Podcast #5: Interview With Dr. Stasha Gominak on How Low Vitamin D Can Ruin Your Sleep (Part 3)

February 25, 2015

This is part 3 and the final segment of my conversation with Dr. Stasha Gominck, a neurologist with some very insightful information about vitamin d and how it’s vitally related not only to sleep, but to every aspect of your health. As mentioned previously, Vitamin D is actually a hormone that’s needed by every area of your body, including your brain. 
 
In this segment, Gominak is going to tell us
  • How to optimize growth hormone release
  • The link between slow wave sleep and the B vitamins
  • How this b vitamin can help REM behavior disorder 
  • How much Vit D is made in your skin by sunlight
  • Vitamin D’s anti-cancer properties
  • The importance of quality sleep and cancer prevention

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NY Time article on Meditation for a Good Night’s Sleep.

Mindfulness meditation sites: calm.com, headspace.com, and saagara.com

CBT-i sites: cbtreferee, CBT-i coach and cbtforinsomnia

Visit Dr. Gominak at drgominak.com
 
Subscribe in iTunes. I would appreciate it if you can rate my podcast and provide feedback within iTunes.
 
Please leave your feedback or any comments about this episode in the space below.

Podcast #004: Interview With Dr. Stasha Gominak on How Low Vitamin D Can Ruin Your Sleep (Part 2)

February 19, 2015

This is Part 2 of my interview with Dr. Stasha Gominak, a neurologist practicing in Tyler, Texas. Dr. Gominak has unique views on how Vitamin D can significantly affect the quality of your sleep, independent of obstructive sleep apnea or upper airway resistance syndrome. In this intervew, she will reveal:

How B vitamins interact with Vitamin D
How B vitamins are related to fibromyalgia
The link between irritable bowel syndrome and headaches
How Vit D is linked with weight gain
What’s the right dose of B vitamins? And for how long?
Which vitamins are made in your gut?
 
 Download audio file
 
Visit Dr. Gominak at drgominak.com
 
Subscribe in iTunes. I would appreciate it if you can rate my podcast and provide feedback within iTunes.
 
Please leave your feedback or any comments about this episode in the space below.
 

Podcast #003: Interview With Dr. Stasha Gominak on How Low Vitamin D Can Ruin Your Sleep (Part 1)

February 11, 2015

This is Part 1 of my interview with Dr. Stasha Gominak, a neurologist practicing in Tyler, Texas. Dr. Gominak has unique views on how Vitamin D can significantly affect the quality of your sleep, independent of obstructive sleep apnea or upper airway resistance syndrome. In this intervew, she will reveal:

1. How Vitamin D is related to sleep
2. Why Vitamin D3 is better than D2
3. How Mice and Pigs Confused Doctors About Vitamin D
4. Why Sleep became much worse in the 1980s
5. How much Vitamin D do we need?
 
Download audio file
 
Visit Dr. Gominak at drgominak.com
Vitamin D Council
Dr. Walter E. Stumpf
 
Subscribe in iTunes. I would appreciate it if you can rate my podcast and provide feedback within iTunes.
 
Please leave your feedback or any comments about this episode in the space below.

The Most Misunderstood And Often Overlooked Treatment For Sleep Apnea (HINT: It’s NOT CPAP)

January 21, 2015

John Wooten, UCLA’s legendary basketball coach was a stickler for fundamentals. He looked down on trick plays, fancy footwork, or high-tech strategies. Similarly, before looking for state-of-the-art treatment options for obstructive sleep apnea, you should always first consider the fundamentals. 
 
If you’ve been newly diagnosed with obstructive sleep apnea, you’re likely to be told to lose weight, diet and exercise. Everyone know this already. Avoiding alcohol is another big no-no, since it relaxes your throat muscles. 
 
One option that is mentioned only casually is to avoid sleeping on your back. This is because being on your back allows your tongue and soft tissues of your throat to fall back more severely. When you add muscle relaxation during deeper levels of sleep, then you’ll either snore, or stop breathing altogether (called an apnea). 
 
In sleep studies, you’ll routinely see that in most cases, being on your back can lead to double, or even triple the number of apneas on your back compared to sleeping on your side or tummy. One study showed that sleep positioning was almost as good as CPAP.
 
Many people know not to sleep on their backs. The problem is that in most cases, you can’t control your sleep position all night long. 
 
If you are one of these people, then there’s an opportunity to use gravity to your advantage. 
 
One of the oldest recommendation is to sew a tennis ball inside a sock to the back of your pajamas. This may work sometimes, but more often than not, you’ll just sleep on top of it, or it’ll keep annoying you causing you to wake up. One of my patients misunderstood me and filled an entire backpack with tennis balls during sleep, and it worked well for him.
 
There are now multiple options for keeping you off your back during sleep. One popular option is the Rematee Anti-snore shirt. It’s a vest that you wear at night with pockets in the back that’s filled with inflatable bumpers. 
 
Another variation is the isidesleep mattress, which is an inclined wedge with a cutout at the top that allow you to drop your arm below the mattress, which cradling your head on a pillow that sits above the cutout. 
 
If you have shoulder or back problems and you can’t sleep on your side, then sleeping on your back on a incline is another option. There are a number of different options that you can find including this wedge pillow. This can be also be good for acid reflux. It’s also why some people can only sleep on recliners.
 
If you must sleep on your back, then it’s important to use a pillow that will tilt your head back somewhat, which will open up your airway. This is similar to what you do as the first step in CPR, but not as far back. There are many of these “contour memory foam” pillows that are promoted to reduce snoring. It’s not going to cure your sleep apnea, but used in conjunction with various other methods, it can help to various degrees.
 
Two of my patients wore neck braces (one soft and one hard) with some success. This may work by preventing your chin from dropping forward, while keeping your neck extended.
 
If you must sleep on your back, there aren’t too may options. One desperate patient actually bought a massage table and slept tummy down with his face inside the hole. 
 
As a last resort, you can always fly into space, where there’s no gravity. In fact, it’s been shown that astronauts have less snoring and apneas while in space compared to levels found back on earth.
 
If none of these options work for you, then it’s time to see a sleep physician. If you’re already using CPAP or an oral appliance, you can supplement positional therapy to your current regimen. Oftentimes, you’ll have to combine multiple options for better results.
 
I’m sure that many of you have tried other creative ways to get rid of snoring using positioning devices or contractions. If so, please share what worked for you in the comments area below.

How Breathing Exercises Can Help Your Headaches

January 15, 2015

Suzy is a 49 year old woman who saw me for daily headaches, ear pain, and fatigue. Her routine blood tests all came back normal. I helped her breathe better though her nose with allergy control, nasal saline irrigation, and nasal dilator strips. But the one thing she said helped the most was the deep-breathing exercises that I taught her.
 
In yogic breathing, the relaxing breath is performed by taking a slow, deep breath in through your nose on a count of 4, holding for a few seconds, and then breathing out slowly through your mouth on a count of 7. Then the cycle is repeated 4 to 5 times. I had her do this exercise multiple times per day: upon awakening, in-between major tasks or activities, and for 5 minutes just before bedtime. 
 
Noted integrative physician Andrew Weil has pointed out the breathing in (inhalation) stimulates the sympathetic nervous system (the fight-or-flight response), whereas breathing out (exhalation) stimulates the parasympathetic nervous system (the relaxing response). So by spending more time breathing out, the more relaxed you’ll be.
 
Another key concept to consider in Buteyko breathing is that by slowing down your breathing, you’re able to raise carbon dioxide (CO2) levels, which can make you calmer and feel more relaxed. During my neurosurgery rotation in my surgical internship year, I distinctly remember that we gave acetazolamide to lower intracranial pressures. Acetazolamide raises CO2, which is known to lower pressure inside your brain cavity.
 
In the sleep apnea research literature, obstructive sleep apnea has been strongly associated with elevated pressures within the brain cavity. One study found increased pressure, worse during sleep and highest in REM sleep, when apneas are most common. Pressures were also higher in the morning compared with evening pressures. This may explain morning headaches which are commonly seen in people with sleep apnea. Another small study reported on six adult patients with idiopathic intracranial hypertension (IIH) who all had various degrees of vision loss, and swelling of the optic nerve. One patient received acetazolamide alone, four received both acetazolamide and CPAP, and one got CPAP alone. Four had complete return of their vision loss and three had no more swelling of the optic nerve after treatment. 
 
This is one example of how many natural healing options may work to various degrees, with scientific explanations. 
 
How many of you practice deep-breathing exercises on a regular basis? How has your life improved as a result of doing these exercises? Please enter your responses in the box below.
 

How Doctors Are Making You Fat

January 2, 2015

Now that it’s the day after New Years, many of you likely made a resolution to lose weight. I’m not going to go into any detail about what you should eat or how you should exercise, since that’s not my area of expertise. What I can say is that poor sleep in general will promote weight gain. It’s also known that sleep deprivation will cause cravings for sugary, starchy, salty and fatty foods. Gaining weight will promote obstructive sleep apnea. Lack of energy and exercise will further enhance more weight gain, and the vicious cycle continues. 

However, one important aspect of weight gain (or not being able to lose weight) is the importance of prescription medications. I wrote a post a few months ago on 7 common prescription medications that can cause weight gain. I think it’s important to take a look at it again. Check to see if any of the medications that you’re taking is on this list. 

If you’ve gained significant weight since taking any of these medications, please tell me your story in the comments section below.

Taking the Mystery Out of UARS: A Must Read

December 31, 2014

Today, I had good news and bad news for Anna, a 28 year old patient regarding her sleep study results. The good news was that she didn’t have obstructive sleep apnea. The bad news was that she stopped breathing 15 times every hour. More bad news: She woke from deep to light sleep 25 times every hour over the course of the entire 7 hours. Lastly, some good news: She has a treatable condition called upper airway resistance syndrome. 

Most sleep physicians think of upper airway resistance syndrome (UARS) as a wastebasket diagnosis when you don’t officially have OSA, despite having many of the symptoms of OSA including severe fatigue, unrefreshing sleep, and brain impairment. Snoring is also sometimes lumped into UARS. But when questioned about what can be done, most will tell you the standard sleep hygiene list of bullet points: lose weight, don’t watch TV before bedtime, don’t eat late, and various other important things that everyone must do, even if you don’t have sleep apnea or UARS. Since most people with UARS are not overweight, it’s hard for some doctors to believe that you can have a sleep-breathing problem, especially if your official score on the sleep study is 0. 

The problem is that you need at least 5 apneas or hypopneas per hour (AHI) to qualify for a sleep apnea diagnosis based on a sleep study. By definition, apneas are total breathing pauses for more than 10 seconds. Hypopnea are more than 30% obstructed breathing for more than 10 seconds. The total number of apneas and hypopnea per hour is how the AHI is calculated.

But if you stop breathing 25 times every hour, and each episode is anywhere from 1 to 9 seconds, then your AHI will be 0. This was the case for Anna, the woman I saw today. Not having a sleep apnea diagnosis means that you won’t be covered for sleep apnea treatment options by your insurance company—even if you stop breathing 25 times every hour. 

Anna’s main complaints were blamed on anemia by her doctors. However, anemia alone can’t explain her daily headaches, anxiety, lightheadedness and dizziness, lower blood pressure, and intense fatigue, no matter how long she sleeps. 

Interestingly, she told me that her symptoms got much worse 3 weeks ago when she began to sleep on her back, when she used to sleep on her tummy. When asked what prompted her to make the change, she commented that her dermatologist recommended staying off her tummy since it can cause facial wrinkles. Not too surprisingly, having her switch back to her tummy improved her symptoms back to baseline again. 

Most people with UARS have very narrowed jaws and upper airways, rather than being overweight. Due to severe dental crowding, gravity, and muscle relaxation in deep levels of sleep, the tongue, soft palate, or even the epiglottis will fall back and cause you to wake up suddenly, long before the 10 second apnea threshold. In a nutshell, once you obstruct, sleep apnea patients take too long to wake up, whereas UARS patients wake up too quickly. Because the pauses are so short, you won’t have any significant levels of oxygen deprivation. 

The problem with so many frequent obstructions and arousals is that your sleep is severely fragmented. You may get the normal amount of deep sleep, but if it’s fragmented, it’s like not getting any deep sleep at all. Not getting deep sleep will cause you to have problems with memory, executive function, and no energy to do anything at all. 

One interesting consequence of UARS is how your heart responds to repeated obstructions. Every time you obstruct, tremendous vacuum forces are created in your chest cavity. This causes your heart muscle to becomes stretched, and your body thinks that there’s too much fluid. The heart then makes a hormone called atrial natriuretic peptide (ANP), which goes to your kidneys to make you produce more urine than usual. This is one of many factors that can cause people with sleep-related breathing disorders to go to the bathroom at night. Usually, you’ll wake up a the same time intervals, about 90 to 120 minutes apart, which happens to be one sleep cycle. Every time you go into deeper levels of sleep, due to muscle relaxation in your throat, you’ll have a more severe obstruction and arousal, and you’ll think you have to go to the bathroom. But oftentimes, it’s not a lot of urine.

Other interesting properties of ANP include low blood pressure, weight loss, digestive problems, low magnesium levels, anemia, and neuro-excitability. Essentially, your entire nervous system is overactive, especially to emotions, weather changes, smoke, chemical, and odors. It’s estimated that about 5 to 10% of people with UARS progress to OSA every year, especially if you gain weight. I often see overweight, snoring women in their 50 and 60s who have high blood pressure, with classic OSA, but when in their 20s, were stick thin and with low blood pressure. Even the cold hands and feet that they had when younger tends to go away after menopause.

Now that you’re more familiar with UARS, you may be asking what you can do about it. In general, you have to treat it just like for obstructive sleep apnea. The challenge is that since insurance won’t pay for treatment, you’ll have to pay for a CPAP machine or dental appliance. I’ve covered OSA treatment options in great detail in other articles, teleseminars and my book, starting with conservative options to standard devices and gadgets, dental appliances, and lastly, surgical options. However, for nasal congestion, it’s generally covered, since that’s a different diagnosis.

Most people with undiagnosed UARS can’t be helped by traditional medical options. Oftentimes, you may be diagnosed with anemia, hypothyroidism, anxiety, depression, headaches, irritable bowel syndrome, nutritional or vitamin deficiencies, allergies, for even food sensitivities. I have had every one of these conditions resolve partially or completely when UARS is addressed fully. Some do well with only lifestyle adjustments like not eating late and using Breathe Right Strips. Others do well with CPAP or a mandibular advancement device. Some need aggressive surgery to feel relief. Unfortunately, not too many people ever end up going up the ladder for UARS treatment, since it takes time, resources and having access to the right health care practitioners that are even aware that this exists. 

By now, you’re probably more knowledgeable about UARS than most physicians in this country. Hopefully, you can use this information to search out the root cause of many of your symptoms, which is an extremely narrowed airway preventing you from getting deep sleep. 

If you have some, or even all of the symptoms of UARS, which options have worked for you? How did your doctor respond to your concerns? Please enter your responses in the text area below.

I interviewed two of the foremost sleep physicians on UARS in my past teleseminars: Drs. Barry Krakow and Avram Gold. Click here to go to iTunes podcast page. Search for Episodes 27 and 31. After listening, please subscribe and rate my podcast. The more feedback you give me and topics that you want to hear about, the more programs I can develop to address your particular needs.

 

Holiday Health Risks For Sleep Apnea Sufferers

December 18, 2014

Did you know that the holiday season is the deadliest time of the year? With the added stresses of the season, more eating and drinking, more sleep deprivation, less sunlight, and less exercise, it’s no surprise. Here are three past posts that are important to read, especially if you have obstructive sleep apnea:

Solutions For Your Biggest Holiday Health Risk

Why Sleep Apnea Increases During the Holidays

10 Tips For Healthy Holiday Eating

 

How to Combat Fatigue Without Drugs or Stimulants

December 16, 2014

It seems that everyone is tired these days. Not just plain tired, but exhausted to the point to not being able to function at all tired. This is what Barbara told me when she came to see me for her stuffy nose problem. She was in her late 40s, had gained about 15 pounds over the past year, and she’s beginning to snore.

Your first thought may be that I’m thinking obstructive sleep apnea, but you’re wrong. If you came to see me for this problem, the most important things to consider are your diet, exercise levels, sleep duration, lifestyle factors, and recent life stress issues. That may seem a little out of my area of expertise as an ENT surgeon, but as a physician, my duty and responsibility is to first address your health in total, in the context of your environment and surroundings. 

Here are 7 things to try to combat fatigue before considering medications, stimulants:

1. Are you eating late? This is a common problem that can aggravate reflux, but this habit can severely aggravate sleep-breathing problems If you’re already susceptible to a sleep-breathing disorder (everyone), even brief pauses in breathing can vacuum up your normal stomach juices into your throat. This causes frequent arousals and fragmented sleep. Try to avoid eating anything within 3-4 hours of bedtime. The same applies to alcohol.

2. Is your nose stuffy? Having a stuffy noses is like sucking in through a flimsy straw: As  you pinch the tip (nose), the middle part (palate or tongue) begins to collapse. This is why it’s important to breathe optimally through your nose. You can start with frequent nasal saline irrigation, with or without breathe right strips.

3. Was there any recent weight gain? Even 3 to 5 pounds of weight gain can aggravate more reflux and obstructed breathing, leading to a vicious cycle of frequent arousals. Going on an exercise plan to lose weight can help.

4. Was there any recent change in your sleep position? If you were a natural side or stomach sleeper, but you recently had to change to your back because of an injury or even surgery, it’s likely that your sleep quality is now much worse on your back. Back sleep is most prone to your tongue or soft palate falling back, and 

5. Orofacial myology. Exercises for your tongue, lips, mouth and throat can help to strengthen your muscles and re-educate proper position, leading to proper function. It’s estimated that regular exercises alone can lower apnea severity by about 50%. Check out my interview with Joy Moeller about this important field.

6. Deep breathing relaxation exercises. You can find these activities through yoga, tai chi, or various other forms of proper breathing, including Buteyko breathing. Slowing down your breathing can help to calm your nervous system. 

7. Check for a vitamin D deficiency. Most modern, Western adults are deficient in this vitamin. Actually, it’s a hormone that affects every part of your body including your brain, heart, muscles, digestive system, bones, and kidneys. Although the lower limit of normal is 20, some doctors are recommending levels between 60 to 80.

Once you’ve considered all the above situations and you’re still not any better, check for obstructive sleep apnea or upper airway resistance syndrome. It’s estimated that up to 1/3 of all adults may have at least mild levels of obstructive sleep apnea. A large number of people will have upper airway resistance syndrome. Many of these people with get diagnosed with a vitamin deficiency, hormone imbalance, or anxiety/depression. Obstructed breathing which can lead to frequent arousals and lack of quality deep sleep can definitely make you tired, irritable, cranky, and exhausted. 

Have you tried any of the above options and if so, how well did it work?

Obstructive Sleep Apnea and Intracranial Pressure (Part 2)

December 1, 2014

Guest blog by Deborah Wardly, MD

Previously I blogged about the relationship between intracranial hypertension and obstructive sleep apnea, and pointed out the similarity between the signs and symptoms of upper airway resistance syndrome (UARS), obstructive sleep apnea (OSA) and those of intracranial hypertension. Intracranial hypertension is characterized by headaches, fatigue, dizziness/vertigo, ringing in the ears (which can be pulsatile), and visual disturbances to include papilledema (swelling of the optic disc). It can be present without papilledema (idiopathic intracranial hypertension without papilledema, or IIHWOP), which many doctors don’t seem to realize, and in these scenarios a lumbar puncture (spinal tap) is the only way to diagnose it. It is associated with obesity in many cases, as is OSA. 

Recently a study was published showing that in a group of patients with chronic fatigue syndrome (CFS), 20% of them met criteria for idiopathic intracranial hypertension (IIH), and 85% of them had improvement in their chronic fatigue syndrome symptoms after reduction of their intracranial pressure after lumbar puncture. The only thing missing from this study was the sleep study results on these patients! But we know how closely UARS can appear to resemble CFS, and this study begs further evaluation of UARS patients’ intracranial pressures, especially given the knowledge that apneas increase intracranial pressure.

My recent published paper discusses what is currently known about how OSA can increase intracranial pressure (ICP), and then further discusses other possibilities for this phenomenon that could be investigated. We know that individual apneas can increase ICP, and that an increase in carbon dioxide effecting an increase in cerebral blood flow may be causal, as well as perhaps an increase in intrathoracic pressure at the termination of the apnea. In my paper I discuss how OSA can increase glutamate excito-toxicity in the brain, and the evidence for glutamate being able to cause brain edema. I discuss how OSA may open the blood-brain barrier, which would also cause brain swelling. 

Alperin, et al. has demonstrated that in obese women with idiopathic intracranial hypertension, they have evidence of both brain swelling and poor jugular venous drainage. I suggest in my paper how the anatomical relationship of the recessed jaw to the narrowed airway, something we recognize is present in many cases of OSA, may also be involved in a compression of the internal jugular veins. This would contribute to the poor jugular venous flow observed in IIH by Alperin, and would increase resistance to CSF outflow. We know that obesity increases the risk of OSA in part by fat compression of the airway in the neck. Perhaps obesity increases the risk of IIH by fat compression of the jugular veins in the neck? Such that it is not entirely a direct causal relationship between OSA and IIH, but that they are conditions which go hand in hand when there is a recession of the mandible or increased fat content of the neck.

An important point that I discuss in my paper is the fact that a Valsalva maneuver will increase ICP. A Valsalva maneuver is created upon “bearing down”, something we do when coughing, sneezing, grunting, crying or shouting, yet even upon laughing, singing or talking. Many people with intracranial hypertension do not tolerate any Valsalva activity, as it will increase their headaches. Think about what it feels like to exhale with your CPAP on—it is a Valsalva as well.  Could this be the reason that some people with OSA/UARS do not tolerate CPAP, but must use BiPAP, or cannot use PAP at all? Do these individuals have undiagnosed IIH?  

If you do not tolerate CPAP, or even BiPAP, do you have headaches or any of the other symptoms of IIH?

Do you find you must have perfect control of your airway problem in sleep, in order to prevent or reduce the headaches, dizziness, and fatigue?

If you have CFS symptoms or IIH symptoms in conjunction with your OSA/UARS, would you consider a spinal tap to further elucidate your symptoms?

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The material on this website is for educational and informational purposes only and is not and should not be relied upon or construed as medical, surgical, psychological, or nutritional advice. Please consult your doctor before making any changes to your medical regimen, exercise or diet program.



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