In this New York Times article on the stresses of too much homework in independent schools, one student newspaper at a prestigious private school published an article last year showing that upper school students slept an average of 6.5 hours per night. I was shocked to see this.  You may think that this is not too bad, but consider this: A teenager should be sleeping 9 to 10 hours per night. 

There are tomes of research showing what chronic long-term sleep deprivation does for people in general, but these negative effects are even more magnified in developing teens’ brains and bodies. It’s not surprising that rate of anxiety and depression are are at already too high levels, and a lot of students are just burning out (mentally and physically). Many of these problems will ultimately manifest when they get to college, where sleep deprivation and poor eating and sleep habits become even worse. This is why the incidence of depression peaks in the college years. 

I realize there’s no easy solution to this problem, but someone has to take a stand and say enough is enough. What do you think about this issue?

We know that having insomnia significantly increases your risk of developing depression later on in life. Having untreated severe obstructive sleep apnea also significantly increases your chances of having a stroke. Not sleeping well from any reason (insomnia or sleep apnea) can cause major biochemical and structural changes in your brain. Do you see the connection? 

In this Expert Interview program, Ms. Lisa Brateman will talk to us about the psychology of obstructive sleep apnea. This is an important topic that affects not only those of you with sleep apnea, but also your loved ones, your friends, and family members.

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However, there’s one more important, but under-appreciated condition that is expected to occur when you gain even a small amount of weight: Fat cells take up space in your throat, leading to a gradual progression into obstructive sleep apnea. As I’ve mentioned before on numerous occasions, eating late promotes more obstructions and arousals, as well as increased gastric contents reaching the throat. This causes more swelling and damage to the protective upper airway receptors in the throat, leading to more frequent and prolonged breathing pauses. Poor quality sleep promotes weight gain, through hormonal, metabolic, and neurologic mechanisms. Drinking alcohol close to bedtime an also relax your throat muscles, leading to more frequent apneas. There’s no need to remind you about sleep deprivation and poor sleep hygiene in college students.

It’s also no coincidence that anxiety and depression peaks in college-aged men and women. Poor sleep quality can not only cause neuro-biochemical changes, but also promotes poor sleep habits and hygiene. It’s no wonder college students are at higher risk of delayed sleep phase syndrome, where one’s sleep clock cycle is shifted many hours later. I suspect that students who are most prone to weigh gain have narrowed jaws and dental crowding to begin with, prefer to sleep on their sides or stomach, and one or both parents probably have undiagnosed obstructive sleep apnea.

Have you or any of your children experienced the Freshman 15?

It you accept the fact that postmenopausal women will have a higher likelihood of developing obstructive sleep apnea, then it’s likely that they will also be at higher risk of having depression, anxiety, hypertension, heart disease, etc. The researchers have done a great job in linking two of the end consequences of untreated obstructive sleep apnea, but failed to look at the common root of both conditions. 

Recurrent sinus infections, throat pain, ear fullness and chronic cough are some of the most common conditions that I see every day. You may think that I typically diagnose and treat for routine bacterial infections in these situations, but in most cases, they’re not really infections at all. What I do find, however, is that if you probe and look back at the patients’ history, there’s always some major life change or recent event that acted as a trigger for their symptoms, especially if their upper airway anatomy is already narrowed or predisposed. Here are 5 common examples:

 Sleepless nights from a newborn child

 The birth of a child is always a joyous event, but everyone knows that your life will change drastically all of a sudden. Your normal routines, eating habits, exercise regimens, and especially the timing for all these events will change. The sleep deprivation, lack of exercise, and bad eating habits can promote weight gain, which can narrow your throat even further. This leads to more problems breathing at night, leading to less efficient sleep, leading to more weight gain. This applies to both the mother and the father.

 It’s also a common phenomenon where a woman is never able to lose her pregnancy weight, despite extreme dieting or exercise. This leads to less effective sleep, increased fatigue, and various other health-related conditions. 

 Newfound independence, more depression

 The freshman 15 is more than just an observation—there’s a good reason why college students gain weight all of a sudden during their freshman year. Dorm meals and cafeteria food tends to be starchy and very high in calories, and because of the buffet-style format, there can be problems with portion control. Home-cooked meals by parents, eaten at relatively normal times (5 to 7 PM), turns into eating later in the night: more episodes of pizza, take out food, and late night snacks while pulling all-nighters for exams. 

 Having stomach juices when you go to sleep will allow more acid and other stomach materials to regurgitate into your throat, leading to more frequent arousals and less efficient sleep. This leads to a cascade of metabolic, hormonal, and cardiovascular consequences that promotes weight gain. Drinking alcohol at night relaxes the throat even further, leading to more frequent breathing pauses.

 This relative sudden change in your eating and sleep routines can definitely affect your mood and mental health. It’s not surprising that depression and anxiety peaks during the college years. This is also the time when the larynx (voice box) descends in the neck to its’ lowest position during maturation into adulthood. The lower your voice-box, the more the tongue can fall back, leading to more frequent breathing problems.

 A new job or a promotion

 It’s great to start a new job, or get that promotion that you’ve wanted. But just like any other major change in your life, your routines will change. You’ll stay later to impress your boss, skip meals, come home later and go to bed later. As a result, you’ll gain a few pounds. Some people can eventually adjust their schedules to accommodate a healthy sleep schedule, diet and exercise regimen, but others can’t. This is when things begin to go downhill.

 Injury or surgery

 Most people with sleep-breathing problems prefer to sleep on their sides or stomach. Any kind of injury or undergoing surgery can force you to sleep on your back, which causes more tongue collapse (due to gravity) and more obstructions and arousals (due to muscle relaxation in deep sleep). In fact, many patients have told me that their lack of sleep, physical activity and subsequent weight gain is what triggered a vicious cycle. 

 Menopause

 This applies mainly to women, but hormonal changes can affect men too. Loss of estrogen and progesterone can diminish their protective effects on the upper airway. In particular, progesterone is an upper airway muscle stimulant/dilator. As it begins to diminish in the early 40s, the tongue begins to relax more and more over the years, leading to less efficient sleep, and the typical vasomotor symptoms begin which includes hot flashes, night sweats, weight gain, mood swings, and irritability. Believe it or not, these symptoms can happen in young men, too. These are your body’s nervous system reaction to the changes with your sleep-breathing status.

As you can see, all of us will go through some or all of these events at some point in our lives. It’s natural as modern humans to be susceptible to these sleep-breathing related conditions. It may sound a bit depressing, but the good news is that now you’re aware of it, you can take preventive measures once it starts. 

You might be asking by now, “What does all this have to do with sleep apnea?”

My answer is, everything. If you happen to follow my blog, I’ve shown studies linking obstructive sleep apnea to almost every chronic health condition out there. This is based on published, peer-reviewed studies. What I did was only to connect all the dots, so to speak, to conceive of my sleep-breathing paradigm: That all modern humans, due to jaw underdevelopment, have various degrees of sleep-breathing problems, where only the end result is called obstructive sleep apnea. This problem begins while you’re an infant, and is aggravated by dietary and behavioral factors such as bottle-feeding, thumb-sucking, and eating the Standard American Diet (SAD). It’s also possible that the back to sleep campaign (although it lowered the SIDS rate by 40%), by forcing infants to sleep on their backs, may inadvertently prevent quality deep sleep in infants. Babies need good amounts of deep sleep for memory consolidation and brain development.

We also know that multiple breathing pauses can cause your stomach juices to reflux into your throat, and then into your lungs (or nose). This can cause various degrees of inflammation. Neurologically, your lungs will tend to over-react to weather changes, such as cold air, or even temperature or humidity changes. Breathing problems can also cause poor quality sleep, leading to major alterations in your brain biochemistry.

Poor sleep can also aggravate or promote the onset of depression. Faulty neurotransmitters or even structural damage from poor sleep can also cause your brain signals to misfire, or activate disinhibition of certain behaviors.

It’s no wonder that in one way or another there are studies (or will be studies) that connect all the various medical conditions already mentioned to one another. So it’s not too far fetched to argue that a large proportion of these children on chronic long-term medications may also have some kind of a sleep-breathing problem.

What do you think about my arguments? A realistic, but scary possibility, or too far fetched?

In this month’s Expert Interview, I interview Dr. Avram Gold, a pioneer in researching the link between upper airway resistance syndrome, chronic fatigue, and the functional somatic syndromes. Some of the topics will include:

- What are the functional somatic syndromes and how are they related to sleep-breathing disorders?

- What’s the relationship between central sensitivity syndrome and stress?

- How is sleep-disordered breathing related to stress?

- How is anxiety or depression related to functional somatic syndromes?

- How is chronic fatigue syndrome connected to the this condition?

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Psoriasis is a common skin condition that affects about 34 million Americans, or about 3% of the population. It’s characterized by red, scaly patches of skin covered by white flakes. It’s thought to be a chronic autoimmune condition, where your body’s immune system can attack or damage your own tissues.

I’ve written before about strong links between psoriasis and obstructive sleep apnea, but here are a series of studies that further solidifies this connection. Some of the studies I’ve cited before. Others are new:

Metabolic syndrome (Syndrome X) is a combination of high blood pressure, insulin resistance, and high cholesterol levels. Having all three conditions has been shown to significantly increase your risk of heart disease, heart attack, or stroke. Numerous studies show that people with metabolic syndrome can also have obstructive sleep apnea. In fact, syndrome Z has been described as all the features of Syndrome X plus obstructive sleep apnea.

A study published in Archives of Dermatology showed that patients with psoriasis had a higher chance of having metabolic syndrome compared to people who didn’t (40% vs. 23). I’ve written in the past about how chronic physiologic stress due to sleep apnea causes diversion of blood flow and nutrients to the bowels, reproductive organs, and the skin, since they’re considered “low priority” organs. Low blood flow causes a relative hypoxia, creating oxidative stress, and along with a heightened immune system, so it’s not surprising that the skin can show psoriatic plaques.

Here’s a study showed that women who drank more than two alcoholic beverages per week had a significantly higher risk of psoriasis. Alcohol relaxes your throat muscles, aggravating sleep apnea.

Researchers from harvard showed that comorbid conditions such as cardiovascular disease, depression, diabetes, obesity, and hyperlipidemia all increased over time. Not too surprising if you already have sleep apnea.

Pregnant women with psoriasis were found by Harvard and Mass General researchers to have higher risk of pregnancy-related complications, including spontaneous abortion, preterm birth, preeclampsia, placenta previa, and ectopic pregnancy. Gaining weight can aggravate sleep apnea. Studies show that CPAP can help with preeclampsia.

People with psoriasis were found to have increased risk of depression (39%), anxiety (31%) and suicidal thoughts (44%). Sleep apnea can cause structural, metabolic, and biochemical changes in your brain due to hypoxia.

And lastly, young adults who are obese were found to have a higher risk of developing psoriatic arthritis later in life. Obesity is a major risk factor for obstructive sleep apnea.

Perhaps psoriasis should be placed on the ever-growing list of complications of obstructive sleep apnea. What do you think?

Almost weekly, I see patients that suddenly gained significant weight after starting an antidepressant medication. We know that certain antidepressants are more likely to cause weight gain. Weight gain can aggravate obstructive sleep apnea, and obstructive sleep apnea can worsen depression. We also know that depression is linked with a higher incidence of insomnia, cardiovascular disease, and even death.

Did you gain weight after starting an antidepressant medication? If so, which one did you take?