October 7, 2014
Over the years, I’ve witnessed countless stories about patients with obstructive sleep apnea who undergo nightmare experiences while undergoing treatment. Oftentimes, the insurance issues can be worse than any medical issues. In his book, The Midnight Stranglers: A Personal Quest For Healthcare Transparency, Aiden Hill chronicles his painful journey from first being diagnosed with obstructive sleep apnea to his ordeal as a consultant helping California residents obtain health care coverage.
- Basic concepts of obstructive sleep apnea and consequence of non-treatment are covered. It’s not taken to be medical advice, but is well-written from a lay-person’s perspective.
- He describes the current flawed state of affairs with our health care system, likening it to Dr. Jekyll and Mr. Hyde. There can be a dark consequence to any good intention.
- With ongoing changes to our health care system, he emphasizes the importance of taking a pro-active approach before undergoing any type of treatment. Even then, you’re likely to get hit with an unexpected bill, despite putting in your due diligence. Expect to spend hours, days or even years dealing with the aftermath. I’ve experienced this personally numerous times.
- The problems that he encountered with insurances companies, doctors, hospitals, and government entities are all governed by the basic rule: “Protect the asset.”
- I completely agree that full financial transparency is needed before undergoing any medical transaction.
October 3, 2014
When I first wrote my book, Sleep, Interrupted in 2008, I had a question mark in my diagram linking obstructive sleep apnea to possible cancer. Since that time, there have been a number of studies making that link stronger, and I am now more comfortable in removing that question mark. One of the basic hallmarks of obstructive sleep apnea is repeated episodes of low oxygen levels (intermittent hypoxia) due to obstructed breathing at night. If you google “intermittent hypoxia and cancer” you’ll see about 460,000 search results, of which 33,000 are scholarly articles. Low oxygen levels are strongly associated with cancer progression.
In a recent review article on this subject, Dr. David Gozal and colleagues published a paper titled, Sleep apnea awakens cancer: A unifying immunological hypothesis. They hypothesized that intermittent hypoxia and sleep fragmentation can promote changes in the tumor microenvironment, leading to a weakened immune system and tumor growth enhancement.
It’s important to remember that intermittent hypoxia not only can enhance cancer development, it can also in theory enhance benign tumor growth as well. One of many possible explanation is the concept of increased levels of vascular endothelial growth factor, which enhances more blood vessel growth, so that more nutrients (via blood) can reach the oxygen starved tissues. Initially, it may only cause localized enlargement of the soft tissues. Imagine if you continue to have intermittent hypoxia, and let’s say that you have a gene that makes you more susceptible to cancer. If you add additional lifestyle habits such as smoking and drinking alcohol, then one mutation can potentially lead cancer.
To date there hasn’t been any particular cancer that’s strongly associated with obstructive sleep apnea. However, one large-scale population study found that your chances of dying from cancer increases almost 5 times if you have untreated severe obstructive sleep apnea. Another study found a 2.5 times increased risk of having cancer and 3.4 times higher risk of dying from cancer with untreated moderate to severe obstructive sleep apnea.
Notice that the most common types of cancer happen in the “low priority” organs when you’re under stress. These areas include the gastrointestinal system, the reproductive organs, hands, feet, and the skin. In general, the core, central areas take priority. Any form of physiologic or emotional stress diverts blood flow and nervous system activation away from low priority to high priority areas. Rarely do you hear about cancer in the brain, heart or muscles, which are considered high priority.
This is another example of how sleep connects the dots between almost every known chronic health condition. Unfortunately, cutting edge cancer research focuses mainly on the molecular, genetic, and biochemical aspects without looking at the big picture. Without addressing proper sleep and breathing, even the best cancer treatments can give possibly suboptimal results.
If you have a diagnosis of obstructive sleep apnea, do you have a cancer history in your family?
September 24, 2014
Oftentimes, I recommend a referral to a dentist to treat obstructive sleep apnea. Most patients will ask me, “How is a dentist going to help me?” My answer is that since obstructive sleep apnea is mainly a problem from small jaws and crooked teeth, they have a variety of different ways of helping you to breathe better and sleep better.
I just came back from presenting at an Airway Dentistry conference in Laguna Hills, CA. It was definitely one of the most exciting and rewarding conferences I have ever attended. All the speakers and the attendees are at the forefront of not only potentially better treatment, but also better prevention of obstructive sleep apnea.
The most common way dentists can treat obstructive sleep apnea is by making a retainer-like appliance that pulls your lower jaw forward. Since the muscle that attaches the base of your tongue connects to the lower jaw, moving the jaw forward will pull the tongue forward. This option works well for most people and is usually better tolerated than CPAP. However, because it’s a device that sits in your mouth, protruding your lower jaw, it can sometimes cause problems like profuse salivation, jaw pain and shifting teeth. It uses the upper teeth as a lever to pull the lower teeth forward, so the upper teeth can shift back to various degrees. Fortunately, this is unusual, and can be adjusted for by your dentist. In many cases, people don’t mind because sleep is so much improved.
Now there are a newer generations of dental appliances that work not by pulling forward your lower jaw, but by expanding your jaw wider and more forward, all without surgery. Granted, it can take much more time, similar to braces. However, it’s different from braces in that rather just straightening teeth, the entire jaw structure is significantly expanded, opening up the airway.
The downside to these newer options is that because they are so new, not too many dentists know about it, and it’s not generally covered by insurance. It’s also important to remember that there hasn’t been large-scale studies on obstructive sleep apnea treatment effectiveness. Hopefully, studies will be forthcoming. Currently, most dental appliances that are FDA approved for obstructive sleep apnea are the advancement devices.
Up to date dentists are also incorporating orofacial myologists who train your tongue and throat muscles properly. Since your tongue is your most important orthodontic appliance, how it’s used (along with the lips and throat muscle) can have a profound effect on the eventual size of your jaws and your upper airway.
I challenge everyone reading this post to find out how much they know your dentist knows about obstructive sleep apnea. Does he or she appreciate how important the teeth are in relation to your upper airway? Does your orthodontist still remove teeth before applying braces for your child? If not, at the risk of possibly offending your dentist, please direct them to the American Academy of Physiologic Medicine and Dentistry, and the American Academy of Dental Sleep Medicine.
What has your experience been with your dentist? How well are they versed in the importance of the airway?
August 28, 2014
Podcast #002 Show Notes
Reader Question: Do those anti-snoring devices that you see advertised really work?
Sleep Tip of the Day: How to minimize light pollution in your bedroom.
Resources mentioned in podcast:
Finding Connor Deegan video
American Academy of Physiologic Medicine & Dentistry (AAPMD.org)
Ride of the Zombies Charity Bike Ride
Subscribe in iTunes @ doctorstevenpark.com/itunes. Thanks for reviewing my podcast and rating me.
Listen to the MP3 file here. (Right click to download)
August 20, 2014
In the wake of Robin Williams’ untimely death by suicide, I think it’s appropriate to talk about the pink elephant in the room that no one seems to notice. Mr. Williams was known to suffer from severe depression, and there are reports that he also had early stages of Parkinson’s Disease. He also battled alcohol addiction.
It’s estimated that about 20 million people suffer from depression. It’s a consensus that depression is caused by a multitude of various factors, with a number of different brain biochemical and structural abnormalities.
Here are 7 known facts about depression, insomnia and obstructive sleep apnea:
1. We know that depression and insomnia and other sleep problems tend to go hand in hand. People with insomnia are found to have a ten-fold increased risk of developing depression later in life.(1) Treating insomnia in patients with depression resulting in almost double the rate of depression remission.(2) Another study found that the presence of depression and insomnia predicted a higher rate of obstructive sleep apnea.(3)
2. The hippocampus is one area in the brain (amongst many other areas) that is found to be smaller in people with depression.(4) This area controls long-term memory and recollection. Interestingly, this is the same area that is also found to be significantly diminished in patients with severe obstructive sleep apnea.
3. Men and women who reported stopping breathing during sleep more than five times per week were 3 times more likely to show signs of major depression. Numerous studies show a strong bi-directional link between obstructive sleep apnea and depression.
4. Patients with severe insomnia who don’t respond to prescription sleep aids have about a 75% chance of having undiagnosed obstructive sleep apnea.(5)
5. In people with obstructive sleep apnea and depression, CPAP resulted in significant improvements in depression scores.(6)
6. Obstructive sleep apnea is known to significantly raise your risk of heart disease. (Mr. Williams underwent open heart surgery in 2009).
7. Many people with obstructive sleep apnea compensate for fatigue by intense physical exercise. (Mr. Williams was an avid cyclist).
There’s now lots more research on the ravaging effects of obstructive sleep apnea and oxygen deprivation on various areas of the brain, including the pre-frontal cortex, hippocampus, and the thalamus. Not only is the brain deprived of vital blood flow and oxygen, but brain tissue density and volume are also found to be smaller. One small shining light amongst all the bad news is that the hippocampus can regenerate to some degree with improved cognitive abilities after many months of CPAP use.(7)
Granted, you could argue that depression can lead to obstructive sleep apnea, since lower levels of activity can lead to weight gain. But then poor sleep quality can lead to low energy levels and lack of motivation to do anything, Poor sleep is also known to cause weight gain. Certain antidepressant medications are also known to cause significant weight gain, which can also aggravate this vicious cycle.
In addition, many people with insomnia or obstructive sleep apnea use alcohol as a sedative to fall asleep at night. However, because alcohol relaxes your throat’s muscles, more apneas can occur.
In my practice, whenever I see anyone with clinically significant depression requiring medication, in the vast majority of cases, the upper airway is very narrow. Typically, they can’t sleep on their backs, and one or both parents snore heavily. They are never able to wake up refreshed.
All this is speculation, since no one has examined Mr. Williams for obstructive sleep apnea. But statistically speaking, given all of the above, and boing in his age group, he has a relatively high chance of having had untreated obstructive sleep apnea.
If you are diagnosed with depression and obstructive sleep apnea, which came first—depression or sleep apnea?
1. Ong, Jason C., et al. “Frequency and predictors of obstructive sleep apnea among individuals with major depressive disorder and insomnia.” Journal of psychosomatic research 67.2 (2009): 135-141.
2. Manber R; Edinger JD; Gress JL; San Pedro-Salcedo MG; Kuo TF; Kalista T. Cognitive behavioral therapy for insomnia enhances depression outcome in patients with comorbid major depressive disorder and insomnia. SLEEP 2008;31(4):489-495.Taylor, Daniel J., et al. “Epidemiology of insomnia, depression, and anxiety.” SLEEP. 28.11 (2005): 1457.
3. Wheaton, Anne G., et al. “Sleep disordered breathing and depression among US adults: National Health and Nutrition Examination Survey, 2005-2008.”Sleep 35.4 (2012): 461.
5. Krakow, Barry, Victor A. Ulibarri, and Edward A. Romero. “Patients with treatment-resistant insomnia taking nightly prescription medications for sleep: a retrospective assessment of diagnostic and treatment variables.” Primary care companion to the Journal of clinical psychiatry 12.4 (2010).
6. Schwartz DJ; Karatinos G. For individuals with obstructive sleep apnea, institution of cpap therapy is associated with an amelioration of symptoms of depression which is sustained long term. J Clin Sleep Med 2007;3(6):631-635.
7. Canessa, Nicola, et al. “Obstructive sleep apnea: brain structural changes and neurocognitive function before and after treatment.” American journal of respiratory and critical care medicine 183.10 (2011): 1419-1426.
August 7, 2014
Sleep position is a perennial topic that you’ll see often talked about in the media. In most cases, your sleep position is thought to predict your personality type. However, there’s a simpler explanation for why you may prefer to sleep on your side or on your tummy. This has to do with the shape of your face, and in particular, the size of your upper airway.
About once every few months, I’ll see a woman who complains of 4 weeks of frequent sinus infections, facial pain and misery. She was given multiple courses of antibiotics and allergy medications, all with only temporary relief. When I examine her upper airway, it’s usually very narrow, especially when she’s lying flat on her back. I ask her about her sleep position, and she’ll state that she likes to sleep on her back. I don’t believe her. Then I ask her what her favorite sleep position was 3 years ago. She replies that she used to sleep on her stomach. When did she change? About 4 to 5 weeks ago. Why did she change? Her dermatologist told her that she’ll get wrinkles on her face if she sleeps on her stomach.
Not unexpectedly, after switching back to her tummy during sleep, her sinus problems get better. In addition, I make sure that she stop eating close to bedtime and that her nasal breathing is optimized. What’s happening is that on her back, her tongue falls back more due to gravity, and during deep sleep, with total muscle relaxation, she stops breathing and keeps waking up. Poor sleep quality over time will cause sinus migraines, and even more facial wrinkles.
In the video below, I talk about how your facial shape can predict your sleep position.
If you’ve had to change your sleep position for whatever reason, why did you do so, and did it affect your sleep quality?
August 5, 2014
As I walked down the cereal aisle of my local supermarket the other day, I was amazed at how may options I had. I saw endless rows of cereal boxes, each claiming to be superior and more nutritious than others. In the same way, available treatment options for obstructive sleep apnea are exploding, and patients and health care professionals are now more confused than ever. You would think that having more options to choose from is a good thing, whether it’s about cereal, CPAP machines, dental appliances, or sleep apnea surgery. But patients as well as physicians are now even more confused and paralyzed with indecision. If you add the internet to this information overload, things get even more out of control.
In a recent Fiscal Times article, the sleep industry is projected to be a $32 billion industry this year. For the past few years, it’s been increasing about 8-9% per year. This includes not only medical products, services and devices, but also over-the-counter, consumer-based products. Bed Bath & Beyond has over 600 products in the sleep category. Resmed, one of the major CPAP manufacturers, had total revenues of $1.2 billion in 2011.
As we become inundated with options for better sleep, what can we do as patients and as professionals? Here are 5 suggestions for patients/consumers and 3 tips for health care professionals:
For patients and consumers:
- Take all product claims with a grain of salt. There’s no doubt that many of the touted success rates and claims on packaging labels my be true to a certain extent. However, marketers have a very low threshold for product claims. They just have to show that it’s true, whether or not it actually works for everyone. For example, if a nasal dilator strip company says, “Relieves nasal congestion and snoring,” they can say this even if only 1/10 people find any benefit. There’s no doubt that some people will experience significant benefits, but in my experience, most people have only slight improvement in symptoms. Objectively, it’s hard to quantify subjective improvement.
- Overcome paralysis by analysis. Having too many nasal dilator strip options can be frustrating. Choosing between CPAP and oral appliances can also be a challenge. Whenever faced with these issues, just pick one and give it a try. Usually, there’s one option that’s relatively easier to get (whether financially or logistically). Worse case scenario, it the first option doesn’t work, you can always go to the next option. Ideally, if possible you should try both options, since you won’t know what will work better. Some people end up using both CPAP and an oral appliance with better results.
- Don’t be afraid to try new things. If it works, keep using it. If you have the times and the resources, give both a try. Sometimes, a very good treatment option for sleep apnea won’t be covered by insurance. For example, a dental appliance for snoring or myofunctional therapy can help significantly, but you’ll have to pay out of pocket. Insurance will usually cover only the bare essentials for options that have a proven track record over many years. New and innovative options, no matter how good, usually won’t be covered.
- Trust your doctors, but take control and responsibility for your own care. Doctors are humans too, so despite years of training and education, they are prone to be biased. They are well-meaning, but they are not all-knowing. Use physicians as trusted advisors, rather than the old paternalistic way when you did everything your doctor recommended.
- Don’t give up. Time and time again, more people who are persistent end up reaching their sleep goals compared to those that either give up trying or try only a few things. In addition, don’t be afraid to fail. Nothing is guaranteed to work. Choose options that are most likely to work, but if it doesn’t work, go on to try another option.
For medical professionals:
- Take all research-based studies and results with a grain of salt. The fundamental concept of good research design looking at one variable while controlling for other confounding variables is something that scientists strive to achieve. The problem is that disease in humans is not due to a single variable, but a combination of millions if not billions of variables. This is why in many cases, if you apply research findings by the book to a patient, results are not always satisfying.
- Customize treatment recommendations to patients, and avoid template-driven medicine. If everyone followed to the letter practice guideline and recommendations, then we don’t need physicians. These recommendations are designed to be applied to the typical, routine, run-of -the-mill patient with classic conditions or symptoms. However, individuals are not statistical averages, and treatment options must be custom tailored to the patient’s unique life situations. For example, someone that travels frequently may be more inclined to use a mandibular advancement device over CPAP, despite the fact that overall effectiveness may not be as good.
- When things don’t make sense, trust your patients. This is the hardest lesson I had to learn, and it took me over 15 years to learn this. After years of training and practicing medicine and surgery, I thought that if I applied everything I learned from textbooks, journals and conferences, that’s practicing good medicine. Oftentimes, no matter how crazy I thought a patient’s explanation was, in the end, they were usually right. For example, one patient kept saying that it was his tongue that was obstructing his breathing. I didn’t see anything in the office. Sure enough, he had major tongue collapse that was seen under sleep endoscopy.
In the end, after going through dozens of different cereals in my lifetime, I’ve found one that I’m happy with (Honey Bunches of Oats). Similarly, if you keep an open mind about sleep apnea treatment options and are willing to try new things, then you’ll have a much higher chance of finding a solution to your sleep apnea problem.
What kind of frustrating experiences have you experienced as a patient or practitioner when faced with too many choices for sleep apnea care?
June 13, 2014
Since I stopped doing my teleseminars, I felt a bit out of touch with you. As a result, within the next few weeks, I’ll be re-launching my podcast, which will feature specific topics related to obstructive sleep apnea and upper airway resistance syndrome. My older teleseminars are already on my podcast. The ideas for future topics will come from you. This is why I recently sent out a reader survey, and the response was overwhelming. I got over 140 people who filled out the online questionnaire, when I was only expecting anywhere from 20 to 30 responses. It was truly gratifying to see how many people not only filled out the survey, but they also took the time to make some very helpful comments and suggestions. Here’s a summary of the major findings:
- Slightly more men than women (57% vs. 43%)
- Well over 90% are over age 40
- People responded from all over the United states
- 19 people from Canada, UK, Australia, Mexico, Jordan, France and Holland
- About 50% have graduate or higher level degrees
- About 1/2 read my book
- Most people liked accessing my information online, and video was #2
- About 2/3 of respondents initially found me through search engines or surfing
- The most popular future book title was tied between The Ultimate Sleep Apnea Manual and The 7-Day Sleep Apnea Solution
- 57% were using Windows, 29% on a Mac, 28% on a Mobile device using Safari, and 1% using Linus.
The range of suggested topics was so broad that I can’t print everything. However, the three most common frustration/suggestion themes were:
- Your doctors don’t listen, or they don’t take your sleep concerns seriously
- Massive frustration with CPAP
- Life and work stress issues
I’m going to cover these three topics in my upcoming podcasts, so please subscribe now in your podcast player or on iTunes. If you have any other topics that you want me to cover, please feel free to respond to this post in the space below.
June 9, 2014
Things are a bit crazy as I ramp up my efforts to restart my podcast series as well to continue production of my second book, Your Ultimate Sleep Apnea Solution: Dr. Park’s Complete Guide to Getting the Sleep You Need and the Life You want.
As I was searching for information on the internet, I stumbled across an old interview that I gave for Sleep-Apnea-Guide.com. I highly recommend that you read the entire article. It give a great summary of the reasons why we have sleep apnea, my general treatment philosophy, and what you can do to help you get the help that you need to breathe better and sleep better.
If you have any comments or questions about it, please come back to this page to post your response or question.
May 5, 2014
If you’re at your wit’s end with a young child who has major behavioral problems, you’re not alone. Before you consider placing him on medications, here’s something that you should know: Your child’s attention deficit hyperactivity disorder (ADHD) may actually be a problem breathing while sleeping. Here’s a powerful video of a young boy whose parents struggled for years before finding the right team of doctors to help their son.
Connor’s mom is organizing a cycling fundraiser to help donate $10,000 to Lurie Children’s Hospital of Chicago’s Sleep Medicine Department.
Do you have similar struggles with your child? Please feel free to comment below.