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My Quote in More Magazine About Alcohol and Sleep

Look for my quote in More Magazine about the effects of alcohol on sleep (under #3).

The Single Most Important Advice I Give

As physicians and surgeons, we like to think that offering medications or surgery is what makes the most impact, but I’ve learned over the years that it’s the simple lifestyle changes that make more of a difference in almost every chronic medical condition we have. It’s a humbling realization.

With every patient, I give a handful of conservative recommendations to being with. This applies to most routine ENT visits such as for sinusitis, ear problems, nasal congestion, throat pain, or hoarseness. In about 75% of my patients, I don’t give prescription medications at all on the first visit.

Of all the recommendations I make, the single most important tip I give to just about everyone is not to eat within 3-4 hours of bedtime. You may have heard this before from your doctor or from magazines or articles, but the reason why this is so important is not for the reasons that you may be thinking. I also stress that it’s not a recommendation—it has to be done, or your throat pain, sinus or ear problems won’t get better.

Traditionally, it’s thought that eating late slows down your metabolism. Another is that food doesn’t digest well since your bowels shut down while sleeping, thus converting the nutrients into fat. There are dozens of other explanations. Here’s an article on the benefits of eating early.

Here’s one that that makes sense: All modern humans have narrowed upper airway anatomy due to the fact that we can talk. Over the past 100 years or so, due to a radical change in our diets and eating habits, our jaws are not widening like they used to. This is why most people in Western countries need braces, since there isn’t enough space for the teeth.

This predisposes people to breathing pauses at night due to the tongue falling back (due to gravity when on our backs) and due to muscle relaxation in deep sleep. You can stop breathing multiple times every hour and not have obstructive sleep apnea. Every time you stop breathing, you’ll literally vacuum up your stomach juices into your throat, causing you to wake up into a lighter stage of sleep, and causing more inflammation and swelling, which causes more obstructions. Your stomach juices (acid, bile, enzymes and bacteria) can then go into your lungs and your nose, causing even more inflammation.

So the later you eat, the more juices you’ll have in your stomach, and the more it’ll come up into your throat. This leads to more frequent obstructions and arousals, leading to less efficient sleep. We know that poor sleep causes weight gain, hormonally, neurologically and biochemically.

Unfortunately, some people are very resistant to this recommendation since it disrupts their lifestyles or they have job schedules that make it very difficult. These are the people who keep coming back over and over again for more medications, and in the long term, many years later, being diagnosed with obstructive sleep apnea.

How many of you notice that you sleep much better when you eat early?

Are Ear Infections Linked to Childhood Obesity?

Here’s another interesting connection with an explanation that may surprise you. Researchers in South Korea found that children with chronic otitis media had measurable taste changes that could explain why these same children tended to be more overweight. This link between chronic otitis media and obesity has been made before, but this is the first time researchers showed what was suspected as a possible culprit: That chronic inflammation of the middle ear can adversely affect the taste-sensing chord tympani nerve, which travels through the middle ear. They showed that children with chronic otitis media had reduced taste capacity to sense sweet and salty flavors, and that this could make children eat more.

The problem with this study is that it doesn’t prove that having fluid in the middle ear causes obesity. It only shows a relationship. What’s more plausible is that these children have significant sleep-breathing problems that can lead to both ear infections and increased weight. We know that obstructive sleep apnea can lead to pharyngeal and nasal inflammation, which can prevent proper eustachian tube function. Poor sleep from poor breathing also promotes weight gain by increasing one’s appetite for sugary, fatty foods.

 

 

Hysterectomy Linked to Higher Risk of Renal Cell Carcinoma (via Sleep Apnea?)

I just happened to come across a study that showed that hysterectomy is associated with a higher risk of developing renal cell carcinoma. Furthermore, undergoing a hysterectomy at an earlier age increases your chances of renal cell carcinoma even more. There was also a small, but significant increase in the rate of bladder cancer. At first glance, this may have nothing to do with obstructive sleep apnea, but once I began to dig a bit deeper into the research literature, here’s how I connected the dots between hysterectomy and renal cell carcinoma:

1. Hysterectomy generally produces surgical menopause. The study didn’t mention what percentage of women also had their ovaries removed, but I’m willing to bet it’s a significant number. Menopause by definition causes sleep disturbances due to a drop in estrogen and progesterone. Progesterone acts as an upper airway muscle dilator, which helps to tense the tongue. Diminishing progesterone allows your tongue to become more relaxed, allowing more frequent obstructions and arousals. This causes less efficient sleep, leading to slow weight gain.

2. Weight gain narrows the throat even further, aggravating or uncovering obstructive sleep apnea. Poor quality sleep also produces vasomotor (or neurologic) symptoms such as night sweats, hot flashes, insomnia, irritability and mood swings.

3. Chronic hypoxia and physiologic stress on the body shunts blood and nervous innervation away from unnecessary body parts and organs when under stress, such as your digestive system, reproductive organs, skin, and your genitourinary system (which also includes your kidneys).

4. Obesity has been shown to be linked to increased risk certain cancers, including the colon, esophagus, prostate, kidney, gallbladder and in women cancer of the breast and reproductive organs. Notice that these are all digestive or genitourinary organs (expect for esophageal cancer, which is mostly due to reflux from apneas).

5. Here are the most common risk factors for renal cell carcinoma: age 50 to 70, obesity, smoking, and hypertension. Notice how all these are risk factors for obstructive sleep apnea as well. We know that nicotine can relax the lower esophageal sphincter, which aggravates more reflux into the throat.

Early menopause has also been shown to increase your risk of heart disease as well. Since we know that untreated obstructive sleep apnea is a major risk factor for heart disease, all these these findings are not surprising.

What do you think about the connections that I’ve made? Please enter your comments in the text area below.

Sleep Apnea and Childhood Obesity

Here’s another study that reinforces how important sleep is (quantity and quality) when is comes to your weight. Researchers reported in the Archives of Pediatric and Adolescent Medicine that too little sleep in children younger than 5 to being more likely to be overweight or obese five years later. It’s very commonplace for young children to stay up late because they want to or to accommodate the parents’ schedules. Routinely I see toddlers and preschool children being taken to the movies and staying up past 11PM.

What this study reports about is a lack in the hours of sleep, but with sleep, quality usually goes hand in hand with quantity. Staying up later usually means that you’re more likely to snack closer to bedtime, or eat a late meal. This causes increased inflammation in the throat and the entire upper breathing passageways, leading to more obstructions and arousals. Eating close to bedtime is one of the most common habits that leads to poor quality sleep. Fortunately, it’s the first and the most obvious thing you can do to improve your child’s sleep quality.

I realize that for some parents, eating earlier and putting their child to bed can be challenging, but if you look at the long-term health implications of continuing this habit, it’s too important to ignore.

How many hours do your children sleep? Please enter your responses in the comments box below.

Proven Weight Loss Strategies for Sleep Apnea Sufferers

My wife just commented to me that just by eating dinner about one hour earlier than usual for the past few weeks, she's automatically lost about 2-3 pounds. We normally eat about 3 hours before bedtime, but by the time we finish dinner and have fruit for dessert, it's about two and a half hours before we go to bed at 10PM. Even our children now seem less tired and more alert during the day. Although we decided to make this change to increase our sleep quality, my wife's weight loss was an unexpected side effect. So how does this apply to sleep apnea sufferers?

The Sleep Apnea Stereotype

At almost every sleep apnea lecture that I've seen in my career, the speaker almost always puts up a picture of Joe the fat boy from Dickens' The Pickwick Papers. If you read any scientific study about obstructive sleep apnea, it almost always starts with, "…typically seen in middle aged or older obese men who snore heavily with large necks."

Although described 30 or so years ago in these stereotypical men, now we know that it can occur even in young, thin women who don't snore. But many overweight people, especially as they get older, will snore or have obstructive sleep apnea. It's estimated that overall, about 24% of men and 9% of women will have it, but by the time you reach your 70 to 80s, the incidence about 55%. Being overweight is still a major risk factor for development of obstructive sleep apnea. If you're overweight and have sleep apnea, then it's much harder to lose weight than if you didn't have sleep apnea. Let me explain why.

How Hormones Affect Your Appetite

It's been proven that poor sleep (quality or quantity) can promote weight gain through various mechanisms. Leptin is one major hormone that provides information about energy status to your brain—essentially, it tells your brain that you have enough energy. Low levels of leptin causes hunger. Normally, leptin increases after you eat, but sleep deprivation lowers this hormone, making you hungry. As leptin drops, your cortisol levels will also increase. As I've mentioned numerous times in my book, Sleep, Interrupted, poor sleep efficiency cause a low-grade physiologic stress reaction that increases your cortisol levels. This hormone also makes you more hungry. Other studies have shown that not only will you be more hungry, you'll tend to crave fattier, sugary, high carb foods.

You can imagine how once this process starts, it's a vicious cycle: Poor sleep makes you more hungry, so you eat more or snack close to bedtime. More frequent obstructions causes your stomach juices to be suctioned up into your throat, causing more inflammation and swelling. These juices can then go into your nose and lungs, causing further inflammation and swelling. Weight gain then narrows your throat further, aggravating sleep apnea, which makes you sleep less efficiently.

First Steps Toward Losing Weight

So what can you do if you have sleep apnea and are overweight? Is it hopeless?

Fortunately, there are steps that you can take that if followed properly, can not only help most people lose pounds, but also sleep better in the process. The first and most important thing is to eat as early as possible before bedtime. I know I keep repeating this, but you'll be surprised by how many people continue to eat late or snack just before bedtime. Three to four hours is the general recommendation to avoid eating before going to bed. The only thing you can have is water within this timeframe. The same goes for any kind of alcohol, since alcohol relaxes your throat muscles, aggravating obstructions and arousals.

The second most important thing to do is to make sure that you can breathe well through your nose. If your nose is stuffy, the challenge is in figuring out what's causing your nasal congestion, since there are a number of different reasons. In many cases, there's more than one reason. This is a huge topic that I cover in my Ask Dr. Park teleseminar called Un-Stuff Your Stuffy Nose. I also have various articles and blogs about this issue on my website at doctorstevenpark.com.

Needless to say, you also have to eat healthy and exercise regularly. I'll leave the specific recommendations for other respective experts in this area. One thing to point out, though, is that if you lift weights or engage in any activity that bulks up your upper chest and neck muscles, remember that your upper airway is unprotected, and that that any degree of neck muscle enlargement and press in on your upper airway. This is why many bodybuilders and weightlifters snore.

Eating earlier helps to reduce inflammation and swelling in your throat, and better nasal breathing lessens the vacuum effect that's created in the throat when you breathe in while sleeping. These two steps alone (along with eating healthy and regular exercise) will help many people, but to various degrees. For some, making these conservative changes alone may be enough, but with others, they will need some form of formal treatment for their obstructive sleep apnea. I won't get into the treatment options for sleep apnea since that's a HUGE topic in itself. For more information about sleep apnea treatment, I have lots of practical information on my website or you can find one comprehensive resource by reading my book, Sleep. Interrupted.

Sleep More, Lose Weight

Lastly, most people in general are sleep deprived. Lack of sleep, in addition to inefficient sleep due to sleep-breathing problems, can also cause similar weight promoting issues. A great example is when Glamour magazine asked women volunteers to try to get consistently 7.5 hours of sleep every night for 10 weeks. Many women lost anywhere from 6 to 15 pounds, all just by sleeping more. Studies have shown that lack of sleep (5 hours or less) per night is a major risk factor for significant weight gain.

So whether or not you are overweight, the recommendations outlined above will help you to breathe better and sleep better. Even if you are thin and don't have obstructive sleep apnea, following these recommendations can the onset of sleep-breathing problems and ultimately lessen the risks that can go along with obstructive sleep apnea. If you are overweight, this is the first step toward losing unwanted pounds.

Is Your Throat Sore Just Before Your Period?

Here’s an interesting observation by more than a handful of my female patients: Their throats are sore for a few days just before their monthly periods. It doesn’t go on to a cold or other more severe symptoms. Just a transient sore throat. Then it goes away.

If you’ve been following my blogs, articles, and especially if you read my book, Sleep, Interrupted, there’s a simple explanation. During your monthly cycles, progesterone levels increase with ovulation, but drops when there’s no egg fertilization. One relatively unknown property of progesterone is that it’s an upper airway muscle dilator. It literally tenses your tongue muscles. When in deep sleep, your muscles (as well as your tongue and other throat muscles) tend to relax to various degrees depending on your sleep stage. If you have less progesterone on board, then it’s more likely to fall back, obstructing your breathing, leading to a temporary vacuum effect in the throat, suctioning up small amounts of normal stomach juices. All this causes a temporary deep sleep deficiency. If you eat a late meal, more of these juices will come up. But once progesterone levels begin to increase again, the tongue tenses, and sleep quality improves as well.

Sometimes, the inflammation in the throat increases to the point of significant deep sleep deprivation, leading to some of the more severe symptoms as pre-menstrual headaches, fatigue, irritability, and weight gain.

For you women out there, do you experience sore throats just before your periods? Please enter your responses in the comments box below.

A Link Between Sleep Apnea and Diabetes Confirmed Again

A Link Between Sleep Apnea and Diabetes Confirmed—Again

It’s almost a given that you’ll see headlines regarding sleep apnea every few days, about how it’s linked with heart disease, diabetes, high blood pressure, weight gain, and sudden death. Unfortunately, it’s gotten to the point where you’re likely to yawns at these findings because you’re so inundated with more interesting medical news and other celebrity media stories. Bare minimum, you might glance at the brief article and think, "that’s interesting," and then go on to the next story. 

 

Recently, there’s been news about the National Transportation and Safety Board making recommendations about mandatory screening for all commercial airline pilots, commercial truck drivers, ship pilots, and transit train operators, in light of many recent events including pilots that fall asleep and miss their destinations due to undiagnosed sleep apnea. Yawn.

 

A recent Johns Hopkins study showed that if you have severe sleep apnea, you have a 46% increased risk of dying compared with those that have mild to moderate sleep apnea. Yawn. We already know this information. Sleep apnea patients have a much higher risk of dying from heart attacks or strokes.

 

A study now shows that your risk of developing diabetes is 2-3 times higher if you have severe sleep apnea and you have daytime sleepiness. We already know that sleep apnea is independently linked to diabetes.

 

I guarantee that many more studies will be released repeating these same findings over and over again, linking or associating one variable to sleep apnea, without flat out saying that one causes the other. 

 

I wonder what will it take to significantly elevate sleep apnea awareness in this country? Celebrities with sleep apnea? We already have a few including Rosie and Regis. Politicians with sleep apnea? With the congress being mostly older men, I’m guessing about 1/3 to 1/2 of our leader have at least some degree of sleep apnea.

 

I Confess—I Broke My Own Rule

I admit it—I broke my own rule. I had apple pie just before going to bed Sunday night. My 6 year old son and I made apple pie from scratch. We made two pies—one for the family and one for our friends that were coming over that evening. We waited patiently as it cooled after taking it out of the oven. My two boys were salivating and eying it all evening. When it was eventually served, it was a hit. But I literally didn’t have time to taste my own pie, since I was too busy making arrangements for our guests. Later that evening, after our guests had left and we finished cleaning up, I just had to have a slice of my pie. I knew that I was going to turn in to go to sleep within 30 minutes, but I still had to eat it. The next day, I paid the price.

 

One of the most common pieces of advice that I give is that you should try not to eat within 3-4 hours of bedtime. There are lots of explanations for why this can lead to weight gain and poor sleep. One such explanation is that having food in your stomach diverts energy and blood to the stomach, depriving the rest of the body the energy needed to rest and regenerate. Another is that it slows down your metabolism. What most people (and doctors) don’t realize is that the more juices you have in your stomach when you go to sleep, the more likely it’ll come up into your throat, leading to poor sleep. 

 

As mentioned in my sleep-breathing paradigm (in my book, Sleep, Interrupted), all modern humans stop breathing once in a while when sleeping, due to our unique upper airway anatomy and our ability to talk. Muscle relaxation during deep sleep leads to these partial to total obstructions. If these episodes happen very often, for longer periods, then this is what we describe in medicine as obstructive sleep apnea. But obstructive sleep apnea is not something you develop suddenly in your 50s or 60s. All of us have minor variations of it at certain times in our lives (during colds, when we gain weight, or during pregnancy for women). All of us are on a continuum.

 

Once you stop breathing (but before you wake up and turn over), a vacuum effect is created in your throat, which can literally suction up your normal stomach juices into your throat. This not only causes you to wake up from deep to light sleep, but also causes the all-too-common symptoms of post-nasal drip, throat clearing, chronic cough and hoarseness, usually worse in the morning.

 

When I woke up in the morning the night after I ate my apple pie, my throat was a little sore, but what really got my attention was the fact that I felt like I only slept for 5 hours, rather than the 7 that I got that night. I was also more tired than usual all day long.

 

It’s not too surprising that sleep length, sleep efficiency, energy, appetite, and weight loss are all directly or indirectly connected. Yesterday, I saw a child in the office who stated that his sleep quality improved dramatically once he stopped eating ice cream before bedtime.

 

If any of you eat close to bedtime, and don’t sleep well are tired during the day, I challenge you to make it a regular habit to eat earlier for the next 4 weeks. Then let me know on this blog when you feel better. I’m confident that you’ll sleep better and feel better. 

 

By the way, if you want the recipe for my apple pie, just let me know. It’s from a Mrs. Fields recipe book.

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