the second 1/2 of the night. If you’re only getting the bare minimum 5 hours, you’ll get enough of the non-REM deep sleep stage, but you’re probably missing out on most of your REM time. 

 

Plus, if you have a sleep-breathing problem, REM sleep is most commonly the time when you’re most likely to stop breathing and wake up. This will prevent you from staying in REM sleep, and more likely to have strange dreams or nightmares (since you’re waking up while dreaming). 

 

Even more reason to prioritize your sleep time.

Interview with Tara Marie Segundo on Children’s Topics

Just reminding everyone about my interview tonight with fitness expert Tara Marie Segundo, host of Hotradio125.com’s The Time is Now. We’re going to continue our discussion about children’s issues, including snoring, ADHD, bedwetting, tonsils and ear infections. It’s at 8PM Eastern, and you can hear the live stream at http://www.hotradio125.com/showpages/taramariesegundo.htm. You can also download the recording after the show.

Can Snoring Cause Stroke?

Snoring is so common these days that no one takes it seriously anymore. One patient commented  that even her dog snores! Yesterday, I saw a man who uses earplugs to cover up his wife’s intense snoring. When someone is caught snoring, giggles and smiles are more common than genuine concern about the snorer’s health.

 

Not all snoring is dangerous, but a significant number of snorers will have undiagnosed obstructive sleep apnea. Recent studies highlight the seriousness untreated sleep apnea. One study showed that untreated apnea patients experience similar changes in brain biochemistry as people who are having a stroke or are dying. Even moderate degrees of oxygen deprivation was found to have profound effects. The abstract can be found here.

 

Another study showed that untreated sleep apnea patients have higher blood viscosity, meaning that their blood is literally thicker than normal. This, coupled with increased inflammation that’s seen in sleep apnea, makes small vessels in the brain more likely to clot.

 

Numerous other imaging studies report finding multiple small areas of damage in different areas of the brain in people with untreated obstructive sleep apnea.

 

Studies in young children found that even very mild degrees of obstructive sleep apnea can lead to cognitive changes and maybe even permanent neurologic injury. 

 

These type of studies go on and on. While we can’t screen everyone who snores for obstructive sleep apnea, if you have any of the potential complications of sleep apnea (such as depression, anxiety, high blood pressure, or heart disease) or if there’s a strong family history of snoring with cardiovascular diseases, there’s good reason to get checked for sleep apnea. 

 

The reason I bring up this issue at all is that once in a while, I’ll see a relatively young patient (in his or her 30s or 40s) who had a stroke. Not too surprisingly, they all snore heavily. If you know anyone that had a stroke at a relatively young age, at least consider the possibility.

Sleep More, Lose Weight

Health care reform is making big news now,  and from what I’ve gleaned from the press, it’s a mess. I’m not too optimistic about any solutions. There are too many interests involved and no one wants to give an inch. 

However, with all the studies coming out showing the benefits of more sleep, I have a suggestion for Mr. Obama: Have a national sleep more month, where everyone in the country makes a commitment to sleep 30 to 60 minutes more every night for one month. There are studies showing that better sleep improves everything from energy levels, to weight loss, to improved memory and cognition,  and lower blood pressure and glucose levels. 

In the February issue of Glamour Magazine, I was quoted in an article where they had overweight women volunteer to change one thing for 10 weeks: sleep 7 1/2 hours every night. Women who stuck to the plan lost anywhere from 6 to 15 pounds automatically, without doing anything else differently. 

Imagine if they continued this regimen for one year. Imagine if everyone in the US followed this regimen. There would be much lower levels of high blood pressure,  depression, diabetes, and heart disease. Think of the billions of dollars in health care savings, just from sleeping a little longer every night.

For those of you that get stressed even thinking about this, think again. You may be thinking that you’ll lose valuable time by sleeping more. What you may not realize is that by sleeping longer, you’ll be much more clear-headed, more energetic, and much more productive.

It’s 10 PM now. I’m going to bed.

“I Know I Don’t Have Sleep Apnea”

A few times every week, when I bring up the possibility of obstructive sleep apnea, a patient will confidently say to me, "I know I don’t have sleep apnea." Nine out of ten times, a sleep study reveals that the person does have sleep apnea. 

A recent study presented at this year’s annual meeting of the Associated Professional Sleep Societies revealed that of all people who were referred for excessive sleepiness, 54% of normal weight people were found to have obstructive sleep apnea. Of these normal weight people with sleep apnea, 54% were found to have moderate to severe levels. 

I’ve been saying for years that young, thin people who don’t snore can have significant obstructive sleep apnea, but it seems like most doctors and lay people still think that only an overweight, snoring man with a big neck can have sleep apnea. Yes, this is the extreme end of the spectrum, but since sleep apnea is an anatomically small jaw problem, you can have this even when you’re young and thin. Later on, you’ll be more likely to gain weight and fit the classic profile, but only after some of the complications of untreated sleep apnea have set in. 

One major reason for this continued myth is that we continue to have studies showing that heavier people are more likely to have sleep apnea. But this doesn’t mean that all thin people don’t. If you’re chronically tired and you don’t have a satisfactory answer for your fatigue, at least think about sleep apnea.

 

Sleep Apnea Causes Sleep Walking and Hallucinations?

Most of us think of sleep walking or sleep eating as strange, but separate and distinct from obstructive sleep apnea, but a recent study showed that in a group of people with obstructive sleep apnea, almost 10% had one or more of the parasomnias (sleep walking, sleep eating, sleep hallucinations and paralysis, etc.). This is not too surprising since having apneas can cause confusion in the transitions from one sleep stage to another. Another study from 2005 showed that in young men who sleep walked, the majority had a sleep-breathing disorder. When they were treated with either CPAP or surgery, the sleepwalking was completely controlled.

Do you ever sleep walk or eat at night without knowing it? Do you ever feel like you’re paralyzed and you can’t breathe as you’re about to fall asleep or when you’re about to wake up?

What We Take for Granted

As I was running through the Van Cortland park trails on top of the New York Stete aqueduct last Saturday, I was thinking about what would happen if this massive pipe either clogged or had a leak. Sure enough, we had a major water main break in the Bronx on Sunday which lead to no water all day on Sunday. 

 

We tend to take our free natural resources for granted, including water and air. In healthcare, we naturally assume that we’re able to get enough oxygen into our bodies, but for millions of people in this country, this is not the case.

 

Here’s a poignant post on SleepGuide that hit a nerve with me. I have to stress that this situation happens routinely. It seems like the writer’s husband had his CPAP mask slip off just before the fatal event. Not everyone with sleep apnea is at risk for what this man suffered, but as long as you don’t treat your sleep apnea condition (if you know you have it), your chances of suffering the same fate will definitely be higher.

Fundamentals of Medicine, Down the Drain

On a routine follow-up visit for bronchitis/pneumonia, I examined a patient by listening to her lungs. The diminished breath sounds on the right side had improved significantly, and after thumping her chest with my fingers, the sounds were resonant and equal. Not only was she feeling much better, her abnormal exam findings had returned to normal as well.

 

After the examination, the patient remarked that in all her life, no doctor had ever thumped her chest with two fingers. I found her comment surprising, since "percussion" is a basic physical exam technique that all medical students are required to learn and perform. 

 

This brings up an all-too-common issue these days where doctors are dispensing with time-tested traditional good history taking and thorough physical exams and relying instead on tests. Although there are various reasons for this, the most likely one is due to lack of time. When I was in medical school, I distinctly remember being chided for ordering a test unnecessarily. We were taught that tests were to be ordered only to confirm your clinical diagnosis, if necessary. Unfortunately, tests are routinely ordered today to make a diagnosis in place of good clinical decision making.

 

Ordering a test should not be undertaken lightly. It should never be ordered, "just in case." Yes, imaging studies and blood tests do occasionally pick up serious conditions, but in most cases, it just leads to more tests and more anxiety for the patient. 

 

Take, for example, ordering an MRI or CT for headaches. If you order 100 studies, 1-2 will show something significant that explains the symptom. However, in most situations, either the study comes back normal, or comes back with a "suspicious" finding, such as sinus inflammation or polyps. The presence of polyps doesn’t explain the headaches, since many normal people will have sinus inflammation and polyps. The word "polyp" also brings up more worries since we associate it with colon cancer or uterine polyps. Any swelling or growth, even if it’s benign, conjures up the worst case scenario in the patient’s mind. Because of the nature of how studies are interpreted by radiologists, every slight abnormality is pointed out, whether or not it’s clinically relevant. 

 

MRIs are very sensitive and can pick up findings that have no explanation. Unidentified bright objects or UBOs are frequently described on readings, and despite having no clinical significance in most cases, will also add to the anxiety and fear that patients will experience.

 

What I’m idealizing is a situation where doctors order tests more judiciously, only after every possible medical explanation has been ruled out. There are certain situations where a test should be ordered urgently, but this makes up only a small fraction of all situations. 

 

In this era of litigation and stories of missed diagnosis, it’s understandable that doctors may want to order tests prematurely "just in case", and will make some strong justifications for doing so. But in the long run, you end up hurting 99 patients to help one. Not to mention all the extra costs, work hours lost and time worrying over test results. With good follow-up, cooperation between the doctor and the patient, and judicious use of tests, that one patient that actually needs the test will eventually get it done, while saving tests for 99 others.

 

Ultimately, it all boils down to fundamentals. If we focused on the basic fundamentals of medical practice, then we wouldn’t need as much fancy, high-tech gadgets and testing equipment. It’s like a basketball team where each player tries to win by constantly performing trick shots and spectacular lay-ups. Instead, it takes, time, patience, trust, and cooperation between the doctor and the patient to order a test only as a last resort.

When Your Cold is Not a Cold

 

In our current age of economic recession and flu epidemics, experiencing hoarseness or a sore throat can conjure up worst-case scenarios. What I’ve noticed in more recent months is that more and more people with these two symptoms are coming in concerned about throat or lung cancer. If you feel a lump in your throat, the word lump itself can cause feelings of stress or anxiety. If you’re a smoker or a past smoker, the situation is even worse. 

The other day a man came in complaining of an itchy, scratchy throat 4 days prior, with loss of his voice the next day. He didn’t have any other viral symptoms such as fever, chills, or muscle aches. Upon further questioning, he normally eats dinner early, but the night before all this happened, he went out to eat dinner late and also had some drinks. 

 

Here’s the explanation to the sequence: Because of his upper airway anatomy, he was predisposed to acid reflux at night due to occasional obstructions and arousals. I talk about who may be predisposed and why this occurs in my book, Sleep, Interrupted. During an obstruction, vacuum forces can suction up small amounts of stomach juices into the throat, leading to various throat symptoms such as scratchiness, pain, hoarseness, post-nasal drip, lump sensation, and chronic cough. More often than not, doctors will give oral antibiotics in this situation, "just in case."

 

Many typical "colds" start of  with a scratchy or sore throat, with no other viral symptoms. Later, it can "travel" up into the nose and sinuses, leading to nasal congestion and sinusitis. What’s happening here is that there was an initial episode of acid reflux, which first irritates the throat, leading to more swelling and congestion, aggravating the vicious cycle. It’s also been shown that your normal stomach contents (acid, bile, digestive enzymes, bacteria) can travel up into your nose and ears. Chronic inflammation can predispose any part of the body to true viral or bacterial infections. 

 

The typical fevers, chills and sweats that are seen in this situation may suggest a viral infection, but you can also have all these symptoms from an involuntary nervous system reaction, which is called vasomotor symptoms. This happens when your involuntary nervous system becomes imbalanced due to a sudden change in your sleep-breathing status. 

 

Even if you start off with allergies or a runny nose from a cold, eventually, the tongue will collapse more and perpetuate this vicious cycle.

 

So the next time you have a sore throat and are convinced that you have an infection, think again. In many cases, you’ll find that either you must have eaten late or drank alcohol the previous night. If not, then you may have a true cold. But since it’s been shown that having colored nasal mucous of throat phlegm does not necessarily mean you have a bacterial infection, things are not always what it seems.

 

How do your typical "colds" begin? I’d like to know.

 

10 Tips for Better Sleep: A Chinese Medicine Doctor’s Perspective

Join me on the next installment of my Expert Interview Series, where Chinese Medicine expert, Dr. Mao, will discuss his ten essential tips for better sleep and better health.

Learn how you can:

- Get a restful sleep without drugs, hormones, or surgery.

- Use what alternative medicine has to offer to help you wake up energized after a night of sleep.

- Live a long, rested, and healthy life by utilizing the natural secrets of the Chinese medical tradition.

Dr. Maoshing Ni is a doctor of Chinese medicine and an authority in the field of Anti-Aging Medicine. Known simply as "Dr. Mao" to his patients, he has lectured internationally on various topics including women’s health, sleep medicine, longevity medicine, diet and nutrition, herbal therapy, stress management, meditation, lifestyle enhancement, integrative cancer care, tai chi, qigong, Chinese yoga, and spirituality. Dr. Mao also conducts longevity retreats throughout the world, where he teaches his patients about the natural healing powers of Chinese medicine. Click here (http://www.askdrmao.com) to visit Dr. Mao’s website.

A three time author and published health columnist, Dr. Mao’s insights on sleep medicine will surely be eye-opening and enlightening, so make sure not to miss this special event.

During this live 60 minute call, Dr. Mao and I will be answering your questions LIVE. And you will have two options to access this event: online or on the phone.

WHEN: SAVE THE DATE - Monday, June 15, 2009 @ 9:00pm EDT / 6:00pm PDT

WHERE: From the comfort of your own home. Register now to receive a call-in number and web adress to access this special event. This is a rare treat for any of you who suffer from obstructive sleep apnea (OSA), upper airway resistance syndrome (UARS), snoring, or anyone who just wants to sleep and live better. And between now and June 14th, I’m making it SUPER easy for you to register for this live call. All you have to do is fill out the registration form below to receive an email with internet and telephone access information. Even if you can’t join us for the call, you’ll get a link to download the recording a few days later, but only if you register.

Click below to register and receive the call in details:

http://doctorstevenpark.com/teleseminar-registration

 

Swine Flu Hullabaloo

My Adventure with Swine Flu(?) and Soybean Sprout Soup

Traditional Korean culture states that you should eat soybean sprout soup to fight a cold. My wife had just bought some soybean sprouts for my two sons, Jonas and Devin, who had just come down with severe flu-like symptoms (along with half their classmates). Unexpectedly, my older son Jonas was feeling well enough to attend his 4th grade graduation recital on Saturday. That left me taking care of my other son Devin, who was still very sick, and our 4 month old, Brennan.

 

Although I had dabbled in Korean cooking in the past, I had never made soybean spout soup. It’s always been a comfort food that my mother and my wife would make for me whenever I was sick. So with my wife gone, I decided to try making it. I couldn’t find it in any of our Korean cookbooks, since it’s such a simple ordinary recipe. I ended up Googling it and found a great Youtube video by Maangchi. She’s a middle aged Korean woman with a thick accent, but thoroughly entertaining, and definitely educational. I made my first soybean sprout soup without any trouble, and my son ate it with some rice. The next day, he was feeling well enough to go fishing later in the day.

 

After watching another few dozen videos on Maangchi’s site, I now have a new desire to start learning to cook Korean. One man from Germany commented on her website that he lost 92 pounds in 18 months eating only Korean food!

 

Along these lines, one frequent question that I get from patients is how I manage to stay so thin in my middle years. Even when I’m not exercising, I don’t gain much weight at all. My honest opinion is that a long as I eat at least one Korean meal every day (preferably dinner and lunch, if possible), I don’t gain any weight. I have to admit that I do eat quite a bit of pasta and take out food, but as long as one or more meal per day is Korean, I’m fine. When I’m able to run at least 2-3 times per week, I feel great. 

 

Besides chicken soup, do you have any other traditional recipes handed down through your family that helps with colds?

 

Next time, I’ll tell you my take on the recent Swine Flu epidemic.

More Connections Between Alzheimer’s and Sleep Apnea

This is a study that Dr. Mack Jones mentioned during my interview with him a few months ago about a mice developing Alzheimer’s-like brain findings after chronic oxygen deprivation. 

 

Amyloid plaques and neurofibrillary tangles are the two hallmark findings on autopsy studies in patients with Alzheimer’s. Accumulation of amyloid-β protein is the major component of plaques, which is derived from a breakdown of β-amyloid precursor protein (APP) by an enzyme called β-site APP cleavage enzyme (BACE1). It turns out that hypoxia (lowered levels of oxygen) stimulates BACE1 activity, which cleaves APP, leading to more accumulation of β-amyloid protein. This was reported in The Proceedings of the National Academy of Sciences journal in 2006. The study authors placed mice in hypoxic environments (16 hrs/dy for one month) and looked at their brains after being sacrificed. They found significantly increased numbers of amyloid plaques compared with control mice. These plaques were also histologically very similar to what humans have with Alzheimer’s.

 

My question to you is: What common medical condition that I mention all the time causes hypoxia for 8 hours every night for years or decades?

 

 

 

Chicken or the Egg? Diabetes or Obstructive Sleep Apnea

Here’s another study that strengthens the connections between the dots in my sleep-breathing paradigm. About 87% of obese type II diabetics were found to have undiagnosed obstructive sleep apnea. Most diabetes studies give the impression that having diabetes can lead to obstructive sleep apnea due to gradual weight gain, but what I propose is that having even very mild sleep-breathing problems can predispose to elevated glucose levels, insulin resistance, and weight gain. I talk about the specific mechanism  in my book, Sleep, Interrupted. What I want to emphasize is the fact that an underlying sleep-breathing condition is what can predispose you to obesity AND diabetes, not the other way around.

10 Tips for Better Sleep: A Chinese Medicine Doctor’s Perspective

A FREE Live Expert Interview Teleseminar Hosted by Dr. Steven Park

Join me on the next installment of my Expert Interview Series, where Chinese Medicine expert, Dr. Mao, will discuss his ten essential tips for better sleep and better health.

 

Learn how you can:

 

- Get a restful sleep without drugs, hormones, or surgery.

- Use what alternative medicine has to offer to help you wake up energized after a night of sleep.

- Live a long, rested, and healthy life by utilizing the natural secrets of the Chinese medical tradition.

 

Dr. Maoshing Ni is a doctor of Chinese medicine and an authority in the field of Anti-Aging Medicine. Known simply as ‘Dr. Mao’ to his patients, he has lectured internationally on various topics including women’s health, sleep medicine, longevity medicine, diet and nutrition, herbal therapy, stress management, meditation, lifestyle enhancement, integrative cancer care, tai chi, qigong, Chinese yoga, and spirituality. Dr. Mao also conducts longevity retreats throughout the world, where he teaches his patients about the natural healing powers of Chinese medicine. Click here (http://www.askdrmao.com) to visit Dr. Mao’s website.

 

A three time author and published health columnist, Dr. Mao’s insights on sleep medicine will surely be eye-opening and enlightening, so make sure not to miss this special event.

 

During this live 60 minute call, Dr. Mao and I will be answering your questions LIVE. And you will have two options to access this event: online or on the phone.

 

WHEN: SAVE THE DATE - Monday, June 15, 2009 @ 9:00pm EDT / 6:00pm PDT

 

WHERE: From the comfort of your own home. Register now to receive a call-in number and web adress to access this special event. This is a rare treat for any of you who suffer from obstructive sleep apnea (OSA), upper airway resistance syndrome (UARS), snoring, or anyone who just wants to sleep and live better. And between now and June 14th, I’m making it SUPER easy for you to register for this live call. All you have to do is fill out the registration form below to receive an email with internet and telephone access information. Even if you can’t join us for the call, you’ll get a link to download the recording a few days later, but only if you register.

 

Click below to register and receive the call in details:

http://doctorstevenpark.com/teleseminar-registration

Ulcerative Colitis, Chron’s, and Sleep Deprivation

Here’s more evidence that sleep deprivation can exacerbate inflammatory bowel disease, which includes ulcerative colitis and Chron’s disease. A study was published in Sleep Medicine where rats who were given a substance to induce colitis (DSS, dextran sodium sulfate). Control rats that were deprived of acute sleep deprivation or chronic sleep deprivation had no signs of colitis. Rats on DSS developed colitis, but acute sleep deprivation showed histologic signs of additional inflammation on histology, but showed no clinical symptoms such as weight loss. However, rats subjected to chronic sleep deprivation showed increased histologic inflammation, as well as clinical symptoms. This study is a follow-up to a previous study that showed that patients with inflammatory bowel disease had significantly more sleep disturbances.

Disappointing Results for Valerian as a Sleep Aid

In this month’s issue of Sleep Medicine, researchers reported that valerian, a popular herbal remedy that’s promoted as a sleep aid, was found no better than a placebo. Sixteen older women with insomnia were randomized and given either 300 mg of concentrated valerian extract or placebo before bedtime. Sleep quality was assessed at baseline and after the treatment phase by using a questionnaire, sleep study, daily sleep logs and actigraphy (nighttime movement analysis). After 2 weeks of treatment, no difference was found in all these assessments between valerian and placebo. 

Interestingly, people taking valerian had significantly more nighttime awakenings seen on sleep studies. This may be explained by the fact that valerian may have stimulant, rather than sedative properties. Herbalists have noted this apparent paradoxical effect of valerian. There have been many conflicting studies on using valerian as a sleep aid, and this study only adds more fuel to the fire. 

My take on this? If valerian works for you, keep using it. Even if its’ beneficial effect is a placebo response, it may be worth using. If not, try something else.

Can Taking Sleeping Pills Increase Your Chance of Dying?

A landmark study from Sweden revealed that taking sleeping pills long term is associated with a significantly increased chance of dying. In men, it was 4.5x higher overall and in women it was 2x. They followed about 3500 men and women for 20 years, and found that 379 men and 278 women died during this period. Breaking down cause-specific reasons for dying, regular sleeping pill use in men was a risk factor for cardiac death, cancer death, suicide death, and death from "all remaining causes." In women it was a risk factor only for suicide. Notably, using sleeping pills in men was a better predictor of dying from cancer than from smoking.

 This study support previous studies that found that short or long sleep duration is associated with increased mortality. It’s important to note that this study doesn’t prove that taking sleeping pills per sé increased your chances of dying. It’s more likely that people with illnesses such as cancer or depression are more likely to use sleeping pills. However, what if it can be shown that poor quality or quantity of sleep can cause depression, heart disease or even cancer? Come to think of it, I think there are already many studies that suggest show these results. 

Sudden Infant Death Syndrome & Obstructive Sleep Apnea

I recently stumbled upon a handful of studies about sudden infant death syndrome (SIDS) in a book on sleep apnea by Dr. Allan Pack. SIDS is a tragic condition where an infant dies suddenly in the first year of life or no apparent reason. Apparent life threatening events (ALTEs, or near-miss SIDS) are episodes then a child stops breathing, but comes back to life. Not too surprisingly, Dr. Christian Guilleminault (who published the original paper on upper airway resistance syndrome, and the link between sleep apnea and cluster headaches and sleep walking) and colleagues reported that in 3/5 families of children with SIDS or near-miss SIDS, parents and grandparents had elevated AHIs and excessive sleepiness. All seven children in this study with near-miss SIDS were found to have obstructive sleep apnea at 12 months. 

In a follow-up study, Guilleminault followed 25 children with near-miss SIDS (by 4.5 months) in a group of 700 that required sleep studies for over one year. All 25 were found to have obstructive sleep apnea by age 5. Deray, et al found that loud snoring frequency in fathers of SIDS or near-miss SIDS children was over 2 times that of control. It was stated clearly that this is a subgroup of all children with SIDS, but my gut feeling is that it’s much bigger than they think it is.

I alluded to another study in a past post where breast-feeding was found to lower SIDS rates. I’ve presented evidence that bottle-feeding may increase the chances of developing obstructive sleep apnea. It’s interesting to note that the peak incidence of SIDS occurs around 4-6 months. This is also the time that the infant’s voice box descends and separates away from the soft palate. This transitional period can be a dangerous time for infants, as they go from obligate nasal breathers (when they can suckle and breathe in parallel) to nasal and mouth breathers. 

Should All Older People Be On High Blood Pressure Pills?

A recent article published in the British Medical Journal concluded that all older people should be placed routinely on blood pressure lowering pills, regardless of whether or not they have high blood pressure. You can read a summary here.

It’s one thing to conclude that lowering blood pressure even incrementally has potential health benefits, but to say that all older people should be placed routinely on a cocktail of high blood pressure medications is going too far. Also, the fact that the authors have financial interest in what they’re recommending does not support their stance.

What they should be asking is what’s actually causing hypertension. One major cause that’s been proven but virtually ignored by the medical community is the presence of obstructive sleep apnea. It’s safe to say that most seniors will have some degree of obstructed breathing. Despite all that we know about the cause and effect relationship between hypertension and sleep apnea, 90% of people who have it are not diagnosed. Instead, they get treated for their hypertension, diabetes, depression, anxiety, weight gain, heart disease, heart attack and stroke.

 

Read the summary article and let me know your thoughts on this. Has research, in the name of science, gone too far?

 

 

 

Sleep Apnea, Hearing Loss, and Thick Blood

I came across this interesting article in Sleep Medicine, where they showed that in patients with obstructive sleep apnea, a significant number were hemodynamically hyperviscosity positive (282/610 patients). Hyperviscous means that blood is thicker and more prone to clog arteries. Of these 282 patients, 239 had brainstem AEP abnormalities. AEPs are tests for ear neurologic reflexes where clicks are given in one ear and brain waves are measured in response. It tests for inner ear and brainstem function.

Ones that didn’t have hyperviscosity all had normal AEPs. Of these 239 patients, 57 had bilateral sensorineural hearing changes (no waves at all), and 182 patients had significant bilateral signal changes. After 6 months of CPAP, hyperviscosity was normalized in 159 patients. In 112 of these 159 patients a repeat AEP became normal. Of the 80 patients on CPAP that did not normalize, hemodilution therapy resulted in normalization in 61 patients. Hemodilution is when blood is made thinner by removing some blood and adding some saline.

This paper talks about bilateral conditions but also brings up the possibility of unilateral sudden sensorineural hearing loss being explained by this mechanism. It’s in line with my personal observation that every patient that I see with sudden sensorineural hearing loss has a history and exam consistent with an underlying sleep-breathing disorder. The handful that agreed to undergo sleep studies showed significant obstructive sleep apnea in all cases. I think the implications of this paper are enormous.

Sleep Doctors vs. Patients: CPAP Data Monitoring

It’s common knowledge that one important way of increasing effectiveness of CPAP therapy is to constantly monitor the data that the machine records, which includes time used, lead rates, effective AHI, and other variables. Traditionally, this data is somehow taken to or transmitted to the patient’s sleep medicine doctor who analyzes the data to monitor compliance and effectiveness, in light of how the patient is doing. 

 

There’s been a growing movement amongst CPAP users to analyze their own data, and some people are even changing their own pressure settings. What I’ve noticed is that these are the most committed users, willing to do anything to get a better night’s sleep. In many cases these people know more about their xPAP machines than the DME vendors (durable medical equipment) or even their sleep doctors. Patients will know all about the latest xPAP models and try new mask models, in many cases paying extra beyond what insurance pays for.

 

There are many vocal arguments for and against this type of self-monitoring, but the issue I want to bring up is a sense that not all, but many sleep doctors are reluctant to have the patient take an active part in monitoring their own therapy. They’re not being told to go elsewhere, but the essential message that patients seem to hear is, "if you do this, you’re on your own." DME vendors are also caught in the middle.

 

Sleep doctors argue that self monitoring is good, but changing pressures should always be done after consulting the treating physician, since improper pressure can lead to problems such as ineffectiveness or even central sleep apnea. Patients argue that they should be able to manage their own condition for the most part, like what a diabetic does. 

 

There’s no black or white issue here—there are some patients that are fully capable and responsible enough to do this on their own, and others that are not. An ideal situation is to have a system in place where patients that want to take more responsibility can do so without feeling like they’re being frowned upon. This takes extra effort on the part of the sleep doctor and a trusting relationship with good communication. 

 

If you’re a CPAP user, where do you lie along this continuum? How much extra effort do you take to maximize your results?

 

Sleep Apnea Can Cause Brain Damage

A recent review of the literature in the Journal of the American Dental Association concluded that episodes of hypoxia (low oxygen levels) due to sleep-breathing problems can lead to permanent brain damage, and can even occur in early childhood. These findings are not too surprising, with a number of studies in recent years that support this finding. What’s troubling, however, is that no one is making the possible connection between brain injury due to sleep apnea and other well known neurologic conditions such as ADHD and Alzheimer’s.

Numerous studies have shown that sleep apnea patients have more areas of injured or dead brain tissue than patients without sleep apnea. This can occur in the gray and white matter (which serve memory and cognition), and even in the lower areas that control breathing, sensation and movement. One sleep researcher at a meeting that I went to many years ago stated that in young children who undergo tonsillectomies for obstructive sleep apnea, they catch up pretty dramatically in terms of cognition, memory, reaction times and intelligence scores. But they never catch up fully with age matched control children that don’t have obstructive sleep apnea. What this implies is that there may be a slight, but permanent brain injury.

Is Excessive Ear Wax Caused By Sleep Apnea?

Breast Feeding Protects Against Crib Death / SIDS

Breastfeeding was found to cut SIDS (sudden infant death syndrome) rates in half. A recent paper published in Pediatrics confirmed previous suspicions about the benefits of breastfeeding on the incidence of SIDS. 

 

This study supports my sleep-breathing paradigm, which is also supported by Dr. Brian Palmer’s assertion that bottle-feeding promotes dental crowding and development of obstructive sleep apnea. The jaw narrowing that results persists into childhood and adulthood, leading to smaller breathing passageways. It’s interesting to note that the peak incidence of SIDS is around 4-6 months. Coincidentally, this is also the time of transition where infants go from obligate nose breathers to mouth and nose breathers. 

 

During this transition, the voice box slowly drops to a position under the tongue, which creates a space behind the tongue that only humans have (the oropharynx). This new anatomy is necessary for complex speech and language ability. During this time, the infant has to adjust to different breathing, swallowing and speaking abilities and you can imagine that problems can occur during this time. 

 

Comparative anatomists and evolutionary biologists have said that speech and language development was ultimately detrimental to humans. If you have a common channel that has to serve breathing, swallowing and communication, then overdevelopment of one can detrimentally affect the other two. This is why only humans have so many problems breathing and swallowing. 

 

As I mention in my book, Sleep, Interrupted, our transition in the past few centuries to more processed foods and highly refined sugars, along with bottle feeding, aggravated this problem by causing even more dental crowding and upper airway narrowing.

 

More News About Football Players and Sleep Apnea

A recent Mayo Clinic study of retired NFL athletes showed that about 60% had significant obstructive sleep apnea. Not too surprising, since an earlier study showed that 33% of active linemen had sleep apnea and overall about 11% of all players. After retiring, due to inactivity and possibly gaining more weight, this extremely high level of sleep apnea is expected. If you add to this the additional issues with traumatic brain injury, ex-football players have a lot of health issues to deal with. I’ve speculated in the past that it’s not only increased fat that aggravates obstructive sleep apnea in football players, but the additional neck muscle mass that can press on the unprotected upper airway. Repeated obstructions leads to increased fatigue, leading to more intense exercise and workout sessions, and the vicious cycle continues.

Tongue Exercise for Sleep Apnea?

Brazilian researchers reported that a series of throat exercises, along with breathing exercises and nasal saline irrigation, could improve signs and symptoms of obstructive sleep apnea. Volunteers with obstructive sleep apnea were given exercises which were similar to those used traditionally for speech therapy. This randomized study showed that the overall AHI dropped 39% in the study group after 3 months. Daytime sleepiness, snoring, sleep quality and neck size were all significant improved. The sham control group underwent breathing exercises and nasal irrigation only, and there were no significant changes.

These are interesting results which are in line with with my limited past experience using tongue exercises—some people do improve. I started a research project may years ago with Janet Bennett, a speech pathologist who’s the inventor of IJustWantToSleep.com, but had to cancel the study to to various logistical issues with follow-up and compliance. However, there definitely were a significant number of patients that did benefit subjectively to various degrees.

There are other reports of using singing lessons or playing the didgeridoo to strengthen tongue and throat muscles. I don’t think these can replace standard ways of treating obstructive sleep apnea, but if a patient is motivated and is looking for alternative options, then I’ll recommend this.

 

 

Ask Dr. Park - A Live Teleconference

Join me on the next "Ask Dr. Park" call.  We’ll talk about lots of things, but the focus of this teleseminar will be sleep apnea. Everything about the quality of your sleep will be discussed: from tips on improving your sleep quality to a discussion on the best treatments for OSA. And, you get to set the actual agenda! I would like to hear from YOU about what your biggest questions and topic areas of concern are. The aim is to arm you with lots of information about sleep apnea that you want to know. This is a rare treat for any of you or your loved ones who suffer from sleep apnea.

This event will be held live on 5/12 at 8PM Eastern. You’ll be able to either call in using your telephone line, or listen in on your computer’s browser. You can ask your question during registration or during the call. 

Click here to register and receive the call-in information.

 

Soundbite Medicine

During lunch the other day in my hospital’s cafeteria, I mentioned to my colleagues that in my recent poll of multiple sclerosis (MS) patients, the vast majority seemed to have symptoms of obstructive sleep apnea or upper airway resistance syndrome: Severe parental snoring, cold hands or feet, never being able to sleep on their backs, and frequent trips to the bathroom at night. Immediately they reflexively dismissed a possible association and attributed the symptoms to neurologic reasons. 

The same situation occurs with patients as well, especially if they already have one (test) confirmed diagnosis. Any other or unusual signs or symptoms are attributed to their original medical diagnosis and a search for other possible causes is never perused. 

 

Many people will develop obstructive sleep apnea as they age. It’s estimated that about 1/4 of all men and 1/10th of all women have obstructive sleep apnea in this country. Eighty to ninety percent are thought not to be diagnosed. After age 60, a majority of people probably have some degree of sleep apnea. If that person already has another diagnosis (such as MS), then symptoms such as fatigue, insomnia, and headaches will automatically be blamed on MS, no matter how unusual. 

 

In the classic book, Influence: The Science of Persuasion, by Dr. Robert Cialdini, he brings up the concept of commitment and consistency. Once you’re committed to something, how you behave and think has to be consistent with your original commitment. The same process applies with medical diagnoses, to a certain degree.

 

In this era of information overload for both patients and physicians, it’s no wonder that alternative or additional possible explanations are not looked into once you already have another diagnosis. Not only are you bringing into doubt the original diagnosis, but it also just takes too much time and energy.

Provent: A New Way of Treating Sleep Apnea

I’ve been waiting a long time for Provent to be available to the general public. I saw a pilot study about this device in one of my sleep medicine journals 6 months ago, and was intrigued by how this device works. Essentially, it’s two nasal plugs that attach to your nostrils using adhesives. During inspiration, you can breathe normally, but during exhalation, it limits the amount of air that can pass through the device. The theory is that when there’s more resistance when you exhale, at the end of exhalation, a slight positive pressure effect is created in the throat, keeping your relaxed muscles more open.

 

Looking at the raw data, it does seem to make a difference, but it doesn’t really "cure" the problem. On average, it lowered the AHI by about 50%. In some people, the results were much better, and in others, it was actually worse. 

 

Since it’s so new, insurance doesn’t cover it. A 30 day supply is about $135, but for a limited time, they’re offering a 50% discount. It must be ordered through a prescribing physician and will be mailed to your house.

 

I got some samples and will offer it to select patients to test it out. I’ll keep you posted on the results.

EMRs to the Rescue

On a routine office visit, a patient asked why, despite our office being technologically advanced in many ways, doesn’t use an electronic medical record (EMR). Good question. 

 

Being somewhat of a gadget and computer geek, I’ve dabbled with EMRs for over 20 years. More recently, in private practice, I’ve looked seriously into a few dozen options, but nothing seemed attractive, and the features and functionality of current EMRs didn’t justify investing thousands, or even tens of thousands of dollars, not to mention probably dozens, if not hundreds of hours of time learning the new system, and years before we get a return on investment. Plus, since these programs are designed mainly for primary care providers, I’d only be using about 10% of the features that I’m paying for. Not one colleague that I’ve spoken to is ecstatic about their experience with EMRs. 

 

Another major reason is that expect for being able to go paperless, and becoming more efficient with patient information in-house, with the lack of a national standard where doctors and hospitals can communicate with each other (like banks), there won’t be any advantage to going electronic.

 

One common buzzword in the EMR field is "point-of-care" documentation. This means that you’re inputing information while you’re interviewing the patient, saving time. If you’re taking copious notes while interviewing someone, notice that more than half your time is spent jotting down notes, with your eyes on your notebook (or tablet PC). You’re not focused on the person you’re interviewing. This is what I found so frustrating. I’m getting the facts down, but I’m missing the message and story that the patient is telling me. 

 

There’s a study that’s often quoted that looked at the relative impact of facial expressions and spoken words. What the study author concluded was that only 7% of real communications happens with words, another 38% through vocal tone and pitch, and the remaining 55% is through facial expressions and body language. What this study implies is that without seeing or hearing any nonverbal cues, it’s easier to misunderstand what the person is trying to convey. 

 

When I tried to take notes while seeing a patient, I found that I wasn’t able to determine the true wants and needs of the patient, despite "hearing" their main problems. There was ultimately a disconnect between what I perceived and what the patient ultimately wanted. There’s always another story behind the obvious reasons why they come to me. When I went back to giving my undivided attention to the patient without being distracted, patient encounters were much more rewarding and satisfying. Unfortunately, with more EMRs being used and doctors’ focus on the computer tablet rather than the patient, the doctor-patient relationship will deteriorate even more. 

Can Sleepwalking Be Cured With CPAP?

I came across this older article by Dr. Guilleminault, published in 2005, which showed that most sleepwalkers have sleep-breathing problems. All sleepwalkers who were compliant with CPAP were cured. Non-compliant patients did not improve. Those that underwent successful surgery also had complete resolution of their sleepwalking. Another study that supports my sleep-breathing paradigm.

Have You Checked Your GABA Levels Lately?

GABA is a neurotransmitter that shows up once in a while that’s linked to a number of various medical and psychiatric disorders. One of the more recent studies was published in the 11/08 issue of Sleep (a summary can be seen here). Chronic insomniacs were found to have 30% less GABA activity in their brains. This finding could be misinterpreted to imply that because of low GABA levels, people can have insomnia. Let me explain.

GABA is one of numerous neurotransmitters in the brain that sends messages from one part of the brain to another. High GABA levels are associated with a calming, relaxing effect, whereas low levels are associated with anxiety and stress. Conventional wisdom says that if this is true, let’s increase GABA levels with supplements. The same can be said for various other neurotransmitters, hormones or vitamins that we use as supplements. In many cases, replacing what’s missing can certainly help, but you’re still not addressing what’s actually causing the lowering of these substances. 

If you look in the research literature (and on the internet), you’ll see many studies linking stress and low GABA levels. Another study showed that practicing yoga increases GABA. This is why any method or discipline that is calming or relaxing can raise your GABA levels. So it’s not a lack of GABA that gives you insomnia, per se, but there’s something else that is causing insomnia and low GABA levels.

This is a problem that we see with almost every area of modern medicine, where we’re great at finding associations, but not very good at solving the root of the problem. 

The common thread with all these studies goes back to stress. Yes, we have many different types of stress in our lives that can lead to insomnia (financial, work, family, poor diets, toxins, etc.), but what I’m suggesting is the possibility that due to our unique upper airway anatomy, all of us are somewhat susceptible to physiologic stress due to an inability to breathe properly at night. External stresses (psychologic, emotional and physical) can also aggravate this internal, physiologic stress.

The extreme end of this spectrum that I describe is called obstructive sleep apnea. But even if you’re "normal," having a narrowed upper airway anatomy can predispose you to microbstructions and arousals, leading to a physiologic state of hyperarousal. These people won’t officially meet the criteria for sleep apnea. Many of these people will also not be able to sleep on their backs, since that’s when the tongue falls back the most, due to gravity.

If you measure neurotransmitter levels in these patients, of course they’ll have abnormalities. This is why chronic insomnia is linked later in life to so many other medical conditions such as depression, diabetes, hypertension, and heart disease. Notice that these are all complications of obstructive sleep apnea. 

This is not to say that we should stop everything we do to treat insomnia. Cognitive Behavioral Therapy (CBT) is a great way to calm the mind and develop good sleep habits. It’s even been found to work better than sleeping pills. My only concern is what happens to these people many decades later, even if their insomnia is initially cured.

Does Sleep Apnea Cause Kidney Disease?

Kidney disease is not something that I’ve written about so far, but a recent study published in the March issue of Chest revealed that having chronic kidney disease is associated with a much higher chance of having obstructive sleep apnea. Knowing what we know about all the various physiologic effects caused by sleep apnea, this new finding is not surprising.

A Surprising Finding About Women and Heart Attacks

Men who suffer from heart attacks typically complain of chest pain, shortness of breath, and radiating pain from the neck to the left arm. But for women, it’s completely different. A recent study financed by the NIH (and summarized in the New York Times) showed that in the weeks before their heart attacks, 70% of women complained of severe fatigue and 48% reported sleep disturbances. Less than 50% had shortness of breath, anxiety, or indigestion. 

Post-menopausal women have a much higher risk of developing heart disease compared with their pre-menopausal peers. We know that obstructive sleep apnea can cause heart disease, and menopause can aggravate sleep-breathing problems. We also know that 90% of women with sleep apnea are not diagnosed. I think it’s safe to assume that many if not most of the women in this study had some degree of a sleep-breathing problem. It’s not surprising that the initial symptoms by women who were about to have heart attacks had mainly sleep-related symptoms. Oddly, these symptoms were called "atypical."  Sadly, 90% of women with sleep apnea will continue to go undiagnosed. 

Old Wives’ Tale or Eastern Wisdom?

After our third son Brennan was born, I noticed that my wife wasn’t eating the tofu that she made for dinner. She commented matter of factly that post-partum women shouldn’t eat tofu or any soy products. This seems to be common knowledge in East Asian cultures, handed down from mothers to daughters. 

In retrospect, it makes total sense, medically. During pregnancy, progesterone is very high, but drops significantly after delivery. We know from studies that progesterone, in addition to it’s reproductive functions, acts as a respiratory stimulant and upper airway muscle dilator. It’s been found to stimulate muscle tone in your tongue. Since all humans’ tongues can fall back due to gravity when we lie on our backs, and sometimes obstruct when we’re in deep sleep (due to muscle relaxation), having less progesterone can cause more frequent obstructions and arousals and prevent achieving deep, efficient sleep. This is what also happens during menopause (very slowly) or just before before women’s periods.

 

We all know that women naturally gain weight as they progress through pregnancy, and this would expect to cause or aggravate sleep-breathing problems due to gradual narrowing in the throat. But progesterone acts to protect the upper airway by increasing muscle tone and respiratory drive. Once you deliver your baby and progesterone drops, you’re left with all the extra weight, but no more progesterone to help you out. This is one good explanation for post-partum depression.

 

Soy has known estrogenic properties, so if you increase your soy intake just after delivering a baby, along with significantly lowered progesterone levels, the estrogen to progesterone ratio increases, lessening progesterone’s effectiveness.  This can lead to worse quality sleep and not feeling refreshed after waking up in the morning. 

 

It seems that the early Chinese medical doctors realized this through astute observation, and this wisdom has been handed down through the centuries. 

The Value of Genetic Testing in Alzheimer’s

ABC News’ Terry Moran wrote a poignant piece on why he decided to get tested for the gene that carries markers that are linked to Alzheimer’s disease. He states that he has a strong family history of Alzheimer’s and wanted to take the test not only to know more about his future health, but also to take responsibility for his own health. He does state that this test does not definitively predict whether or not he will get Alzheimer’s. It only gives statistical information based on his innate genetic risks. It ends up that he has a 19% chance of getting Alzheimer’s. It’s about 10% greater than the average population.  

Alzheimer’s is a devastating disease, not only for the patient, but also for the immediate family members. Research so far has focused on the molecular and genetic mechanisms, with progress being made day by day. However, I can’t help but to wonder if we’re going about this the wrong way. 

 

Let me explain: We know that Alzheimer’s is linked with cardiovascular conditions such as heart disease, heart attack and stroke. Untreated obstructive sleep apnea is a major risk factor for developing heart disease and significantly increasing your risk for sudden cardiac death and stroke. Sleep apnea is something that you don’t just develop when you’re older—you’ve had some degree of it all your life. 

 

Recent sophisticated imaging studies have revealed a much higher incidence of multiple areas of brain injury or damage in people with untreated sleep apnea compared with normals. MRIs in people with sleep apnea show many more areas of "lacunar infarcts," or small areas of strokes. Rats with the Alzheimer’s gene that were subjected to chronic hypoxia were found on autopsy studies to have very similar histologic findings as in humans with Alzheimer’s. We also know that chronic hypoxia and inflammatory state that results from sleep apnea can cause microscopic areas of blood vessel clotting (rather than your more typical large vessel stroke). The authors of some of these studies were very careful in only alluding to the implications of their findings: That obstructive sleep apnea can lead to Alzhiemer’s. 

 

I’m not discrediting all the great research out there on Alzheimer’s, but at least consider the possibility that in some cases of Alzheimer’s, untreated obstructive sleep apnea can lead to Alzheimer’s, with the same clinical symptoms, biochemical and histological changes that are seen in classic Alzheimer’s patients. 

 

Mr. Moran is more likely to know about his future health if he screens himself for obstructive sleep apnea, rather than undergo genetic testing for Alzheimer’s. At least there’s something you can do about sleep apnea.

 

(See related article by guest columnist Dr. Mack Jones.)

 

 

What’s Your Real Age?

A recent story in the New York Times describes Dr. Mehmet Oz’s online quiz that calculates your "real" age based on a series of health and lifestyle questions. The slant on the article was to bring up the fact that major pharmaceutical companies were using this data to market to people who use this service, but what I want to point out is that there’s another, simpler way of determining how quickly you’ll age:  the size of your breathing passageways. 

 

I’ve described in my book, Sleep, Interrupted, a concept called the sleep-breathing paradigm, which proposes that all modern humans are susceptible to breathing problems at night to various degrees. Our ability to talk caused anatomic changes that predisposes tongue collapse in deep sleep. Your genes determine the size of your jaws, and the smaller your jaws (with more dental crowding), the more susceptible you’ll be to breathing problems while sleeping. As one ages chronologically, our airways begin to narrow due to various factors, including obesity, inflammation, and gravity. The upper extreme end of this continuum is called obstructive sleep apnea, but even "normal" people are on this line.

 

Poor quality sleep due to multiple obstructions causes a myriad of physiological stresses, leading to everything from weight gain, hypertension, anxiety and depression to heart disease, heart attack and stroke. This process heightens your nervous system, making you edgy and hypersensitive. It also makes you more susceptible to external stresses.

 

So the next time you are brushing your teeth, take a look inside your mouth in the mirror. Is the space behind the tongue wide open? Can you see the back of your throat easily? Do doctors tend to cause you to gag using a tongue depressor to see the back of your throat? Is the roof of you mouth arching sharply upward, rather than a flat slope? Is there a family history of heart disease or early death in your family? Do you feel much older than your real age? 

 

Post your answers below—I’d like to know. I promise, I won’t give your information to pharmaceutical companies.

 

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Why Does Depression Increase Heart Attacks in Women?

Researchers found that women with depression were found to have an increased risk of sudden cardiac death. What other medial condition dramatically increases your chances of sudden cardiac death? If you guessed obstructive sleep apnea, you’re right. What condition is not diagnosed in 90% of women who have it? Correct again. It’s sleep apnea. What’s one of the biggest risk factors for women who go on to develop heart disease? Right again. Sleep apnea. What’s a common complication of sleep apnea? Depression. Do you see a pattern here?In modern medicine, it’s hard to see the forest from the leaves (not trees!). We’re so focused on determining statistical likelihood between two isolated variables, while trying to exclude every other variables, that it’s hard to see the big picture. It’s gotten to the point that you can’t even say A causes B anymore. You can only say that A is strongly associated with B. In the end, most end up saying that causality can’t be proven and that bigger and better studies are needed. Despite this study showing that women with clinical depression are more likely to die earlier, nothing will change to prevent these premature deaths. As long as we focus too finely on individual diseases, rather than looking at how everything is connected, women will go on dying earlier than they should.

A Link Between Psoriasis and Heart Disease?

Skin disease is one area that I haven’t covered so far, but data from three large clinical trials suggests that having psoriasis significantly raises your risk for heart disease and stroke. Looking at this issue through my sleep-breathing paradigm, it all makes sense. Not being able to achieve deep efficient sleep can cause a low-grade physiologic stress response, which does two things: It constricts blood vessels going to end organs and parts of the body that you don’t need when you’re running from a tiger. This includes the bowels, the reproductive organs, and the skin. Less blood flow in general leads to poor healing and poor functioning. Chronic low-grade stresses can also ratchet up your immune system which ends up attacking it’s own body parts. In light of these possibilities, it’s not surprising at all that people with psoriasis have increased risk of cardiovascular disease. 

Can Sleep Apnea Cause Alzheimer’s?

Join me tonight (3/17 at 8 PM Eastern) as I interview Dr. Mack Jones, a neurologist and sleep apnea sufferer, on the association between Alzheimer’s and obstructive sleep apnea. He’ll give some convincing reasons for this link that most doctors are unaware of. 

To register and receive the teleconference call in number, click here. 

The Value of Sleep Endoscopy in Sleep Apnea

Important Children’s Health Topics

Tara Marie Segundo, host of HotRadio125.com’s The Time Is Now, will be interviewing me on Tuesday, 3/10 at 8PM Eastern. We’re going to discuss children’s health, including ADD, bed wetting, allergies, tonsils, ear infections, snoring, breast-feeding, pacifiers and other important and very controversial topics. I guarantee you’ll learn some valuable information, even if you’re an adult. Go to Hotradio125.com and click on Tara’s face to hear the live stream. Be sure to call in during the show with your questions.

Can The Recession Make You Fat?

There’s been a lot of press recently about how the current economic situation is causing people to lose sleep. According to a recent National Sleep Foundation poll, 16% of Americans report losing sleep at least a few days in the past month due to the current financial situation. Another 15% are worried about the economy, and 10% are anxious about losing their jobs.

Lack of sleep for any reason and stress go hand in hand. One aggravates the other. Physiologic stress that develops as a result of inefficient sleep causes hormonal changes that can cause you to gain weight. Any external stresses such as psychological, emotional, or physical stress can also aggravate internal physiological stress.

When cortisol is increased due to stress, your appetite is increased for fatty and sugary foods, or "comfort" foods. This sets off a hormonal chain reaction where as you gain more weight, the fat cells in your throat can narrow slightly, aggravating any underlying breathing problems that I describe in my sleep-breathing paradigm. This perpetuates more sleep disruption and the vicious cycle continues.

Have you gained any weight recently since the recession began?

CPAP for Upper Airway Resistance Syndrome?

I recently came across a post on a sleep apnea support forum where a member asked about upper airway resistance syndrome (UARS) and how being on CPAP took care of a variety of his medical problems:

"So many things are better on the CPAP: 

My severe peripheral neuropathy of 5 years is almost gone. 
All the aches and pains are pretty much gone. 
My peripheral edema is gone. 
The age spots on my face are going away. 
I’m not huffing and puffing just doing simple things (like walking my son to his classroom.) 
My night sweats are gone. 
No more getting up to go to the bathroom at night. 
My heat intolerance is resolving -no longer sweat when I blow dry and curl my hair. 
I can exercise again and it’s enjoyable.  I no longer come home and go straight to bed. 
I don’t get so sore after exercise. 
My calf muscles are relaxing.  They used to just stay contracted all the time and I couldn’t get them to relax. 
My morning tremors are gone. 
Haven’t lost any weight, but dropped two pant sizes."

Fortunately, this person tolerated and responded very well to CPAP, whereas most people with UARS can’t stand having anything on their faces due to their hypersensitive nervous systems. Unfortunately, he was given CPAP by mistake before it was approved and the insurance company is refusing to pay for it anymore. Since his AHI was below the cut-off line of 5 for diagnosing obstructive sleep apnea (his was 1.9), officially he didn’t have sleep apnea. But he did stop breathing 8 times every hour on average. This is the dilemma with UARS.

My point here is that if the anatomic sleep-breathing problem is fixed definitively, regardless of the method (CPAP, dental devices or surgery), the patient will feel better. I describe a similar, very dramatic story about a young woman with even worse problems in my book, Sleep, Interrupted.

 

Multiple Sclerosis And Obstructive Sleep Apnea: Is There A Link?

I participate on a medical forum called Medhelp.org, where I’m the sleep-breathing expert. I answer people’s questions on various topics related to sleep and breathing. Somehow, I stumbled onto the multiple sclerosis (MS) community and was surprised to see that many people have severe fatigue issues, cold hands and various sleep issues. Their symptoms sounded surprisingly like upper airway resistance syndrome, which I’ve described before. So I decided to take a poll: I asked three questions: 1. How many MS patients have cold hands or feet? 2. How many MS patients have one or both parents that snore heavily, and if so, what kind of medical problems do they have? And 3. What’s your favorite sleep position (back, side, or stomach)?

The answers to this informal and unscientific poll was surprisingly lopsided. Out of 36 responses, 31 people said that they had either cold hands or feet. Many had to wear socks before going to bed, but some had to kick them off later. Fifteen out of sixteen stated that a parent (usually their father) snored heavily, and many also had major heart disease. Lastly, 26/30 responded that they prefer to sleep on their sides or stomachs. Many complained of intense fatigue.

This is the exact pattern that I see in patients with upper airway resistance syndrome, where they also have cold hands or feet, has a parent that snores, and wears mittens and socks to bed. Typically one or both parents snore, and have various degrees of heart disease. As many people with UARS slowly gain weight over the years, their cold hands may get better, but they’ll slowly develop into obstructive sleep apnea.

It’s a given that both UARS and MS will have a physiologic stress response, for different reasons. This can lead to various autonomic nervous system dysfunctions, such as cold hands or feet. It’s also known that chronic low-grade physiologic stress can stimulate the immune as well as the nervous system, heightening both these systems, leading to various pain issues or autoimmune conditions. I can’t say if there’s a definite cause and effect relationship between UARS and MS, but one thing for sure is that both have problems staying in deep sleep. The only definitive way to find out is is examine these MS patients with a flexible fiberoptic camera to examine the airway.

Am I going too far with my sleep-breathing hypothesis, or could I be onto something big?

 

 

 

Take Charge of Your Headaches: Interview with Dr. David Buchholz

Join the Thousands of Headache Sufferers Who Are Finally Living Again WITHOUT medications…

How would you like to: 

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• Take control over your headache rather than have it control you?

Well, these are just a few of the benefits you’ll gain by attending our live teleconference on Tuesday, 2/17/09 @ 8 p.m. called:

"Take Charge of Your Headaches"

During this live 60 minute call I’ll be interviewing headache expert, Dr. David Buchholz, a Johns Hopkins neurologist and author of the groundbreaking book, Heal Your Headache: The 1-2-3 Program for Taking Charge of Your Pain. Having served as the Director of the Neurological Consultation Clinic at Hopkins, Dr. Buchholz has had extensive experience in successfully treating thousands of headache sufferers overcome and take control of their pain. Dr. Buchholz has been featured extensively in the media including Good Morning America, NPR, Larry King Live as well as the 700 Club. Click here for more information on Dr. Buchholz.

This is a rare treat for any of you who suffer from headaches and are looking for a way to beat this problem without medications. And between now and February 16, I’m making it SUPER easy for you to register for this live call.

All you have to do is click on the link below and and register:

http://www.westside-ent.com/teleseminarsignup.html

This is a special event we are offering to you for FREE for a limited time. Also, we only have a limited number of call lines available and we really want you on the call — so whatever you’re doing, stop now and take a minute to register for this teleconference, today!

And even if you can’t make it to the live teleseminar, register anyway and a free, downloadable recording of the interview will be sent to your inbox the next day.

Is Insomnia Really A Sleep-Breathing Problem?

Sleep doctors have always thought of insomnia as a behavioral or stress aggravated issue, and the standard ways of treating this all-too-common condition is to either give sleeping pills or have the patient undergo cognitive behavioral therapy. However, a recent study directed by Dr. Barry Krakow at the Sleep and Human Health Institute is looking at the possibility that insomnia may actually be caused by a sleep-breathing problem, such as obstructive sleep apnea. 

 

If you’ve read my book, Sleep, Interrupted: A physician reveals the #1 reason why so many of us are sick and tired, I stated my opinion that in my experience, almost all people with insomnia have narrowed upper air passageways, especially behind the tongue. Some will have undiagnosed sleep apnea, but many will have instead something called upper airway resistance syndrome. This is a variation or precursor to sleep apnea where the length of time of each breathing pause is not long enough to be called an apnea. Because of the multiple pauses in breathing in deep sleep, a low-grade stress response is created which causes the insomniac’s mind to race or think about stress-related issues before going to bed. Their nervous systems are edgy and en garde all the time. No wonder it’s hard to fall asleep, especially if you’ve had a stressful day.

 

I’ve also experienced multiple instances where treating an underlying sleep-breathing problem also significantly improves insomnia symptoms as well.

 

You may be asking by now, "why do sleeping pills or cognitive behavioral therapy work?" The older type sleep aids were generally tranquilizers and only helped to numb the nervous system so that you can fall asleep faster. But these medications did nothing to prevent the sleep-breathing pauses. The newer medications don’t have as much of the sedating properties, but it’s very controversial that they even make any significant difference. Although industry supported studies find significant  improvements in sleep scores using sleeping pills, non-industry supported studies show that these same sleeping pills only increase total sleep time by only 5-10 minutes. 

 

Cognitive behavioral therapy (CBT) is another underused option that has been shown to work much better than sleeping pills in general. CBT works by re-programming your thinking and behavior about sleep to promote good sleep hygiene and habits. 

 

CBT will work to some degree even if you have an underlying sleep-breathing problem because you’re addressing the physiologic stress-aggravting end result of the breathing problems that occur during sleep. Multiple micro-arousals from deep sleep to light sleep due to tongue muscle relaxation can definitely aggravate stress and anxiety problems.

 

This process also confirms other recent findings that report increased rates of depression and heart disease later in life in people with insomnia earlier on in life.

 

The main purpose of Dr. Krakow’s study tries to determine what percent of insomniacs have undiagnosed obstructive sleep apnea. Although not part of the study, it would be interesting to perform upper airway endoscopic exams like what I describe, to confirm what I describe in this post. 

 

Here’s my question to all insomniacs: Do you prefer to sleep on your back, side or stomach? If you prefer your side or stomach, there’s your answer.

Do You Have To Go A Lot? Nocturia, Urinary Incontinence, And Sleep Apnea

If you’re one of the millions of men and women who have to go the the bathroom far too often, or have embarrassing leaks of urine once in a while, here’s some important information that you should know. The New York Times (Feb. 3) reported on an article from the New England Journal of Medicine which revealed that postmenopausal women with urinary incontinence issues had significant improvement after losing weight. They also benefitted in other areas such as improvements in their blood pressure, lipids, sleep and libido.

 

Another article in this month’s Journal SLEEP reported that OSA is associated with overactive bladder in men with or without urinary incontinence. The worse the severity of OSA, the worse the level of urinary problems. Not too surprisingly, nocturia (getting up at night to go to the bathroom frequently at night) is a known complication of obstructive sleep apnea. 

 

Most people with these issues end up seeing a urologist initially and are placed on various medications that work to various degrees. However, a recent study suggests why you should see a sleep doctor instead—people who wake up in the middle of the night to go to the bathroom do so not because their bladders were full, but rather because they stopped breathing and then realized that they had a full bladder. OSA has also been shown to increase atrial natriuretic peptide (ANP), which is produced by the heart when it gets too much blood due to the sudden rush of blood after a lack of blood flow during an apnea episode. ANP causes you to make more urine to get rid of the excess fluid.

 

Something new to think about for all our senior citizens (and young adults too).

The Real Reason for Chronic Fatigue in Mono?

Did You Take Your Vitamins Today?

One of the most common questions that I get is, "are there any specific vitamins that I can take for this condition?" In light of the slew of often conflicting studies regarding the benefits of taking vitamins, I was reminded of my wife’s ordeal just after she delivered our first son, Jonas. 

 

In Korean culture, it’s customary to serve seaweed soup just after delivering a baby. The benefits touted include being good for the mother in general, lessens post-partum bleeding, and various other reasons. There’s probably some truth to the bleeding issue since seaweed or kelp has high amounts of iron and iodine, both of which are needed to promote clotting and normal body function.

 

My mother helped us out by cooking meals for Kathy, but one thing she always served was seaweed soup. Sometimes it was the only thing. Kathy got so sick of seaweed soup from that experience that even today, she cringes at the smell of seaweed. What she craved during those first few weeks was a good normal meal—not seaweed soup for breakfast, lunch and dinner. Apparently, my mother thought that since it’s good for you, the more the better.

 

This same line of reasoning is how most people in our country think about vitamins. I won’t get into all the controversy and the pros and cons of vitamin usage. The point I want to make is that for anything related to your health (and everything else in life), there’s no magic bullet. If you’re not eating well, no amount of vitamins will cure your ills. If you don’t sleep well, no amount of dieting or exercising will keep the weight off for good. Whatever good habit you develop or good food you eat, it has to be done in light of a much bigger, holistic, integrative approach. 

 

If compound A is good for you due to it’s antioxidant properties, then due to all the marketing messages you receive (dozens of times every day), you’ll be convinced that if you have a lot of it, you’ll cure yourself of that nagging health issue. It’s only natural that the larger the quantity or the more concentrated it is, the higher the perceived benefit. That was the logic that my mother used when she overdosed my wife on seaweed soup. What my wife really needed was a well-balanced, nutritious meal, which included a healthy portion of seaweed soup. We also need a a wide variety of vitamins taken from different food sources, in conjunction with a regular exercise regimen, good quality sleep and proper stress management routines. An overdose of one particular beneficial food or habit, taken out of context, may end up being detrimental for you.

 

If you think about this issue from an "organic" standpoint, vitamin pills are one of the least organic substances you can eat. By definition, an organic product is something that’s naturally occurring that has not been processed or purified. Vitamin pills, by definition, are highly purified and processed substances, artificially taken out of their natural environments. Even organic milk or any other natural or organic food products with added vitamins by definition is not organic, since highly purified vitamins were "artificially" added. 

 

One of the frequently proposed mechanisms which explains why people feel better when they take vitamins is that by nature, people who take vitamins are more apt to lead healthy lifestyles, eat better and engage in activities and habits that are health-promoting. Whether or not this this true, you can imagine why this makes sense. There will always be a magic "pill." If it’s not a vitamin, it’ll be exercise. If not exercise, it’s relaxing music. If you’re acutely aware of how your body feels in response to various foods or activities, then you’ll naturally adjust and gravitate towards activities that make you feel better.

 

In the classic movie, Kung-Fu Panda, everyone is trying to discover the secret ingredient of life. In the end, they all discover that there isn’t just one thing—but that the true secret is actually YOU. The total, whole, complete conglomeration of all the countless ingredients that make up you as a person—that is the secret. When any part of your natural you becomes separated from the whole or overwhelms everything else in your life, that’s when things start to fall apart.

Truckers And Obstructive Sleep Apnea

I was recently interviewed on Sirius Radio’s trucking channel, "The Road Dog Channel" by Mark Willis, host of the program, "The Loading Dock."  We had an hour-long interesting conversation about the how common sleep apnea is amongst truckers. One study found that 28% of commercial truck drivers had sleep apnea. More than 1/3 were found to have moderate or severe sleep apnea. We know that untreated sleep apnea can lead to weight gain, obesity, high blood pressure, diabetes, heart disease, heart attack, or stroke. 

 

Another study stated that over 5000 deaths occur every year where a commercial truck was involved. However, one caller did mention the caveat is that a majority of these accidents were due to the passenger cars’ fault. Regardless, drowsiness during driving is a killer, no matter who’s doing the driving. 

 

There seems to be much more awareness in the trucking community about the dangers of untreated sleep apnea, not only for the safety of the public, but also for the health of the commercial driver. In conjunction with various sleep-related non-profit organizations, there are many screening programs and trucking company directed efforts at early detection. 

 

The Federal Motor Carrier Safety Administration has proposed more stringent rules regarding mandatory screening and criteria for return to work once the sleep condition was treated. As we all get more and more overweight, I guarantee that this is become a bigger issue than what it is now.

Sleeping Pill Use Amongst Young Adults Triples

I did a double take when I read this article in the New York Times. Among young adults aged 18 to 24, use of prescription sleeping pills tripled from 1998 to 2006. We know that chronic insomnia is associated with depression and anxiety, and possibly heart disease later. It also mentioned another study that revealed that 50% of all college-aged individuals suffered from a psychiatric disorder within the past year, of which 25% sought treatment.

College students have a lot of reasons to have insomnia, including the erratic sleep schedules, eating late and doing all-nighters. But one interesting comment made by a psychiatrist is that these are the same people that were raised on Ritalin. This is an interesting comment.

I’ve discussed before many studies in the past that a significant number of children with ADHD have obstructive sleep apnea. When treated properly for obstructive sleep apnea, many children do much better. I’ve seen children come off Ritalin after a routine tonsillectomy. We’re probably picking up and treating only a small fraction of all children with obstructive sleep apnea. Many of them will be diagnosed and treated for ADHD instead. So what happens when they grow up? 

Since they continue to have jaw narrowing and dental crowding, they’ll still have sleep-breathing issues. Yes, many will "grow out of it," but a significant number will go on to develop insomnia, depression, anxiety, and panic disorders, and high blood pressure and heart disease later in life.

 

 

Does Oprah Have Sleep Apnea?

Oprah’s recent revelation in her magazine that she’s back above the 200 pound threshold made a lot of headlines recently. She was quoted as saying that rather than falling off the wagon, the wagon fell on her. Oprah attributes her weight problem to an ongoing thyroid condition. An excellent detailed description of her thyroid condition can be found on Mary Shomon’s site. 

 

Ninety percent of women with obstructive sleep apnea in this country are undiagnosed. Instead, they are treated for the signs and symptoms of obstructive sleep apnea, such as weight gain, depression, hypothyroidism, diabetes, high blood pressure and heart disease. It doesn’t matter if you’re a celebrity—many women are susceptible to sleep-breathing problems, especially if you’re peri or post-menopausal.

Here are the tell-tale signs that Oprah may be suffering from untreated sleep apnea, including:

 

     • yo-yo-like weight fluctuations

     • her highly publicized diets and weight loss programs

     • her well-known thyroid hormone imbalance

     • an admitted food addict and cravings for junk food   

     • her feelings of depression and anxiety  

     • her chronic fatigue

I can prove that Oprah has sleep apnea—all she has to do is to undergo a formal sleep study.

The Pinkberry Factor

My younger son, Devin, wanted some ice cream after lunch, so we stopped by a local ice cream and snack store. On the way out, the the owner wanted us to taste their new frozen yogurt. He gave us a very large sample, and we were pleasantly surprised. My first impression was that it tasted very similar to the popular Pinkberry brand, which we like very much. But there was something missing. It wasn’t Pinkberry.

If you’ve experienced Pinkberry, you know what I’m talking about. Yes, their yogurt is good, but their experiences is unique. From the initial ambience and music to the smile and obviously scripted greeting where they call you by your first name, the entire experience is what makes it so satisfying. Other companies that understand this include Apple and Disneyland. 

This concept should be applied in healthcare as well. Seeing the best doctor is like your typical good frozen yogurt. But what really promotes true healing is the entire experience from the first phone call to the greeting as you leave the office. It’s the support staff that sets up the patient so that the doctor can spend quality time with the patient and provide the best possible care. 

Most doctors are still stuck 50 years back thinking that all you need to do is to provide good medical care. But back then you didn’t have all the nonsense and third party issues that prevented you from benefitting from your optimal medical care. We can learn a lot from other industries and companies that know something about customer service and just plain common courtesy. 

Have you ever experienced a memorable visit to a doctor’s office? 

Can Sleep Apnea Cause Alzheimer’s?

Researchers found that when people with Alzheimer’s and OSA are treated with CPAP, cognition and memory improves. This study was published in the November edition of the Journal of the American Geriatrics Society. They estimated that about 70-80% of Alzheimer’s patients have at least 5 apneas every hour. The authors concluded that CPAP may be an effective tool to improve cognitive skills if someone with Alzheimer’s also has OSA. They pointed out, however, that it’s unlikely that OSA causes dementia, and that the lowered oxygen levels and sleep fragmentation is what can aggravate poor cognition and memory loss.

 

The Twilight Series & Sleep Deprivation: Be Warned!

One of the hottest new books is Stephenie Meyer’s series called The Twilight Saga. My sister-in-law gave my wife a copy of the first book in the series and for three straight days, she couldn’t put it down. She was going to bed about 1-2 hours later than her usual time, and when my wife is sleep-deprived, even a little bit, we all pay the price. Furthermore, she’s now 8 months pregnant! 

 

Going to bed at a regular time, along with practicing good sleep hygiene (such as not watching TV or eating in bed) should be practiced by everyone. Of course things happen and you can’t always go to bed at a regular time, but choosing a particular book to read is one thing you have control over. Especially now that I’ve waned you. 

 

Consecutive nights of even mild sleep deprivation have been shown to diminish memory, mental acuity, and reaction times, not to mention mood changes and irritability. Imagine if you went through all three of Ms. Meyer’s books. Depending on how quickly you can read, most women (since mostly women are reading these books) will probably lose anywhere from 1-2 hours of sleep on average for about 1-2 weeks. In our already sleep-deprived, stressed-out society, additional sleep deprivation is the last thing we need.

 

I rarely put my foot down on any issue with my wife, but on this issue, I insisted that she stop reading further books in the series.

 

Are you currently reading one of Stephenie Meyer’s books, and if so, how much sleep are you losing?

Discover The Secret To Better Health & Better Sleep

 

Dr. Park’s Expert Interviews Teleseminar Registration A LIVE interview with yoga expert Deborah Quilter   Register Below To Receive Your Telephone Access Code   During this information packed call, you will learn:         - What type of breathing exercises are harmful, and even             detrimental to your health    -   Simple step by step instruction on how to breathe properly             throughout your day to increase energy and stamina    -      Which breathing exercises will get you to relieve stress,          anxiety and help you sleep better fast   Date: Tuesday, January 6, 2009 Time: 8 p.m. to 9 p.m. Eastern Standard Time (EST)    Important: We have a zero tolerance spam policy; your email address will never be rented or sold to a 3rd party.   *denotes required responses

 

     

 

Can Snoring Help You Lose Weight?

A recent study published in the Journal Archives of Otolaryngology - Head & Neck Surgery showed that snorers burn more calories while sleeping than nonsnorers. For obvious reasons, the press and the internet is buzzing with this new finding. For those of you who think that you can lose more weight by continuing to snore, the study authors did note, however, that this does not mean that you can continue snoring away without any sort of treatment. 

 

Most people who snore will have some degree of sleep apnea, and this is a serious medical condition. Untreated sleep apnea can lead to high blood pressure, depression, diabetes, heart disease, heart attack or stroke. 

 

If you snore (or have simultaneous apneas) your body is in a stress state, more commonly known as the fight-or-flight response. This increases your metabolism, as well as keeping you from staying in the lowest metabolic state, which is the deeper stages of sleep. We know from numerous studies that inefficient sleep, due to whatever reasons, will promote weight gain.

 

There are even studies that suggest that the vibrational trauma can cause carotid artery plaque formation. 

 

Do you snore, and if so, are you overweight?

A Surgeon’s Adventure With Yoga

Last night, I went to my first ever yoga class. I was invited by Deborah Quilter, a certified yoga teacher, personal trainer, author and consultant, to experience her class. I gladly accepted and I’m so glad that I did. 

 

You may be wondering what a card carrying member of the American Academy of Otolaryngology - Head and Neck Surgery and the American Academy of Sleep Medicine is doing going to a yoga class. You see, it all started with may passion for helping people to breathe better. What I discovered was that not being able to breathe properly at night also affects how you breathe during the day, and vice versa. After having read tomes of book and articles on breathing, I was drawn to the concepts of pranayama in the yoga literature. When I was invited by Ms. Quilter to experience her techniques of breathing in her yoga class, I gladly accepted. 

 

One thing that struck me about her method of teaching is that nothing is forced, not even the breathing. One particular aspect of pranayama breathing that I’ve already learned is what’s called the relaxing breath, where you take longer slowly exhaling compared to the time you take to inhale. In Ms. Quilter’s class, she emphasizes that you should follow and observe your natural breathing rhythms, rather than trying to modify it or alter it in any way. After this "natural" breathing pattern is established, she adds subtle, gentle movements that are in sync with theses natural, spontaneous breathing patterns. I must say that the one hour session seemed more like 15 minutes. It was truly a memorable, and relaxing experience. 

 

Even my wife, who’s 8 months pregnant, is raving about her yoga for pregnancy DVD program that she performs 4-5 times every week. This is the best she’s felt out of her 3 pregnancies to date.   Now I know having experienced this first hand, why people seem to love yoga.

 

Have you tried yoga, and if so, how do you feel afterwards?

 

Can Smoking Be Good For You?

Despite all the really bad known consequences of smoking, there’s one aspect of the act of smoking that may actually be beneficial. It’s been shown that it takes about 1-2 minutes for nicotine to go through the bloodstream and reach your brain which gives you that "relaxed" feeling. But what most smokers will tell you is that they feel better after the first 1-2 deep inhalations. Plus, since nicotine is a stimulant, how can it make you feel more relaxed?

 

I sometimes joke with my patients that in the typical workplace, the only people that get regular breaks are the smokers. Modern society has gotten rid of all the natural,  built-in breaks. So smokers, by going out of their stressful environments every few hours, are taking grown-up time-outs. Not only are they taking these "breaks," as they puff in the cigarette smoke, they are actually performing deep breathing exercises. They’ve associated the good feeling that they get with the physical act of smoking, which also happens to make you take some slow deep breaths. This is the concept that George Wissing describes in his fascinating book, Quit Struggle Free. 

 

By no means am I recommending that everyone who’s stressed go out and start smoking. But by using these concepts, you can get the same benefits of smoking without inhaling the toxic chemicals from cigarets. There are various resources for learning deep-breathing exercises, or take a yoga class.

Can Singing Help Your Sleep Apnea?

There are a number of programs on the internet that promote programs or products that are said to "cure" sleep apnea. This ranges from singing lessons to didgeridoo playing. Whether or not they work is up for debate, but one interesting thing about all these options is that they involve profound breath control. 

 

One of the key concepts in breathing physiology is that the muscles that control inhalation is activated by the sympathetic nervous system (the stress half of your involuntary nervous system). Muscles that control exhalation is activated by the parasympathetic nervous system (the relaxation half). In yoga, the act of breathing, called pranayama, emphasizes slow, deep, long, controlled periods of exhalation, relative to a shorter period of inhalation. This is sometimes called the relaxing breath. Therefore, if you spend more time exhaling than inhaling, you’re spending more time relaxing. No wonder some people rave about how calm and relaxed they feel after a yoga session.

 

When you sing (or play a any wind instrument), you’re spending much more time exhaling than inhaling—almost a 50 to 1 ratio sometimes. That means that the parasympathetic nervous system is being constantly stimulated, leading to a relaxed state. Yes, you may be exerting yourself somewhat, but you’re more relaxed. This may be the reason why many people like to sing—it makes us feel good. 

 

So can singing or playing the didgeridoo help your sleep apnea? It probably won’t cure sleep apnea, but by keeping you more relaxed, you may feel less stressed or tired.

 

Do you feel good when you sing?

An ENT with ESP?

Three times this week, people have asked me if I have ESP. If they are in front of me, their eyes open wide and with a scary look and they asked me, “Do you have ESP?” I assured them that I do not. In all three situations, I had just asked these people questions from a list of common symptoms that people with airway resistance syndrome have. Some of these symptoms include: sleeping on their side or stomachs, never waking up refreshed, cold hands or feet, occasional dizziness or lightheadedness, frequent headaches, and a parent that snores heavily. More often than not, the parent that snores also has a complication of untreated obstructive sleep apnea such as hypertension or heart disease.

These list of symptoms are so consistent that I stopped asking if either of their parents snore, or which position they sleep in—their back, side or stomach. Instead, I now ask, which parent snores, or do you sleep on your side or stomach? Sure enough, about 99 % of the time, they’ll answer one or the other. 

Do you have any of the symptoms that I described above?

Sleep Apnea, Michael Phelps & Swimming Records

This may just be coincidence, but on an online forum for sleep apnea sufferers, a member commented that he could hold his breath the longest while swimming when he was in the military. Shortly thereafter, two others replied with similar experiences when they were children. As we know, sleep apnea is not something that develops all of a sudden at a certain age when you reach a certain age. If you have sleep apnea, you’ve had some degree of it since you were an infant. So if you have episodic breath holding spells while sleeping when young, it makes sense that your capacity to utilize oxygen is enhanced, similar to what occurs when elite athletes train in higher altitudes to acclimate to lower oxygen levels.

This brings us to Michael Phelps. He seems to always surge ahead when he’s swimming underwater just after the turns. Next time, look at his narrow jaws and malocclusion. Could he have a sleep-breathing problem? Look at his mother.

Is there anyone reading this post who has sleep apnea with a similar story?

When Men Cry

Once in a while, I see male patients that reveal that they sometimes cry in the mornings upon awakening from sleep. There are two major reasons: The first group includes men who can’t stay asleep or keep waking up, feeling exhausted when the alarm goes off, and they feel as if they only slept for 2-3 hours. The other group includes men who undergo definitive treatment for obstructive sleep apnea (whether via a positive air pressure machine, a dental device or via surgery), who are able to achieve deep sleep for the first time in years. These men have tears of joy.

The most memorable experience is one man who had severe sleep apnea who couldn’t tolerate a positive pressure mask, and after a long discussion, decided to undergo major throat surgery involving the soft palate and tongue. He noted that one morning, a few weeks after the surgery, he awoke and for the first time in years, felt light he achieved deep sleep and felt clear headed. This is when he noticed his eyes welling up with tears.

Unfortunately, I see more people in the former group, in women as well as in men. One woman even told me that she curses the mornings when she has to wake up. 

 

Do you ever cry because you can’t sleep?

 

 

Ear Mystery, Solved

In many cases, taking a good history and asking some pointed questions can solve a medical problem without resorting to medications. For example, I saw a man in his late 30’s who came to see me with 3 days of left ear sound distortion and reverberation with mild fullness. He had no other problems, including hearing loss. His exam was completely normal. Most doctors at this point will give a diagnosis of Eustachian tube dysfunction, where due to mild nasal inflammation, the tube that connects to the ear is partially blocked, leading to pressure changes that can cause ear problems. Many patients will walk out the door with prescription allergy mediations or over-the-counter decongestants.

After going through my standard list of questions addressing what changes or lifestyle issues that he’s been going through, it turns out that his wife delivered their first child 2 weeks ago. Obviously, this can be detrimental to sleep. Upon further probing, he admitted to working later the last few days, coming home late, and eating just before going to bed. He also had some alcohol late at night as well. To top it off, he normally likes to sleep on his left side.

 

The history alone solved the puzzle: He normally likes to sleep on his side to partially compensate for his tongue falling back during deep sleep (due to muscle relaxation). When he ate late the last few days, every time he stops breathing even temporarily he sucks up small amounts of stomach juices into his throat, and since he’s lying on his left side, it can easily travel to his left Eustachian tube, causing mild swelling and partial blockage. He also noted afterwards that he has post-nasal drip and mild throat clearing, which is consistent with reflux in the throat.

 

He was advised to eat dinner much earlier and avoid alcohol close to bedtime. This should be a life-long habit. Another great example of using my sleep-breathing paradigm to solve a medical problem without the need to give to medications.

 

 

Surgery For Insomnia?

I’ve been holding off saying this until now, but, "I told you so." In my recently published, book, Sleep, Interrupted, I proposed that many people with insomnia may actually have a mild sleep-breathing disorder due to very narrow breathing passageways which worsen in deep sleep. Inefficient sleep sets off a low-grade stress response which stimulates the nervous system, preventing the insomniac’s mind from calming down before going to bed. In this month’s issue of Sleep, Dr. Guilleminault and colleagues reported on a study where they took patients who have both insomnia and mild sleep breathing problems, and randomized them into either a surgical arm (to treat the sleep-breathing problem) or to cognitive behavioral therapy (CBT). Based on subjective questionnaires, people who underwent surgical management rated much better in their insomnia scores than people who underwent CBT, although the CBP scores did improve to what was considered "normal.". The researchers went further and crossed over each group into the other, and the effects were additive.

I realize that they didn’t choose purely insomniacs, but their premise in designing the study was to determine how to approach someone with both insomnia and a mild sleep-breathing disorder. They also noted that most patients who have mild sleep-breathing problems also have insomnia, are women, and are thin and don’t fit the typical sleep apnea profile. 

This study is one more in the daily to weekly studies that are published that only serves to strengthen the sleep-breathing paradigm that I describe in my book. I realize it’s controversial to say that most of insomnia is actually a breathing issue, but take a look at all the studies that show that having insomnia places you at a higher risk for developing depression, diabetes, and heart disease later in life—all complications of obstructive sleep apnea. Of course CBT is still very useful and should be recommended much more often than offered currently. In addition, good sleep hygiene is still the gold standard and must be tried first. Unfortunately, our medical establishment’s obsession to search for the magic bullet to insomniacs to sleep better without all the side effects will dominate treatment recommendations for years to come.

Another Important (Boring) Finding

A study published in the Oct. 30 edition of the the New England Journal of Medicine reported that CRP, a marker of inflammation and heart disease, does not cause heart disease. Rather, it’s just an innocent bystander (Surprise!). The same can be said for almost every medication out there that targets specific biochemical markers, such as for high cholesterol, high blood pressure and depression. Researchers are so caught up linking biochemical markers for various disorders, that somehow, the words "linking" or "associated with" slowly morphs into "causes." So then the search goes on to lower or eradicate this particular marker, thinking that this will somehow get rid of the disease. 

Imagine if you were allergic to dust and the dust particle sets off an allergic reaction in your nose that turns into an inflammatory cascade, almost like a tree trunk that branches into hundred or thousands of smaller branches and so forth. If one biochemical process is the equivalent of one particular branch, of course you’ll see the same branch with the same tree trunk. But cutting off this particular branch, although it may make you feel better, won’t get rid of the tree. The same analogy holds for most of modern medicine, including allergies. Shutting down histamine production may help your allergies feel better, but you have to keep using the medication to stay that way. You’re also not addressing the other hundreds or thousands of other known and unknown inflammatory markers that wreak havoc in other ways.

I predict there will be a proliferation of other biochemical markers that are found to be linked or associated with a medical condition, with researchers and drug companies jumping on the bandwagon to block this chemical, only to find later that it doesn’t work in the long term. 

Do you have other examples of not seeing the forest from the trees?

 

The Male Menopause Myth

It’s commonly known that women going through menopause experience hot flashes, night sweats, moods swings, irritability, insomnia and weight gain, but these same symptoms are known to occur in men as well. They generally occur in men in their 40s to 50s, thought to be due to slowly decreasing testosterone levels, along with other symptoms such as loss of sexual desire or functioning, depression, memory loss, or chronic fatigue.

But what if I told you that I see young men in their 20s coming in to see me with the same exact problems? What I’ve discovered is that it’s really not mainly a hormonal issue, but a problem with their breathing. Let me explain.

What I’ve noticed in all these young men is that they all have in common a relatively narrow upper airway. When examined with a thin flexible camera, the space behind their tongues is very narrow, about 2-3 mm wide. This is mainly due to smaller jaw structures and dental crowding. Whenever someone with this anatomy starts to fall asleep, his tongue muscle starts to relax, and in deeper levels of sleep, it relaxes almost completely, leading to partial obstruction, and awakening. Once awakened, the man turns over. In most cases, they usually don’t like to sleep on their backs for this reason.

Most people compensate very well by sleeping only on their sides or stomachs. However, if there’s anything that narrows the upper airway, either due to inflammation (allergies or a cold), or structurally (fat), the tongue collapses much easier and the person gets less efficient sleep due to multiple arousals.

Inefficient sleep leads to an imbalance of the involuntary nervous system, leading to what are called "vasomotor" conditions, such as sweating, heart palpitations, and temperature fluctuations. So is a young man with a predisposed anatomy is slowly gaining weight, he may experience all the above "male menopause" symptoms.  If these obstructions last for more than 10 seconds, they are called apneas.

If you have more than 10 to 15 apneas every hour, then you may be diagnosed with obstructive sleep apnea. Untreated obstructive sleep apnea can lead to depression, anxiety, weight gain, erectile dysfunction, memory problems, hypertension, glucose intolerance, going to the bathroom often, heart disease, heart attack and stroke. The physiologic stress state that’s created also can lower one’s thyroid and testosterone levels, making it seem like he may have either hypothyroidism or low testosterone. 

So in a sense, the "male menopause" phenomenon does happen, but not for the reasons that you may think. The word menopause literally means cessation of menses. Since men don’t have periods, this is not an appropriate word. Instead, it should be renamed something alluding to the progression of a sleep-breathing disorder. Do you have any of these symptoms or know anyone who’s going through "male menopause"?

Does Snoring Protect Your Heart?

A recent study presented by at the European Sleep Research Society revealed that men with moderate sleep apnea had a lower death rate (about 1/3) than those without sleep apnea. These findings were presented by Dr. Peretz Lavie of the Technion-Israel Institute. This paradoxical finding could be an aberration, but one possible explanation proposed was that repeated bursts of breathing pauses can condition the body to become more conditioned to this situation.  Although in general, the higher the apnea score, the more symptoms and medical problems people generally have, sometimes I do see elderly men in their 70s or 80s with an index of 70 or 80 (80 times per hour one stops breathing for 10 seconds or longer). But these people are completely without any subjective complaints and are unaware of any medical problems.  What do you do with these healthy 80 year olds that snore heavily, but do not have not have any medical problems? Do you know anyone that snores like a chainsaw, but is completely healthy otherwise?

How Many Calories Are In Your Burger?

After my interview with health counselor and nutritional expert, Peter Lappin a few nights ago, I began to look more closely at food labels on grocery products as well as in convenience and fast food stores. I wondered if people eating in fast food restaurants will actually make healthier choices now that they know exactly how many calories are in everything they eat. My opinion is no, that their habits won’t change. The only benefit that will come from this is that the fast food industry (as well as the general food industry) will use this as a disclaimer, similar to all the other legal disclaimers that you see everywhere (like the Surgeon General’s warning about smoking). The next time someone takes legal action against one of the fast food chains, they can argue that the customer was given full disclosure about the ingredients and the number of calories. In a perverse way, these labels and disclaimers may end up somewhat legitimizing people’s poor eating or smoking habits.

What this goes to show is that anytime the government takes action with genuinely good intentions, there always seems to be negative consequences. Helping people with bad eating habits to count more calories won’t make a dent in our obesity epidemic. What needs to be stressed is a holistic model, where the person’s nutritional, exercise, emotional, spiritual, socioeconomic, and family support factors are all accounted for and properly addressed. I’m highly skeptical of anything that touts one thing only, whether it’s counting calories, restricting one food group, eating lots of one mineral, etc. 

What’s your take on this? Do you think these labels in fast food restaurants will change peoples’ eating habits?

New Treatment For Sleep Apnea?

I came across an interesting article on one of my sleep medicine journals (Journal of Clinical Sleep Medicine) describing a new device that is designed to treat snoring and obstructive sleep apnea using two small plugs that go into the nose. Essentially, it’s a one way valve that allows air to go in through your nose when you inspire, but builds up a certain amount of resistance when you exhale. The theory behind why it works is a little complicated, even for me, but a simple explanation is as follows: At the end of exhalation, your upper airways are the most relaxed and narrow. So by preventing full exhalation, a slight amount of pressure is built up, keeping the upper airways slightly more open. I looked at the raw numbers and the results were pleasantly surprising. For most people with mild to moderate obstructive sleep apnea, there was a significant improvement in the number of obstructions and oxygen lowering. It doesn’t bring the numbers of breathing pauses down to 0, but the numbers were significant. Availability for use in the general public is still unknown, but I’ll keep you posted.  What other innovative or unusual ways of treating obstructive sleep apnea have you seen?

No Magic Bullets

I’ve stated before that the vast majority of conditions that patients come to see me for (over 90%) are directly a result of the person’s diet, lifestyle, and stress factors. A broken nose, a foreign body or an abscess are acute conditions that can be treated quickly, but many symptoms that I see such as nasal congestion, chronic sinus complaints, ear fullness, chronic fatigue, throat pain and hoarseness, are all conditions that are aggravated by, if not caused by the person’s lifestyle choices. For most people, when I point this out, are grateful that they don’t have to use a medication, and are willing to make the changes so they can start to feel better. Many of these patients do improve.

But there is a small minority that are adamant that there must be pill they can take to get rid of their throat pain or cough or sinus pressure. They are typically younger, and refuse to give up their social lives, and continue to stay up late, eating and drinking, especially on the weekends. If this were you, you may argue: others seem to get by just fine—why am I the only one with this problem?

My answer is that your anatomy is different. They are perfectly happy sleeping on their backs, and are able to breathe properly, even during deep sleep, when their throat muscles relax. In your case, because of smaller jaw anatomy, your tongue falls back easier when on your back, and whenever you go into deep sleep, your tongue relaxes during deep sleep, which causes obstruction and a vacuum effect is created, sucking up stomach juices into your throat, This causes more throat inflammation and swelling, aggravating this vicious cycle.

This is why it’s important that if you’re susceptible to this condition, you shouldn’t eat late or drink alcohol close to bedtime. This is one mechanism that explains why you can gain weight if you eat late. Inefficient sleep promotes weight gain. In addition, alcohol relaxes your muscles and only aggravates this problem.

How many of you are willing to make the necessary sacrifices to improve your health?

58% of Diabetics Have Obstructive Sleep Apnea

I came across this blog that mentioned that the International Diabetes Federation did a study which showed that 58% of type 2 diabetics have obstructive sleep apnea. Not too surprising, since we’ve known for years that the stress response created by sleep-breathing problems can cause glucose intolerance. This number may be much higher if you take into consideration all diabetics that obstruct 5 to 25 times every hour who wake up after 1-9 seconds each. Since they didn’t reach to 10 second threshold to count as an apnea, their apnea score (AHI) is officially 0. Rest assured, there will be many more of these “links” between obstructive sleep apnea an a myriad of other conditions such as hypertension (many studies already published), stroke (many studies), depression (many published), anxiety (many published), heart disease (many published), headaches (many published), obesity (many published), ADHD (too many to mention), and many other various conditions such as chronic fatigue, IBS, migraines, TMJ, chronic sinusitis, etc. So many associations between all these conditions and obstructive sleep apnea…hmmmmmm….is there a common link?

Knowing about the results of this study, do you think it will sway doctors to at least start screening for obstructive sleep apnea in their diabetic patients?
photo credit: Yogma

New Study Reveals That Drinking Water Cures Dehydration

You may have thought after reading this post’s title, “I know that already.” But in science, you can’t say A causes B without double blinded prospective randomized placebo-controlled studies. Even then you can’t say definitively that A causes B—all you can say is that there is a very high likelihood that A is associated with B.

In the fields of sleep medicine and ENT, I see occasional studies that are similar to the water curing dehydration title. For example, in one article, “The nasal decongestant effect of xylometazoline in the common cold,” the authors show that applying an over the counter topical decongestant spray can help you breathe better. Here, a double-blinded placebo-controlled study was performed, where the placebo was nasal saline. Other common titles that I see frequently go something like this: “CPAP improves quality of life in patients with obstructive sleep apnea,” or “Lack of sleep is associated with drowsiness and poor concentration.” 

There are many well-intentioned investigators that publish good papers, but sometimes you have to question the value of some of these studies. How does it help you and me, now? Of course, for three reasons, no one will ever do a large, expensive prospective study on the merits of giving water for dehydration. First, it’s just common sense that it’s true, and two, there’s no profit in marketing water for dehydration. Third, you can’t say that something cures or helps a medical condition without FDA approval. Essentially, mothers are practicing medicine without a license by giving water, an unapproved “supplement,” to their young children whenever they get dehydrated from diarrhea. 

If you scan the health news headlines, it’s the same old stuff - exercise can reduce your weight, or lowering stress can prolong your life. Yes, there’s been tremendous advances with technology, but why is it that as a whole, our country is sicker than ever?

I think this is one of the major reasons why there’s not too much progress in medicine. We continue to perform  studies to confirm previous confirmed studies which confirm previous confirmed studies, and so on. For this reason it’s rare to ever see a radically new approach to treatment.

Do  you think our current scientific method is adequate for our health care needs, or de we need to revamp the entire system?

Insomnia And Depression

A new study reveals that people with insomnia are more likely to develop depression later in life. The traditional thinking is that insomnia is a symptom of depression, but the authors argue that insomnia may come before depression. 

This is old news, if you look at it from the sleep-breathing paradigm described in my forthcoming book, Sleep, Interrupted. I address both insomnia and depression as manifestations of interrupted breathing while sleeping that deprives you of deep, restful, restorative sleep. This process begin in childhood, affected by multiple factors, including anatomic issues, diet, infections or stressful situations. The sleep-breathing paradigm doesn’t contradict what’s out there in insomnia knowledge and research, but suggests a different perspective on ideas that we take for granted. For the most part, it even agrees with and supports the evidence in insomnia research. So it’s not important which comes first (insomnia or depression), but that both can coexist together. If so, what can cause both to occur?

This is another example of the peculiarities of medical research when you try to isolate and correlate one variable against another. Yes, you’ll get some interesting results, but more often than not, you’ll end up asking more questions as a result, or end up with multiple conflicting results. Once you look at humans as a complex interaction of innumerable processes, by looking at the “big picture,” things just make more sense.

Commitment and Consistency

One of my greatest frustrations is when I reveal to a patient that a major cause of his or her underlying medical issues (such as high blood pressure, dieabetes or weight isues) are from untreated obstructive sleep apnea. Most people are ecstatic about finally finding an answer to many of their medical problems and are excited to find how to go about treating it. But there are some individuals that give me a blank stare, with a glazed over look in their eyes. Some are even adamant that they know that they don’t have obstructive sleep apnea.

At this point, I go over again all the reasons I think they have sleep apnea, but only some are convinced. The rest go on treating their end-stage symptoms such as migraines and chronic throat pain with either pain medications or acid reflux reducers, which may help temporarily, but the problem usually comes back. Many of these same people will come back months or years later after worsening of their problems, admitting that “you were right.”

This phenomenon reminded me of a psychology book I read a while ago called Influence: The Psychology of Persuasion, by Dr. Robert Cialdini. One of the principles that he describes is commitment and consistency. He states that humans prefer to think the same way, act the same way, and take comfort in the consistency of their ways. In their minds, they’ve already committed themselves towards repeating the same steps every time.

For example, if you’ve been taking high blood pressure medications for 20 years, and you’re suddenly told that it was actually obstructive sleep apnea that caused it in the first place, how would you respond? If you’ve suffered from migraines all your life, how would you respond to being told that not sleeping efficiently due to partially obstructed airways can aggravate migraines? Being told something that completely refutes the daily actions (taking pills) you’ve taken for 20 years. It also conflicts with what your doctor said about your health.

If you were told something by your doctor that completely went against what you’ve revolved your life around for years, how would you respond, and how do you think your doctor should handle this situation? I’d like your feedback.

Heavy Snoring & Stroke

We’ve always known that that heavy snorers are at increased risk for stroke. But a recent study from Australia showed that carotid artery narrowing in the worst snorers was 10 times higher than those who snore the least. In typical scientific journal fashion, a much larger sample size was said to be needed to establish a casual relationship. You can read a layman’s summary here from the New York Times. The authors proposed that perhaps vibrations themselves can damage the thin inner wall lining, leading to plaque buildup and eventual narrowing.

There are many more published articles that associate snoring with stroke. We know that a significant percentage of people who snore will have obstructive sleep apnea, and sleep apnea is strongly linked to stroke. The frustrating thing is that despite regular reports like this that warn of the the dangers of snoring, people continue to equate snoring as something to be laughed at and doctors continue to treat the end effects of obstructive sleep apnea (such as hypertension, diabetes, depression, anxiety, heart disease, heart attack and stroke). At least once per week, I see a younger snoring patient that tells me that his (or her) father snored heavily and suffered a stroke or a heart attack in their 40s or 50s. The frightening thing is that we know now that you don’t even have to snore to have obstructive sleep apnea.

Do you have a parent that snores heavily, and if so, did they suffer from a stroke or a heart attack at a relatively young age?
photo credit: achichi

The New York Deli Phenomenon

One of my biggest pet peeves is whenever I order a deli sandwich, the deli guy sometimes forgets one or more of my requested ingredients. For example, if I order a roast beef on a roll with lettuce, tomato, mayo, mustard, onions and sweet peppers, the last few ingredients are typically left out. Usually, it’s the ingredients listed at the end, never the first few items. Ever since I noticed this, I watch the sandwich maker like a hawk. I hate it when they have to turn their backs to me to make a sandwich, since I can’t see what they’re doing. Every time I let my guard down, I always regret it.

You may be asking by now what this has to do with sleep and breathing and medicine in general. Unfortunately, too much.

When it comes to medical diagnoses, many physicians are guilty of the same phenomenon. For example, when I had to learn about obstructive sleep apnea in medical school, I had to memorize a long list of signs and symptoms. Usually, they’re listed in order of importance. By the time you get to the 39th or 40th sign and symptom, your brain can’t memorize any more. Most multiple test exams in medical school test you on the more common signs or symptoms, and rarely an unusual one. So by default, we tend to memorize the items higher on the list.

But this is where the problem starts. For example, going back to the obstructive sleep apnea example, the most frequent findings that are mentioned in textbooks or in a lecture are: older, obese, snoring, male, and big neck. Since these were the features first described in obstructive sleep apnea, no wonder. But if you read further down the list or look at published studies on this condition, you’ll find dozens or even hundreds more common and uncommon features that no one has time to list out when asked about this condition. So lecture after lecture, I’ve seen the same description about obstructive sleep apnea: typically seen in older, snoring, obese men, and untreated, can lead to diabetes, high blood pressure, heart disease, heart attacks and strokes. It still continues to this day, even with numerous studies showing that obstructive sleep apnea can occur even in young thin women that don’t snore. Of course, in a young thin woman complaining about sinus infections or fatigue, sleep-breathing problems are near the bottom of the list.

Despite the facts that doctors know about obstructive sleep apnea in the typical patients, they forget about the second part: the link with heart disease, heart attack and stroke. It’s shocking to me how many people I see that have suffered from heart attacks or strokes that are found to have significant obstructive sleep apnea when eventually tested. The same can be said about sinusitis, throat infections, ear infections, etc. Too often, ear pain alone with no obvious infection is treated with antibiotics.

It’s obvious that a human being is not a deli sandwich. To label a person with “sinusitis” is like saying, remember to add nasal congestion, yellow pus, fever, facial pain, poor sleep, ear fullness, or post-nasal drip. The problem is that this list gets whittled down to yellow pus and facial pain. Or that obstructive sleep apnea patients snore and are overweight, Yes, the majority of people with these symptoms will have the respective conditions, but you’re missing out on many other patients that only have poor sleep or ear fullness for sinusitis and post-nasal drip for obstructive sleep apnea.

So if you have post-nasal drip, and are treated for allergies, no wonder the medication didn’t work. Without getting a full and complete medical history and thorough physical exam, it’s hard to get a complete picture of what’s going on. In this age of managed care and rushed doctor’s visits, it’s no wonder that we end up treating the symptoms only and almost never the true cause of the illness, leading to missed diagnoses and incorrect treatment regimens.

Unfortunately, the New York Deli phenomenon will continue, with doctors making diagnoses and prescribing treatment based on incomplete pictures. Just as an incomplete sandwich just doesn’t taste right, an incomplete history and examination can lead to an unsatisfying outcome.

Sleep Position Matters

I just saw a young man who complains of many months history of right-sided throat pain and swollen glands. Past medical history is significant for anxiety issues. He noted that he usually sleeps on his back. He also mentioned that he’s had a nagging right chest, and shoulder discomfort, which started around the same time as his throat problems. When asked how he slept prior to his problems began, he stated that he normally slept on his sides. He also complains of chronic post-nasal drip, throat clearing, and coughing. He also has a relatively small lower jaw. He eats late and complains of being tired all the time, no matter how long he sleeps.

Bad Advice from the American Academy of Dermatology

 

 

Can Sleep Apnea Lead to Alzheimer’s?

Sleep apnea and Alzheimer’s are not commonly known to be associated, but a recent study in the Journal of Clinical Sleep Medicine reported that the greater the severity of one’s sleep apnea, the greater the chance that you’ll have what are called lacunar infarcts in your brain on an MRI study. Lacunar strokes (or infarcts) occur when small vessels supplying a specific part of the brain gets blocked and can show up on an a CAT scan or MRI as multiple small lesions. These areas correlate with small areas of dead brain tissue in the distribution of small arteries. In the study, 54% of people with severe OSA, and 12% with mild OSA, were found to have lacunar infarcts. All these people were asymptomatic neurologically at the time of testing. Their conclusion was was people with severe OSA have a higher incidence of silent cerebrovascular lesions than their counterparts with less severe OSA.

 

An interesting finding, in light of the fact that Alzheimer’s is now thought to be a disease of small vessels in the brain. There’s still a lot of controversy about the clinical significance of incidental lacunar infarcts on an imaging study, but I think you would agree with me that having dozens or hundreds of these small areas of dead brain tissue is not good for your memory. Add to this all the research studies that show that people with OSA are more likely to clot due to increased inflammation in general. Others studies have shown that people with lacunar infarcts have a higher incidence of heart disease. Over 80% of people with OSA are not diagnosed in this country. OSA is known to be strongly linked to heart disease. Heavy snorers are 10 times more likely to have carotid artery narrowing than nonsnorers. The links go on and on.

 

Do you think this is a valid association that’s worth further research, or am I taking the sleep-breathing paradigm a little too far?