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Do All Pregnant Women Have Sleep Apnea?

We know that significant weight gain is a common aggravator of obstructive sleep apnea. If you already have narrowed jaws and gain some weight, then you'll move up the sleep-breathing continuum that I describe in my book, Sleep, Interrupted. But why is it that when women become pregnant, sleep apnea is the last thing that's considered whenever they develop depression, high blood pressure or extreme fatigue? 

 

Two recent published studies perpetuate this myth amongst doctors that sleep apnea can't happen in pregnant women. One study showed that about 2/3 of pregnant women responded to depression using acupuncture. Another study showed that antidepressant use during pregnancy led to small, but measurable developmental delays at 19 months. Depression (during pregnancy or post-partum) is a major problem with many women. But rather than saying that it's pregnancy-related depression, it should be looked at as a sleep-breathing problem, since one major reason for depession is lack of deep, quality sleep that's common with all pregnant women. Pharmaceutical companies promoting anti-depression medications to replace deficiencies in brain biochemistries doesn't help either.

 

One reason why not every woman that's pregnant goes into depression during or after pregnancy is due to the effects of progesterone, which has been called the "feel good" hormone. One of the interesting properties of progesterone is that it's an upper airway muscle stimulant. It increases tongue muscle tone and tension. During pregnancy, progesterone goes through the roof, since it's needed for maintaining the uterus and development of the baby. But if the weight gain is too much, or if your jaw is too narrow, then the effects of progesterone won't be as helpful. Once you deliver, progesterone drops, but you're still left with all that weight. This is one major revelation that I had when my wife experienced severe post-partum depression after the birth of our first son, Jonas.

 

We also know that many women who develop pre-eclampsia (dangerous high blood pressure) during pregnancy have various degrees of sleep-breathing problems, which can be treated effectively with standard sleep apnea treatment options.

 

For the women that's reading this blog, did you have any significant depression during or after pregnancy? How did you deal with it, and if your saw a doctor about it, what did they recommend? Please enter your answer in the comments section below.

Sleep Apnea, Restless Legs and Erectile Dysfunction

There are studies linking sleep apnea with restless leg syndrome (RLS) and sleep apnea with erectile dysfunction, but now there's a study linking restless leg syndrome with erectile dysfunction. Not too surprising, since sleep apnea seems to be the common denominator for almost every imaginable disease, known or unknown. You may think that this statement is over the top, but you'll have to admit that not breathing well during the day, and especially not breathing well at night while sleeping can potentially lead to or aggravate almost every disease known to man. 

 

In this particular study, researchers found that men with RLS  had significantly increased risk for having erectile dysfunction (ED) compared with men who did not have RLS. The lead researcher, Dr. Gao, commented that the findings indirectly support the role of dopamine as a common pathway, in light of another study of his in the past that showed an association between ED and Parkinson's disease. He also points out that these same people with ED were more overweight, more prone to depression and anxiety, and had a greater chance of having hypertension or a history of stroke (sound familiar?)

 

It sounds like dopamine deficiency is a popular explanation for a number of different conditions. For both PLS and Parkinson's, giving dopamine-like agents help with the respective symptoms. The problem is that it never cures the problem completely, with a number of serious side effects. 

 

This approach to medicine is the replenish what's missing method. If you're deficient in dopamine, replace it. If you're deficient in Vitamin C, B12, or thyroid hormone, replace it. The problem is that this approach works in some people, but not in everyone. Then the next step is to increase the dosage, and then even more people respond, but not everyone (with more side effects). Ultimately, you're not addressing what's causing the deficiency. 

 

If you have a sleep-breathing problem, it's been shown that you can easily clot in certain small and large vessels of your brain very easily. If you happen to have a clot in the dopamine area of your brain, or if the brain biochemistry changes as a result of hypoxia, then you'll get various symptoms. But I think even the neurologists will tell you that a lack of dopamine itself won't lead to Parkinsons; it's just one part of a much larger picture. Could it be that obstructive sleep apnea may be that bigger picture, since by definition, all modern humans are susceptible to sleep breathing problems to various degrees?

 

What's your opinion on this? Should we continue to treat every medical condition in isolation hoping to target that one missing protein or gene, or should we step back and try to connect the dots until we see the bigger picture? Please enter your comments in the box below.

Sleep Apnea and the Stroke Belt

A new report on stroke mortality confirms that seven southern states continue to told the title of having this highest stroke risk in the country, up to 50% higher in some states compared to the rest of the country. These states are: Alabama, Arkansas, Georgia, Mississippi, North Carolina, South Carolina, and Tennessee. The study authors also added, "Our results cannot pinpoint a specific explanation, but they are consistent with other research suggesting that the roots of stroke risk begin in childhood or even infancy,"

 

If you’ve been following this blog or read my book, Sleep, Interrupted, you’ll remember that having obstructive sleep apnea increases your risk of stroke by 50% or more. I’ve also stated that sleep apnea is not something that suddenly develops when you’re in your 60s and 70s. The risk factors for sleep apnea begin when you’re an infant. Your upper airway anatomy determines your risk for sleep apnea later in life. This is also when cardiovascular risk factors are first established. 

 

If you look at obesity rates in the deep south, they’re some of the highest in the country. So is depression and ADHD, which all happen to be strongly linked with obstructive sleep apnea. If you were born in one of these states and eventually move to another state later in life, your stroke risk remains increased.

 

Interestingly, residency in these states had little association with conventional stroke risk factors, social resources, or access to medical care.

 

What’s your take on this interesting finding? Please enter your thoughts in the comments box below.

Are You Depressed? Check Your Heart First

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?

 

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.

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.

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.

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?

 

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