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Hair Loss and Sleep Apnea?

This is what I posted to the NY Times Blog for an article on hair loss in women:

 

Hair loss in women is a serious condition with lots of conventional explanations. One area that's never mentioned is the connection to poor sleep quality, especially due to breathing problems at night. A significant percentage of men and women have undiagnosed sleep-breathing problems, with the end extreme being called obstructive sleep apnea. 

 

It's estimated that about 1/4 of all men and 1/10 of all women have at lease mild sleep apnea, and 90% are not diagnosed. However, there's a variation of sleep apnea called upper airway resistance syndrome (UARS), where you'll stop breathing while sleeping, but not long enough to be called obstructive sleep apnea. 

 

Typically these people (more typically thin women) will have colds hands or feet, prefer not to sleep on their backs, feel tired all the time, no matter how long they sleep, and will usually have at least one parent that snores heavily.

 

These multiple arousals lead to a chronic low-grade physiologic stress response which heightens the nervous system (and immune system). During times of stress, blood is shunted away from low-priority organs like the GI  system, reproductive organs, the distant extremities and the skin. Chronic lack of blood flow can lead to a number detrimental effects, including hair loss.

 

It's also been shown that chronic physiologic stress also raises your cortisol levels, lowers your thyroid levels, and alters your estrogen/progesterone/testosterone balance. 

 

There are also anecdotal reports of people who report hair regrowth after starting sleep apnea treatment.

 

If you have any of the symptoms mentioned above, you should get checked for UARS. In many cases, UARS progresses into obstructive sleep apnea, especially after menopause. Even if it doesn't help your hair loss, being diagnosed may prevent complications of sleep apnea, including hypertension, diabetes, weight gain, anxiety, depression, and heart disease.

A Link Between Endometriosis and Sleep Apnea?

Endometriosis is a common condition that's estimated to occur in about 5 to 10% of all women. It's characterized by pelvic and abdominal pain, along with infertility, and not too surprisingly, hypothyroidism, chronic fatigue syndrome, fibromyalgia, autoimmune conditions, allergies and asthma. 

 

Does this list sound familiar? Right — upper airway resistance syndrome (UARS). Doing some more research, I came across a health-related website (CureTogether.com, an open source health research site) that anonymously aggregates patients' symptoms and and other conditions to give you statistical data. Here are the top symptoms and the top associated conditions for endometriosis.

 

If you look down the list of associated conditions, many are also seen in patients with UARS. Since endometriosis is more commonly seen in women during the reproductive years, you may not see obstructive sleep apnea as often. I'm willing to bet that many of these women will go on to develop obstructive sleep apnea, especially when much older and if they gain weight after menopause. If you look at their parents, one or both parents will snore heavily. In addition, Raynaud's (cold hands for feet) is also a common feature in both endometriosis and UARS.

 

Knowing that upper airway resistance syndrome can cause profound changes in women's physiology, all these findings are not surprising.

 

Do you or anyone you know have endometriosis? If so, how many of the above symptoms or conditions do you see? Please enter your observations in the comments box below.

Can Sleep Apnea Cause Celiac Disease?

I know that the topic of this post may inflame a lot of readers out there, but please hear me out.

Celiac disease is a well-defined autoimmune condition that was originally described in children with chronic, severe gastrointestinal symptoms (diarrhea, cramping, abdominal pain and bloating). It’s known to exist in around 1/100 people in this country (97% don’t know they have it), and it’s responsible for various non-gastrointestinal symptoms, including a specific skin rash called dermatitis herpetiformis, migraines, ADHD, numbness, depression, chronic fatigue, and seizures. Others have reported a link between celiac disease and migraines, PCOS, and infertility. Only 1 out of 6 people have classic abdominal and gastrointestinal symptoms. For unexplainable reasons, the incidence has increased 4 time in the past 50 years.

The theory behind this widespread condition is that the in susceptible people, antibodies in the small intestines attack gluten, a common protein in wheat-based food. Humans don’t have the enzyme to digest gluten, so it passes harmlessly, but in people with celiac, an immune response is created which causes severe inflammation in the small intestines, leading to the classic symptoms. The only known effective cure is to avoid eating anything that contains wheat, in favor of alternatives such as rice, flax, oats, quinoa, teff, and buckwheat.

People who are eventually diagnosed and who go gluten free have remarkable success stories, with more awareness within the medical community and the lay public. One proposed explanation as to why this condition is so underdiagnosed in the US compared to other developed countries is that there’s no pharmaceutical drug that treats this condition, and that in other countries with centralized medical systems, prevention is stressed, rather than just treating the symptoms.

So far, pretty basic information, right?

Here’s my take on celiac disease: For the past few years, whenever I see patients with known celiac disease who come to see me for various ear, nose and throat symptoms, they all have various degrees of sleep-breathing problems. Almost invariably, they have small jaws, cold hands, can’t sleep on their backs, are tired all the time, and have at least one parent that snores heavily. If you look at the space behind the tongue, the airway is extremely narrow. I’ve always suspected that there’s a link between celiac disease and a sleep-breathing disorder such as upper airway resistance syndrome, but I’ve been waiting to accumulate enough studies and evidence before adding celiac disease to my sleep-breathing paradigm.

Various other gastrointestinal conditions have been linked to sleep-breathing problems such as irritable bowel syndrome, Chron’s and ulcerative colitis, so why not celiac? Remember that with upper airway resistance syndrome (UARS), repeated micro-obstructions and arousals prevents deep sleep, which causes a chronic low-grade physiologic stress response. Stress shuts down blood flow to the intestines, which leads to the food just sitting in your intestines without proper digestion and nutrient absorption. After a while, the food becomes an irritant, which causes an inflammatory reaction, creating antibodies in the process, and food being rapidly expelled in the form of diarrhea. Chronic low-grade stress heightens your nervous system and immune system, where your body tends to over-react to normal stimulants or irritants. Just like in the nose, not only will you have an allergic reaction, you’ll also have a nervous system reaction (since your gut has a lot of nerves).

It’s no surprise that every symptom that you see with celiac disease is also seen with upper airway resistance syndrome, including hypothyroidism, migraines, PCOS, dizziness, low blood pressure, and cold hands. There’s even anecdotal evidence that breastfeeding lessens the chance that you’ll develop celiac, which is consistent with what I’ve been saying about how bottlefeeding can increase your risk of upper airway resistance syndrome and obstructive sleep apnea.

I’m not discounting the significant strides made in celiac disease research. There needs to be more awareness and more screening to treat this all-too-common condition. However, even when people go on completely gluten-free diets, they continue to have many of the various other non-gastrointestinal symptoms, including chronic fatigue, migraines, and poor sleep. The way I see celiac is that it’s kind of like a bad allergy, where your main reaction occurs in the intestines. Removing gluten definitely can help, similar to removing a cat from your house if you’re strongly allergic. But ultimately, you’re not treating what’s making you allergic in the first place. Celiac is possibly one of the early signs of an underlying sleep-breathing disorder, just like hypertension, ADHD, depression and heart disease. In modern medicine, we only tend to treat the end result, rather than the cause.

If you have celiac disease, ask yourself the following:

1. Do you prefer to sleep on your side or stomach?

2. Are you tired, no matter how long you sleep?

3. Do you have cold hands or feet?

4. Do you get frequent sinus headaches or nasal congestion?

5. Do either of your parents snore heavily?

What’s your take on my theory? Please enter your feedback in the comments box below.

Which Comes First, Sleep Apnea or Stress?

Sleep apnea is a major cause of physiologic stress. External stress of any kind (especially the holiday season) only aggravates the internal, physiologic stress that I describe in people who don’t sleep well.

To help you better manage your stress this holiday season, I’ve invited Dr. Niloo Dardashti, an integrative psychologist and holistic healer for this month’s expert interview, and I hope you’ll dial in and join us.

During this free information-packed hour, you’ll learn:

- What’s the interaction between stress, sleep problems and heart disease?

- What are some techniques for quieting "inner chatter" when stress has its’ hold on us?

- How can I stop unwanted thoughts?

- Which comes first – the chicken or the egg – does lack of sleep cause stress, or does stress cause lack of sleep?

- How can stress be handled returning to work after holidays or vacations?

- What are Dr. Dardashti’s thoughts on ADHD, Adderall and stimulants, especially for someone who has both anxiety and sleep apnea?

- How can I quit smoking if I’m very stressed and exhausted?

- What’s the best way of controlling work related stress?

- How can one reduce stress during a very stressful situation, such as being stuck in a large crowd, for example?

- How can I deal with being short on cash?

Tuesday, December 15th, at 8PM Eastern.

Register here to receive the call-in details.

An Uncomfortable Situation Regarding Sleep Apnea

One of the biggest dilemmas in my personal life is how to deal with friends or family members that I’m sure have obstructive sleep apnea or upper airway resistance syndrome. Should I even mention this condition at all, outside of a professional relationship? Is it even ethical, not to mention practical, to give medical advice to close friends or family members?

 

Once your eyes are opened to how common sleep apnea is, you’ll see that almost every other one of your friends or family will have varying degrees of sleep apnea. Many more won’t have sleep apnea, but a lesser variation called upper airway resistance syndrome. As you get older, I guarantee that a significant number of your friends will have it. Sadly, only 10% of sleep apnea is ever diagnosed and treated by doctors, who instead tend to treat the complications of sleep apnea such as high blood pressure, depression, anxiety, heart disease, heart attack and stroke. 

 

Ultimately, I’ve decided to take these situations on a case by case basis. Invariably, we’ll get on the discussion of what I do at work, and the topic of sleep apnea comes up. Depending on how interested he or she seems, I’ll gently suggest getting evaluated for it. I’ve had various responses to this approach. A number of my close friends have their lives changed radically after being diagnosed and treated for severe obstructive sleep apnea. Others who I know have severe sleep apnea either don’t take it too seriously, and continue their lives thinking that their fatigue, high blood pressure, and weight gain is just a normal part of getting older. In many cases, spouses of these people are frustrated because he or she won’t listen and go see a sleep specialist about this problem.

 

The other day, I ran into the wife of a couple that I know in my apartment complex. She relayed that her husband is sleeping much better since getting his CPAP machine and wanted to thank me for my advice. A few months before, the topic of her husband’s severe snoring came up during a conversation about what I did for a living.

 

As long as I can make a difference in my personal, as well as my professional life, I’m still going to do everything that I can to make people aware that sleep-breathing problems are a major cause of illness, fatigue, disability, and even death.

 

Have you reached out to your friends or family about sleep apnea? What was their response? Please respond with your comments below.

CPAP Success Secrets Revealed

Can H1N1 Cause Sleep Apnea?

You may be thinking that I’m stretching things a bit by making the suggestion that H1N1 can cause sleep apnea, but in my mind, there’s no doubt that whether it’s H1N1, the common cold, allergies, or strep throat, any degree of inflammation and swelling in the nose and the throat can aggravate sleep-breathing problems. If you didn’t have sleep apnea to begin with, then you may go into sleep apnea territory temporarily, and come back to normal once the infection is gone. This is why you’ll toss and turn when you have a simple cold. If you already have some degree of sleep apnea, then any infection or inflammation will only make things worse. Some people will recover, whereas others will be stuck in a continuous vicious cycle, leading to various other medical complications.

 

As I detail in my book, Sleep, Interrupted, most modern humans have narrowed jaws that lead to dental crowding and a predisposition to breathing problems while sleeping at night. My sleep-breathing paradigm proposes that all modern humans are on a continuum, where the upper extreme is formally called obstructive sleep apnea. But even if you don’t have sleep apnea, you can still stop breathing multiple times every hour. This disrupts your sleep and causes more inflammation and swelling due to suctioning up of your stomach juices into your throat. More swelling causes more upper airway narrowing, leading to more obstruction, which leads to more swelling.

 

The most dramatic example is what happens with mononucleosis. The Epstein-Barr virus which is thought to cause mono preferentially attacks lymphoid tissues. Your tonsils are made of lymphoid tissues, like the glands in your neck, armpits and groins. When your tonsils swell up for whatever reason (infection, irritation, inflammation), it narrows the throat, aggravating more frequent collapse, perpetuating the vicious cycle described above. This is why it takes a long time for mono to go away. In some people, the cycle never stops, leading to chronic fatigue syndrome. The physiologic consequences of this process can lead to hormonal, biochemical, and neurologic changes which may or may not show up on blood tests.

 

In this situation, it’s not that the tonsils are too big, but the jaws are too small, causing chronic inflammation and swelling, which keeps the tonsils larger than normal. This leads to further narrowing of the upper airways. It’s also been shown that you can have persistently enlarged lingual tonsils, which are lymphoid tissue at the base of the tongue in the midline. The size of lingual tonsils has been correlated to the level of reflux material in the throat. Your adenoids, which are lymphoid tissue in the back of your nose, can also become inflamed from colds or allergies, aggravating nasal congestion, which creates a vacuum effect downstream in the throat.

 

Ultimately, what’s more important than what’s infecting you is the size of your upper airway and how well your body is able to handle these infections. An underlying sleep-breathing problem can definitely aggravate your symptoms. This is why living by the principles that incorporate my sleep-breathing paradigm will help you to minimize or even prevent serious complications from any infection this winter season. My wife and I live by these principles and so far (knock on wood), so good.

 

Do simple colds lead to prolonged symptoms or repeated infections for you? If so, please explain in the comments box below.

Sleep Apnea and Breast Cancer: Is There A Connection?

There’s been a lot of press coverage recently about the new mammography screening recommendations for breast cancer. The United States Preventive Service Task Force recently recommended that women begin routine mammography screening at age 50, rather than 40. This is an important issue for me as my aunt died from metastatic breast cancer in her early 40s. 

 

One thing that I see over and over again is how obstructive sleep apnea can affect every aspect of your health, from your mood, to diabetes, to heart disease. You may think that cancer and sleep apnea are totally separate conditions, but with the human body, everything is ultimately connected in one way or another. This lead me ask the question: Do sleep apnea and cancer have a common origin?

 

In my practice, anytime I see a patient with a history of breast cancer, I almost consistently see the following: cold hands or feet, unrefreshing sleep, an inability to sleep on their backs, and a severely snoring parent, typically with cardiovascular disease. What’s remarkable is that when I examine their airways with a fiberoptic camera, the space behind the tongue is usually very narrow, especially when they lie flat on their backs. This anatomy leads to repeated obstructions and arousals, especially when sleeping on their backs and in deep sleep, when muscles relax the most. For this reason, these women prefer not to sleep on their backs.

 

In my book, Sleep, Interrupted, I describe a process where due to poor breathing and inefficient sleep, a physiologic stress state is created, which leads to lack of proper blood flow to certain parts of the body that are considered unimportant when you’re in a fight or running from a tiger. These areas include the digestive system, reproductive organs, your hands and feet, and your skin, amongst others. 

 

During periods of stress (whether internal/physiologic or external/emotional), there can be severe blood flow restriction to any of these body areas. As an example of how dramatic this can be, there’s a description of a man who was severely injured during battle, and most of his abdominal wall was missing, with his bowels clearly visible. While he was recovering in bed, his doctors noticed that whenever he was angry or in pain, his bowels were dark and dusky, whereas when he was happy, his bowels looked pink and healthy. Similarly, there can be dramatic fluctuations in blood flow to the breasts depending on the woman’s mood and stress-inducing states.

 

One common finding in both cancer and sleep apnea research fields is that hypoxia (lack or oxygen) in tissues can lead to production of signals that tell the body to bring in more blood and nutrients. As a result, a number of inflammatory mediators are released, including the well-known vascular endothelial growth factor (VEGF). VEGF promotes local growth of blood vessels in oxygen-poor areas. Imagine if this process happened all the time, with slow but gradual growth of local tissues, with activation of genes and proteins that promote more inflammation and more cell reproduction. 

 

We know that chronic overstimulation of any tissue can lead to cell replication that can go out of control. Chronic overstimulation of breast tissue can initially lead to localized benign growths or cysts, and some of these can end up transforming into malignancies. Perhaps some women with certain genes may be more susceptible to this transformation. This same process can also be described for prostate cancer.

 

Most younger breast cancer survivors probably won’t have obstructive sleep apnea if tested. But what they most likely will have is upper airway resistance syndrome, which results in multiple microscopic obstructions and arousals that prevents deep, efficient sleep. This can cause the nervous system to become hypersensitive, with increased physiologic states of stress. As they gain weight later on in life, many will progress into formal sleep apnea. 

 

Studies show that breast cancer survival is poorer in obese patients. Similar findings are also found with prostate cancer. This is possibly explained by the fact that the more obese you are, the more likely you’ll have obstructive sleep apnea. Having obstructive sleep apnea significantly increases your risk of dying in general.

 

Granted, what I’m describing here is a very different perspective in explaining breast cancer, and is sure to be controversial in some people’s minds. However, rather than trying to explain breast cancer from a molecular, genetic, or organ level, wouldn’t you agree that it’s much more satisfying when you can explain this illness from a whole-person perspective? As much as Western medicine tries to deny it by fragmenting care to different specialties, we know intuitively that whether it’s the breast, the heart, the mind or the prostate gland, everything is ultimately connected.

 

What’s your opinion on this important issue? Please enter your comments in the box below.

The 5 Dangers of Benign Snoring

Snoring is so common these days that it’s synonymous with sleep. In the movies or on TV, a sleeping person is depicted with snoring sounds. Even in the comics, the ZZZZZZZZs that you see coming from the sleeper may signify snoring.

 

Within the sleep community, we often use the term benign snoring to mean snoring without any sleep apnea. We see it as the least important form of obstructed breathing, without any medical consequences. Every time I see this in our medical journals or in the media, I get mildly annoyed, since there’s so much information to show that snoring is never benign.

 

Snoring itself is usually caused by vibrations from the soft palate. Think of a reed in a wind instrument, or a flag flapping in strong winds making lots of noise. In the human throat, any degree of abnormal narrowing of the throat promotes vibrations of the free edge of the soft palate. The loudest recorded snore was found in a British woman whose sound levels reached 113 dB, which is louder than a low-flying jet. There are other areas in the throat that vibrate and make sounds, but they’re probably a secondary effect of the soft palate vibrations.

 

Here are 5 reasons why snoring is never benign:

 

1. If you snore, you have a 35% chance of having obstructive sleep apnea, which is a potentially serious medical condition where you stop breathing multiple times every hour, leading to oxygen deprivation, heart disease, heart attack, and stroke. The best way to diagnose sleep apnea is to undergo a formal overnight sleep study. If you stop breathing at least 5 times every hour, with each episode lasting 10 seconds or longer, then you’re told you have sleep apnea. But what if you stop breathing 15 times every hour, but you wake up after 1-5 seconds for each episode? Then you’re told you don’t have sleep apnea, with no clear explanation why you’re so tired all the time.

 

2. It’s been shown experimentally in rabbits that artificially applying vibrations to the carotid artery causes thickening of the carotid artery walls, similar to what we see in humans with plaques.

 

3. Snoring without sleep apnea has been shown to increase your chances of being involved in a car accident.

 

4. Not only is snoring potentially dangerous for your own health, it also disrupts your bed-partner’s sleep quality, health, and relationships. There have been reports of bed-partners becoming deaf in one ear.

 

5. By not taking snoring seriously, it’s likely that you’ll delay diagnosing obstructive sleep apnea. Many people try various over-the-counter anti-snore aids with mixed results. Most end up giving up until the problem gets worse.

 

If you or your loved one snores, take it seriously and get it checked out by a sleep physician or an ear, nose and throat doctor. Even if you’re found not to have sleep apnea, treat the snoring. Just because the sleep study doesn’t say you have sleep apnea doesn’t mean that you don’t have a sleep-breathing problem.

Is the XMRV the True Cause Of Chronic Fatigue Syndrome?

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Copyright © 2008 Doctor Steven Y. Park, MD | New York, NY | Integrative Solutions for Obstructive Sleep Apnea, Upper Airway Resistance Syndrome, and Snoring · Design by Fervent