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How Diabetes, Dementia and Sleep Apnea are Linked (or Associated)

Here’s a new study out of Japan showing that people with uncontrolled diabetes had about a 35% increased risk of developing dementia. The article talks about how diabetes can cause clogging and blocking of the arteries, leading to lack of oxygen and brain damage. But guess what else causes lack of oxygen? Obstructive sleep apnea. Hypoxia has been shown to cause brain damage in numerous sleep apnea as well as Alzheimer’s research studies. As always, researchers are careful to point out that association never implies causality.

Sleep Apnea Worsens Dementia In Elderly Women

Here’s an important study that must be taken seriously. Researchers from UCSF and various other institutions showed that in elderly women, having sleep apnea significantly increases your risk of developing mild cognitive impairment or dementia compared to those women who don’t have sleep apnea. In a study of 298 women as part of an osteoporosis study that underwent sleep studies, 105 (32%) were found to have significant obstructive sleep apnea (AHI >15). After 5 years, women with sleep apnea had a higher rate of cognitive impairment or dementia (44.8%) than those without sleep apnea (31.1%).

Knowing what we already know about sleep apnea and how it can ravage the brain, these results are not surprising.

Can Sleep Apnea Cause Skin Cancer?

I’ve alluded to the possibility of cancer development from chronic hypoxia that’s seen with obstructive sleep apnea. Here’s one study that supports my hypothesis: Researchers in Spain injected melanoma cells into mice and subjected one group to intermittent hypoxia and the other group to normal oxygen levels. At the end of 14 days, the tumor weight in the hypoxia group was almost two times that of the normal oxygen group.

Remember that chronic physiologic stress that results from hypoxia leads to lowered blood flow, metabolites and resources to unessential body parts and organs. The skin is considered unessential. There are tons of research in the cancer literature showing how hypoxia is a major player in cancer development. Other organs that are commonly affected by cancer are your reproductive and digestive organs: colon, prostate, breast, uterus, and ovaries.

This connection isn’t surprising, given the fact that hypoxia has been shown to cause amyloid plaques and neurofibrillary tangles in mice brains. If the Spanish researchers tested brain tissues as well, they probably would find similar pathology.

How many of you with obstructive sleep apnea also have skin cancer?

Can Colon Cancer Be Caused By Sleep Apnea?

Colon cancer is usually thought to be due to hereditary causes, along with your diet and lifestyle factors, but a new study revealed that sleeping less than 6 hours per night increases your chances of getting colon cancer by 50%, compared with sleeping 7 hours per night. The study authors speculate that perhaps melatonin may be involved, but no plausible explanation was given.

Here’s my take on it: Lack of sleep of poor quality sleep causes a physiologic state of stress. Your adrenaline levels are constantly increased. Since digestion is your last priority (especially when you’re running from a tiger), blood flow and nervous system activity are shut down when you’re under stress. Now imagine if you place food in your bowel, and your gut is not able to digest properly, or clear toxins appropriately. Hypoxia (low oxygen) causes local tissue damage (causing inflammation) and what’s called neo-vascularization, where new blood vessels are created to try to bring in more nutrients. Chronic over-stimulation of tissues in a state of low oxygen levels can create a perfect storm for cancer development. This process can also be applied to reproductive organs such as breast or prostate.

If you have or had colon cancer, how many hours of sleep do you normally get?

Autism, Vaccines, & Sleep Apnea: My Multi-Hit Theory

I remember during M&M (morbidity and mortality) rounds as a resident, our chairman felt strongly that an error never occurs in isolation. He insisted that a bad outcome happens from a series of mistakes, oversights and lack of communication. Even in engineering or aviation, whenever something goes wrong, there’s usually a series of events that led to the final adverse outcome. The same analogy also applies with cancer.

Although vaccines were essentially exonerated by recent large-scale studies (showing that the rate of autism was no different before and after Thimerisol was removed), there are still many proponents of the vaccine theory. I think that there’s some merit to this possible connection, but not for the reasons that you may think. Let me explain.

You may remember in one of my previous posts, I described reading about a theory that proposes that since the Back to Sleep campaign for infants in the early 90s, the incidence of autism went up significantly afterwards. This campaign led to a 40% reduction in sudden infant death syndrome (SIDS). However, one of the consequences of keeping infants on their backs is to keep them in a lighter state of sleep. This can prevent proper memory consolidation and brain development.

Although it sounds like a feasible explanation, it’s going to be difficult to prove. Medically and politically, doctors are not going to retract this recommendation, even if it is found to be plausible. However, if you add to this the fact that modern jaws are smaller due to a more bottle-feeding and poor nutrition, sleeping on your back can definitely lessen your deep sleep efficiency.

In another recent post, I alluded to allergy shots aggravating obstructive sleep apnea, by increasing nasal congestion. Anything that causes inflammation in the nose or throat, including allergies, colds, migraines, reflux or weather changes, can aggravate more frequent pauses in your breathing, especially when in deep sleep.

The human voice box is unique in that it’s located below the tongue. This migration downwards begins at birth and continues until your 60 or 70s. Around 4 to 6 months, a space is created between your soft palate and your voice box, called the oropharynx. Only humans have a true oropharynx. Descent of the larynx is needed for complex speech and language. But this also predisposes humans to breathing problems, especially when on our backs. This is when the tongue and voice box falls back the most, due to gravity. When you add muscle relaxation during deep sleep, you’re more likely to stop breathing and wake up.

Not breathing at night while sleeping, from a brief second to 30 seconds or more, can be detrimental to your brain. The end extreme of this spectrum is called obstructive sleep apnea, but even multiple short episodes of breathing pauses due to upper airway obstruction can lead to various pathways that can lead to significant neurological impairment.

If you put all these mechanisms together, then it creates a situation where you can suffer serious brain damage. In most cases, you won’t be able to see any anatomic changes using traditional imaging studies, such as with a CT scan or an MRI. These are sub-radiologic changes that occur within the brain tissues itself.

Vaccines and flu shots, just like anything else that creates a mild infection, can cause swelling and inflammation in your nose and throat. If your anatomy is already predisposed, and you add additional variables such as back sleeping and bottle-feeding, then even an allergy attack could in theory cause changes in your brain that can mimic autism. Given that the total number of child immunizations has increased tremendously only adds to my argument. Not too surprisingly, there are also known reports of children who develop autism after a simple cold or flu infection.

Ultimately, it may not be the specific type of vaccine or flu shot, or even the specific materials that they’re made with, but rather the general inflammation causing properties of these immunizations that may be the trigger that tips children over the edge to progress into any of the autism spectrum disorders. I may be going out on a limb here, but in the big scheme of things, autism may even be a childhood manifestation of the same process that causes Alzheimer’s.

What’s your opinion on my thought experiment? Will you agree with me that autism has multifactorial causes and not just one trigger?

More Dead End Tests For Alzheimer’s Disease

There have been a number of recent studies that report on markers to predict whether or not you'll develop Alzheimer's in the future. All these tests, whether blood tests or cerebral spinal fluid samples, measure various levels of beta-amyloid, which is the protein that makes up the plaques that are typically found in diseased brains. 

One study showed that measuring three different markers had almost a 90% rate of accuracy in predicting Alzheimer's disease. Another showed that measuring beta-amyloid in spinal fluid was found to be useful.

If you've been following my posts about Alzheimer's disease, you know how I feel about beta-amyloid plaques. I believe amyloid plaques are the end result of damage that's done to the brain from other reasons, and not the cause of Alzheimer's itself. I've also alluded to numerous studies showing that chronic hypoxia can lead to amyloid buildup in the brain, along with lowered volume and density of brain cells in critical areas of the brain (including memory, motor movements, executive function, breathing and autonomic control) and numerous small strokes (lacunar infarcts) in people with untreated obstructive sleep apnea. I believe that a significant number of people with the most common type of Alzheimer's (idiopathic, not genetic) have an untreated sleep-breathing problem that over time, can lead to various degrees of brain damage. Preventing amyloid plaques won't treat what's actually causing the problem, just like when we treat high cholesterol or high blood pressure with medications.

I'm reminded of a very funny and poignant video by Dr. Mercola, called The Town of Allopath. Its' message is very relevant when it comes to Alzheimer's disease.

What do you think about these new tests for Alzheimer's?

Why Sleep Loss Can Make You Gain Belly Fat

Dieting and weight loss has surpassed baseball as America's national pastime. It's estimated that 2/3 of all Americans are officially overweight, and 1/3 are obese. Besides the routine bulges that you see on the outside, the presence of visceral fat (or belly fat)—not the flabby fat under the skin that you can grab—but the fat deep within your abdomen that's attached to your intestines, is thought to increase your risk of heart disease, diabetes, metabolic syndrome, high blood pressure, colon cancer, and in women, breast cancer.

With all the news about the importance of belly fat as a risk factor for heart disease and other medical conditions, it's almost gotten to the point where the press and the lay public perceive belly fat as a cause of all these various medical condition, rather than just an association. The real question is, what causes belly fat to begin with?

The Link Between Stress and Belly Fat

Any type of stress, whether physiologic, or external, can cause dramatic changes in your physiology. The sympathetic nervous system, or the classic fight or flight response, is activated when you're under stress. This in turn diverts blood flow away from less essential body parts and organs, such as your gastrointestinal system, your reproductive organs, your skin and distant extremities. It’s like if you were being chased by a lion—every nerve and fiber of your being will be focused on getting away, not on digesting what you had for lunch.

Although you’re probably not being chased by a lion, any type of prolonged periods of stress which results in low blood flow to the intestines causes biochemical changes that lead to accumulation of belly fat. It's also thought that increased estrogens created by belly fat further suppress the natural progesterone levels in both men and in women, aggravating the vicious cycle even more.

Poor Circulation Can Cause Belly Fat

You don't need a serious medical condition to cause these rapid changes in intestinal blood flow. Even your emotional state, and the various life stresses that you experience every day can significantly affect the rate of blood flow to your stomach and your intestines.

Researchers have found that periods of low oxygen in the intestines can cause biochemical changes that lead to fat accumulation. Is this low oxygen level the result of the standard atherosclerosis that's seen with cardiovascular disease as we get older, or can there be something else? Is there anything else that can cause intestinal hypoxia?

How Your Jaw Size Can Affect Your Waist Size

As I describe in my sleep-breathing paradigm, modern humans have difficulty breathing properly while sleeping at night, especially when on our backs and when in deep sleep, due to muscle relaxation. This is from a slow but significant narrowing of our jaws, due to a major change in our diets and with the addition of other feeding tools, like infant bottles and pacifiers.

The smaller the jaws, the less room there is for the tongue, and the more likely it'll fall back during deep sleep, especially when lying flat and in deep sleep. Depending on how often this tongue collapse obstructs our breathing at night, we all fall somewhere along this continuum, where the end extreme is officially called obstructive sleep apnea. It's not surprising that periods of interrupted breathing, whether very brief or pauses of 10 to 30 seconds (apneas), is known to cause physiologic states of stress.

And this sustained form of stress can in turn, slow down our metabolic rate making it difficult to lose weight if not gain it.

Hormones and Weight Gain

In women, there is yet another major variable that can cause you to gain weight as you get older, and that's the role of diminishing progesterone, which begins during the late 30s and early 40s.

Progesterone is a major upper airway muscles stimulant, which essentially tenses or stiffens the tongue, especially when in deep sleep. This is why as the levels of progesterone diminish during perimenopausal age, women begin not to sleep as well as they did before the onset of menopause. A relative change in a woman's sleep-breathing status can then lead to neurologic symptoms, such as night sweats, hot flashes, weight gain, mood swings, and irritability. Not too surprisingly, these same symptoms can be seen even in young men who are moving up the sleep-breathing continuum. Lack of deep or efficient sleep is a major cause of physiologic stress.

Sleep Your Way to Weight Loss

A recent article in Glamour magazine profiled 7 women who where all slightly overweight, and asked them to do one thing for 4 weeks: sleep more. Without making any other changes, they all loss anywhere from 7 to 21 pounds. Sleeping longer is one way to restore health in our sleep deprived culture, but increasing sleep efficiency while you sleep is another way to increase your energy levels, improve your health, and lose weight more easily.

Not Only Your Breathing Problem

Not being able to breathe well at night while sleeping, and not sleeping long enough are important factors to address, but there are many other factors that also prevent you from achieving the quality sleep that you need: Eating late close to bedtime is a common modern ritual that occurs for a variety of different reasons. Gastric juices still lingering from your last meal (or snack) can be suctioned up into the throat, causing more swelling and inflammation, causing more obstructions and arousals. Drinking alcohol close to bedtime causes your throat muscles to relax more, leading to more frequent obstructions and arousals, as well as louder and more frequent snoring.

The Right Way to Lose Weight

Before you begin that new diet plan, or take advantage of your new gym membership, make sure that you're able to breathe properly at night. If your nose is stuffy for whatever reasons, do everything possible to straighten it out first. If you've had a stuffy nose for years or decades, you may not realize that your nasal breathing is compromised. Proper sleep and lowering your stress levels is critical to getting rid of that excess belly fat.

Sleep Apnea, Concussions and Dementia in the NFL

There's been a lot of media coverage recently about the high incidence of dementia in retired NFL pros. One report using a phone survey of retired NFL players revealed that the incidence of dementia or memory-related problems was 19 times higher than normal for men ages 30 to 49. Repeated head trauma is thought to create conditions that significantly increases the chances of developing dementia. A number of states are even enacting legislation that sets certain criteria for removing high school football players after any head injury with prompt and proper medical evaluation.

While these concerns are legitimate, I think the NFL officials are missing a very important piece of the puzzle, and that's the very high incidence of obstructive sleep apnea in current and retired pro football players. One recent Mayo Clinic study showed that 60% of all retired linemen and 46% of all other positions were found to have significant obstructive sleep apnea. Amongst active players in 2003, the overall numbers were 14% and 34% with linemen.

 

If you look at what happens to the brain with repeated episodes of hypoxia during apneas, then you'll see that the implications are profound. Untreated patients with sleep apnea are found to have multiple areas of dead or non-functioning brain tissues. Another similar study showed multiple areas of microscopic strokes, called lacunar infarcts. Chronic hypoxia in mice resulted in brain biopsy studies revealing amyloid plaques (similar to what we see with Alzheimer's disease). 

 

So with this logic, it makes sense that repeated concussions in someone with untreated obstructive sleep apnea is more likely to suffer from the cumulative effects of head trauma compared with someone without sleep apnea. As with everything else in medicine, diseases never exist alone in a vacuum. It would be interesting if they did a study looking at the incidence of obstructive sleep apnea in these ex-players with dementia. I'm willing to bet a very high percentage will have undiagnosed obstructive sleep apnea. Another, more costly and ambitious study would be to screen all current NFL players for sleep apnea and follow them for years (or decades) while undergoing proper treatment, measuring their rate of progression to developing dementia. 

 

What do you think about this issue? Should be continue treating medical conditions in isolation, or look at other co-morbid conditions that can aggravate the original diagnosis? Please enter your comments in the text area below.

Breast Cancer and the Sleep Apnea–Alcohol Link

I’ve been accused in the past of of trying to link everything to sleep apnea. While not everything is caused by sleep apnea (taxes, the weather, etc.), I can make a good argument that not breathing properly during the day and while sleeping can directly or indirectly affect every aspect of our state of health and well-being. Obstructive sleep apnea is only a small fraction of what I describe in my sleep-breathing continuum. Due to the way we define sleep apnea, you can have major sleep-breathing problems and not have any sleep apnea. 

 

Along these lines, here’s something interesting to think about: Can a sleep-breathing problem cause or aggravate breast cancer?

 

Drinking alcohol was found to increase a woman’s risk of not only developing breast cancer, but also increase the risk of developing recurrence in breast cancer survivors. In a recent study from Kaiser Permanente, women who drank 3-4 glasses of wine per week were 34% more likely to develop a recurrence compared with women who drank little to no alcohol.

 

The researchers speculated that alcohol can increase levels of estrogen, which increases metabolism. However, they didn’t have a clear explanation for these findings. What’s more relevant to this discussion is the fact that post-menopausal women and overweight women who drank were at higher risk for recurrence.

 

Like many other studies, researchers never commit themselves to state that one thing causes another—they can only state statistical likelihood of an association, but not causation. 

 

Similar finding are being reported with prostate cancer—that heavy alcohol consumption and being overweight increases your risk of recurrence.

 

Here’s my interpretation of these findings: Alcohol is a strong muscle relaxant that’s usually taken with dinner or later in the evening. Muscle relaxation during deep sleep causes more frequent obstructions in your breathing, which can cause or aggravate existing sleep apnea. The resulting activation of the sympathetic nervous system leads to a relative hypoxic environment in preferential body parts and organs, such as the gastrointestinal system, the reproductive system, the skin, and the hands and feet. 

 

Since the breast is a combination skin and reproductive structure, it’s more susceptible to various levels of hypoxia. Physiologic stress that develops in sleep apnea constricts blood vessels that feed blood into the breasts. This is also why many women with breast cancer also have cold hands and feet.

 

As I’ve described in my book, Sleep, Interrupted, hypoxia creates chemical mediators that tell the body to send more blood. One particular substance is vascular endothelial growth factor, or VGEF, which promotes new vessel formation and more aggressive tissue growth and regeneration.

 

Menopause is stage in life in a woman’s life where progesterone slowly diminishes, leading to more and more frequent obstructions and arousals (since progesterone promote tongue muscle tone). Furthermore, inefficient sleep can promote weight gain. Weight gain narrows the throat, leading to more frequent obstructions. Women’s rate of cardiovascular disease also increases significantly after menopause, along with a significant increase in obstructive sleep apnea. We know that sleep apnea can cause heart disease, but so far, these conditions are treated separately. It’s not surprising that breast cancer is treated independently, rather than looking at the bigger picture. 

 

Granted, this is an unorthodox explanation for breast cancer, but as Einstein once said, "The significant problems we face cannot be solved at the same level of thinking we were at when we we created them." In other words, we must think outside the box.

 

What I’m proposing doesn’t contradict traditional explanations for breast cancer. Rather, it’s a different perspective that can only complement existing treatment options.

 

What you do think about this explanation? Please enter your responses in the box below.

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