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UARS: The Hidden Sleep Condition

You’ve gained some weight over the years and you’re just not sleeping well. Your husband says you’ve begun snoring. You know that your father has obstructive sleep apnea and is doing well with CPAP. You mention this to your doctor and she orders a sleep study. The sleep study comes back completely normal. Now what?

The Real Reason for Your Chronic Fatigue

Before you begin searching for other reasons for your chronic fatigue, don’t rule out a sleep-breathing problem too quickly, even if you don’t have obstructive sleep apnea. In fact, a sleep-breathing problem can cause if not aggravate conditions such as hypothyroidism, chronic fatigue syndrome, depression, insomnia, and even irritable bowel syndrome.

Sleep doctors have defined obstructive sleep apnea as having at least 5 apneas or hypopneas every hour on average. An apnea means you stop breathing completely for 10 seconds or longer. Hypopneas are similar 10 second or longer pauses but with restricted airflow. But what what happens if you stop breathing 25 times every hour but each episode lasts only a few seconds?

In the early 1990s, Dr. Christian Guilleminault of Stanford University looked at young, thin men and women who were tired all the time, no matter how long they slept. These people were found not to have obstructive sleep apnea after undergoing formal sleep studies. However when they placed thin pressure catheters in their chest and throat, they found the they had frequent episodes of partial obstruction which led to subtle, but significant limitation of nasal airflow, along with very negative vacuum pressures in the throat. Most of these minor episodes were not apneas or hypopneas, but still lead to an arousal—from deep to light sleep. What was happening was multiple partial obstructions and arousals that were not severe enough to be called apneas or hypopneas, but enough to wreak havoc on deep sleep quality.

It’s been shown that even very subtle levels of restricted breathing can lead to deep brain stimulation and arousals that prevents your ability to stay in deep sleep. These reflex signals to the brain can be so weak that it doesn’t even reach the outer layers of the brain where standard scalp electrodes can pick up these disturbances.

Blame It On Your Parents (And Your Jaws)

The fundamental problem in UARS is due to smaller upper airway anatomy, caused by having smaller jaws and dental crowding. The smaller the space behind the tongue, the more likely you’ll obstruct while breathing when on your back (due to gravity, the tongue can fall back), and when in deeper levels of sleep (when your muscles relax). This is why most people with UARS can’t, or prefer not to sleep on their backs. The problem is that you can still have breathing problems despite sleeping on your side or stomach, just not as bad as being on your back.

Lack of sleep and especially lack of deep sleep has been found to cause a whole host of physiologic changes. In general this happens due to chronic overstimulation of your sympathetic nervous system. This is the fight-or-flight half of your involuntary nervous system. Since your body thinks it’s under attack, it heightens your nervous system, making you en garde, edgy, hypersensitive or overreact to normal situations. This also leads to diversion of blood flow, energy and resources away from less essential body parts and organs, such as your digestive system, reproductive organs, skin, hands, feet, and other “end organs.”

Due to this “hypersensitivity,” the nose and sinuses can be overly sensitive, reacting to stimulants such as weather changes, chemicals, scents, and even allergies. Chronic stress that results from sleep deprivation also can heighten your immune system.

Is It Hormones or Your Breathing?

A number of other studies point out that UARS patients are more prone to have cold hands or feet, hypothyroidism, irritable bowel syndrome, depression, chronic fatigue, and various other “somatic” syndromes. I see this all the time in my practice. In fact, a recent study even showed that chronic long-term sleep deprivation caused significant lowering of the TSH and T4 levels, with women being much more susceptible to this effect compared with men.

With time, as people age, and especially as they gain weight, most people will progress into true obstructive sleep apnea. You’ll find that most younger, thinner people with UARS will have one or two parents with significant obstructive sleep apnea.

Now that you’re convinced that you may have this condition, what can you do about it? For the most part, it’s treated just like obstructive sleep apnea. You should start with all the conservative options first, such as weight loss (if you’re overweight), diet, exercise, improving your nasal breathing, and not eating late. If these options don’t work, then all the formal options for treating obstructive sleep apnea are possible including CPAP, oral appliances, and even surgery.

Unfortunately, if you don’t officially have a sleep apnea diagnosis based on a sleep study, then insurances generally won’t cover any of the treatments. The irony is that our health care system won’t treat or prevent diseases in the early stages, and would rather wait until it’s much more severe before covering for medical services.

If you think you may have upper airway resistance syndrome, you may be disappointed to find that the medical community in general will not be responsive to your queries. With a few exceptions, many sleep doctors are not convinced that UARS is even a legitimate condition, and would rather lump it into the spectrum of snoring to obstructive sleep apnea. Time after time, whenever I see patients who are told they don’t have obstructive sleep apnea and I treat the upper airway narrowing and inflammation, patients almost always feel better. Your best option is to continue to educate yourself and be persistent. Your first priority should be to be able to breathe better so that you can sleep better.

Raynaud’s and Sleep Apnea

There was an interesting Q&A article on Raynaud's in the New York Times. This is what I responded with:

 

Notice how almost everyone one of you with Raynaud's can't (or prefer not to) sleep on your back. The reason for this is that due to smaller jaw structures and narrowing of your upper airway, you literally can't breathe properly when you sleep. When normally on your back, your tongue fall back partially due to gravity. But if you have a smaller mouth, the tongue takes up relatively more space and falls back a bit more completely. This becomes a problem when when you're in deep sleep, since all your muscles (including your throat muscles) begin to relax. In this situation, you'll stop breathing and wake up to turn over to your side or stomach. This is something that began when you were a child, and most people compensate by normally sleeping only on their sides or stomach. 

Problems occur when you're suddenly forced to sleep on your back, such as from an injury or after undergoing an operation

Despite being able to compensate by avoiding the back position, it's usually not good enough. By definition, you won't be able to achieve deep, efficient sleep, which causes a low-grade physiologic stress response. This activates the sympathetic (fight or flight) nervous system which tends to constrict blood flow and nervous innervation to low-priority organs and body parts, such as your hands, feet, skin, digestive and reproductive organs. This is also why Raynaud's is also associated with autoimmune conditions.

Chronic low-grade physiologic stress over-activates your immune system, resulting in your body attacking its' own tissues. Not only is your immune system over-reactive, but your nervous system is also overly activated, leading you to be en garde, edgy, and hypersensitive in general. These symptoms are seen often in people with upper airway resistance syndrome.

Inefficient sleep leads to chronic fatigue issues. But most people compensate by staying active during the day, or participating regularly in intense physical activity.

Typically, most people with Raynaud's improve as they get older. But as you gain weight, many of you will begin to develop obstructive sleep apnea. Notice how one or both of your parents may snore heavily and have have cardiovascular disease. If you don't gain weight, then your Raynaud's may last longer. 

This is also why anything that helps to calm your nervous system (meditation, yoga, acupuncture, biofeedback, etc.) can help your symptoms. It also explains why when the breathing problem is taken care of definitively, Raynaud's symptoms can improve.

Reflux And Spontaneous Arousals In Mild Sleep Apnea

Gastro-esophageal reflux and laryngopharyngeal reflux disease are commonly seen in patients with obstructive sleep apnea. Many of you will have the typical throat clearing, post-nasal drip, chronic cough or hoarseness that's seen with laryngopharyngeal reflux disease. Sleep apnea causes your normal stomach juices to leak up into the throat, which not only causes you to wake up, but also causes swelling and inflammation in the throat. 

 

We know that any form of breathing obstruction (apnea, hypopnea, RERA) can cause you to wake up. But what's not too commonly known is the fact that any degree of acid in the throat can stimulate certain chemical receptors, which causes you to wake up so you can swallow. It's thought that this is needed to prevent aspiration of stomach juices into your lungs. 

 

A recent Japanese study not only confirmed these concepts, but found an interesting additional observation: While people with severe obstructive sleep apnea have mostly arousals due to  breathing pauses, those with mild to moderate sleep apnea have a higher number of spontaneous arousals. Spontaneous arousals are noted on a sleep study when your brain waves go from deep sleep to light sleep or temporary awakening, without any objective evidence of breathing pauses.

 

What this study doesn't address is the fact that it's not only acid that comes up into the throat when you stop breathing. Your stomach juices also contain bile, digestive enzymes, and bacteria. An obstruction causes a tremendous vacuum effect that's created in the throat, literally suctioning up your normal stomach juices. This initial obstruction will lead to the typical respiratory arousal, but lingering juices will irritate the throat leading to spontaneous arousals. Think of your stomach juices as a sort of sensory form of stimulation, like a loud noise or a bright light. Your throat has a number of very sensitive chemical and pressure receptors that can cause your brain to wake up, without any physical obstruction.

 

There are also studies that show that chronic exposure to acid can make pressure sensors less sensitive over time, leading to longer and longer pauses with each obstruction.

 

Furthermore, there's research showing that some of these arousals don't ever show up on routine brain wave leads during a standard sleep study. This is because these protective reflex signals are so minimal that they stay in the deeper levels of the brain, never reaching the outer cortex.

 

I've always felt that spontaneous arousals are somehow related to breathing pauses. This study only confirms my suspicion that too many spontaneous arousals may be a sign of upper airway resistance syndrome or early obstructive sleep apnea. 

 

What's your opinion on this? Do you have laryngopharyngeal reflux disease?

 

 

 

 

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.

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