Wellness

Sleep Apnea Is More Common
Than You Think

The vast majority of people in the world who have sleep apnea don’t know it. That wouldn’t be a big deal if you ignore the fact that the consequences of sleep apnea can range from heart disease to weight gain to depression. “Many believe it’s a vicious type of loud snoring, like in a movie,” says Dr. Param Dedhia, the director of sleep medicine at Canyon Ranch in Tucson, Arizona. In fact, sleep apnea is a sleep-related breathing disorder (from the Greek word “apnous,” meaning breathless). There are two main types:

Obstructive sleep apnea: The most common, this is a full or partial obstruction of the airways during sleep for ten seconds or longer. The obstruction can be at the level of the nose, behind the tongue, or in the throat.

Central sleep apnea: Less common, this is a failed signal from the brain to the muscles responsible for controlling breathing.

(It’s also possible to someone can have a combination of the two.)

The symptoms can be subtle, says Dedhia, who dedicates a large part of his practice to working with people who may have the condition—many of whom are in denial. “Quite often, I talk to my patients about it, and they respond, ‘Oh no, I don’t have that,'” he says. “This makes me chuckle. They’re sleeping, so how do they know?”

The number of people who don’t realize they’re living with sleep apnea is high. Studies show that 80 percent of sufferers go undiagnosed—and there are already about 18 million American adults who have been diagnosed. While some of the signs are what you might expect–daytime fatigue, lack of concentration, a feeling of mental or emotional disconnection—others, like cardiovascular disease, aren’t as obvious and can be potentially life-threatening. Dedhia’s approach to diagnosing and treating the disorder is holistic: “When you treat somebody’s sleep, you’re also talking to them about how they eat, how they move, and how they live,” he says. “It’s such an important conversation to have, and one of the reasons why I love what I do.”

A Q&A with Dr. Param Dedhia

Q

What are the signs and symptoms of sleep apnea?

A

Snoring is the most classic sign and symptom of sleep apnea—a loud snore before a ten-second pause followed by more snoring, gasping, or a choking sound. However some people may have heavy breathing followed by the pause of ten seconds before a sigh or more labored breathing. This points out that there is a wide spectrum of presentations of sleep apnea.

Another classic sign is sleepiness. If you’re not breathing well while you sleep and you’re not getting a healthy delivery of oxygen at night, you’re likely not getting the quality rest and recovery you need. That, in turn, can affect your physical, mental, emotional, and spiritual wellness, and it can be stressful on the body. This is why I often ask my patients about other aspects of their life, such as how they feel during the day and how their concentration at work is. Someone suffering from sleep apnea may experience an energy dip in the middle of the day. I often check my patients’ blood pressure, check family history, and inquire about alcohol use and other substances—such as sedatives, anti-anxiety medicines, and muscle relaxants—which can all have an effect on one’s breathing during sleep.

Physical signs that point to obstructive sleep apnea include:

  • A thick neck: Weight gain can go both outward and inward. The latter can crowd the airway and obstruct it.

  • A small jaw: This often leads to a smaller airway and potential obstruction.

  • A smaller, narrow nose: Another indicator of a smaller airway, this can also mean a deviated septum.

  • Nasal congestion or nasal fracture.

It’s important to note these are classic risk factors, yet more people that I am seeing do not note these. Many people have nontraditional risk factors that include a crowded airway when looking at the back of their throat, waking up with dry mouth or headaches, atrial fibrillation, or weight gain or trouble with weight loss that doesn’t seem to correlate with their nutrition and exercise. What amazes me is that these are clues when someone actually denies being sleepy. Some people come in to my office complaining of their partner’s snoring; others talk of daytime fatigue or a lack of mental concentration. And some just feel they have a mental or emotional disconnection with the world.

Q

How is it diagnosed?

A

The gold standard is a formal sleep study—called a polysomnogram­ or -graph—in a fully equipped lab, which is recommended by the American Academy of Sleep Medicine. Unfortunately, this isn’t always an option, as many insurance companies don’t cover it (and it can be expensive). A popular alternative is a home sleep study. It can be a decent option if you have a straightforward medical history, but sometimes important things can be missed. Home sleep studies are not recommended if you have severe pulmonary disease, neuromuscular disease, or congestive heart failure. Moreover, they are not recommended if you have suspected central sleep apnea, restless leg syndrome, sleep walking or talking, circadian rhythm disorder, or narcolepsy. For a home sleep study to be the most effective, it’s important to have a straightforward medical history for your doctor.

If you’re not breathing well while you sleep and you’re not getting a healthy delivery of oxygen at night, you’re likely not getting the quality rest and recovery you need. That, in turn, affects your physical, mental, emotional, and spiritual wellness.

In diagnosing sleep apnea, something called the AHI (Apnea-Hypopnea Index) is used. This measures the number of apnea (a full collapse of the airway for ten seconds or longer) and hypopea (partial collapse of the airway for ten seconds or longer) events. A severe example would be a full collapse of the airway for ten seconds or longer–what people think of as “classic” sleep apnea. Lastly, the AHI determines the number of events per hour of sleep: Zero to five times per hour is considered normal (we can all have a little mucus or to be a little stuffy at times), five to fifteen is mild, fifteen to thirty is moderate, and above thirty is severe.

Q

What are the risk factors?

A

There are many potential risk factors, which include:

  • Weight gain: This is one of the most significant causes, and it can have multiple effects. Sleep deprivation can cause someone to be hungry and crave sugar and fat. It also prevents the body from optimizing the production of testosterone, which helps repair the body. When looking specifically at weight issues, oftentimes you have to help the patient sleep so they can engage in a healthier lifestyle; otherwise there a vicious cycle with weight gain and sleep apnea can develop.

  • Physicality: A small jaw, small nose, etc., outlined above.

  • Hormonal changes: Estrogen and progesterone help to maintain the integrity and strength of the airway muscles, but as these hormones decrease after menopause, the tissues become softer and more susceptible to collapsing.

  • Anxiety and sleep medications: These include well-known benzodiazepine receptor agonists Xanax, Ativan, Restoril, and nonbenzodiazepine receptor agonists Ambien, Sonata, and Lunesta—all of which can mildly relax the airway.

  • Allergies: About 50 percent of the people who come into my office have nasal passages congested due to high pollen counts and other allergic reactions.

Q

What are the risks for sleep apnea sufferers?

A

When you have severe sleep apnea, your oxygen level drops, increasing the risk for cardiovascular events, such as heart attacks. It also poses a risk for arrhythmia, sudden cardiac death, stroke, early memory change, depression, prediabetes, and or diabetes.

Sleep apnea also affects one’s quality of life, including daytime performance at work, along with mental and emotional health.

Q

Who’s most likely to be affected?

A

Men of all ages are at risk for sleep apnea. Women are more at risk after menopause because of decreased estrogen and progesterone, as noted above.

Approximately 50 percent of people with atrial fibrillation, an irregular heart rate, have sleep apnea. With atrial fibrillation, the top chambers and the bottom chambers of the heart are not in unison, which can inhibit the blood from flowing smoothly, potentially leading to clots. If you don’t treat the sleep apnea, it’s harder to maintain the heart in proper rhythm.

Q

What are the treatment options?

A

The level of severity will determine how best to approach sleep apnea. There are many methods and options:

CPAP (Continuous Positive Airway Pressure) Machine: This is basically a very sophisticated fan or blower that is connected to a mask while sleeping. It maintains one continuous pressure during the entire sleep night.

There are specialized CPAPs called autoPAPs that allow for an assessment every three breaths; with every three breaths, the machine senses the resistance in the airway and increases or reduces the pressure accordingly. During exhalation, the pressure drops slightly to allow for easier expiration, but it does maintain some pressure so that there is enough air in the airway to allow it to stay open and not collapse.

Bilevel PAP (Bilevel Positive Airway Pressure) Machine: Also worn as a mask while sleeping, this device delivers air at a higher pressure.

What’s great about today’s breathing machines is that they can adjust according to your needs. For the first week or sometimes longer, I sometimes give somebody a sleep aid to help them get used to the machine (this technique is a bit controversial). But if someone doesn’t like the sleep machine the first week, how likely are they going to like it the second or third week? They already feel beat up by their sleep situation, so why would they want to feel as if they were getting beat by something new? Sometimes I ask my patients to wear it for an hour during the day to help them get used to it. For the right person, these machines can be a life changer. When you see somebody finally getting real quality sleep, it’s amazing.

Dental appliance: Custom-made by a specialty dentist, it fits into the mouth and moves the lower jaw slightly forward, allowing for an open airway. These can be helpful for mild sleep apnea and/or positional sleep apnea, when someone is not breathing well on their back but normal when they’re on their side. A dental appliance can be worn alone or sometimes in conjunction with a sleep machine. It is important to go to a specialist, because without the proper custom fitting and adjustments, dental appliances may lead to TMJ (temporomandibular joint) syndrome.

Surgery:

  • UPPP (Uvulopalatopharyngoplasty): An older surgery, this procedure entails removing excess throat tissue, including tissues from the tonsils and uvula. It works about half the time–and takes approximately three months to recover from.

  • DISE (Drug-induced Sleep Endoscopy): This is a very exciting development in the field. It involves giving the patient an anesthesia to mimic sleep, then putting a small wire camera through the nose to look down the airway to discover the obstruction. Since we don’t have the ability to put the camera in people when they are naturally sleeping, this requires a leap of faith that the anesthesia-induced state is much like natural sleeping. It is important to know where the obstruction is in order to review the surgical options and determine the best procedure for the person.

Saltwater rinse: Sometimes it’s a matter of simply opening up the nasal passage, which can be done with a neti pot. Another option is a Breathe Right Strip that helps flare out the nasal passages.

Q

Does snoring automatically mean someone has sleep apnea?

A

I love this question. It does not. If we screened everybody who snores, we’d find that about one third of the time, snoring is just snoring, and the other two thirds of the time, some level of sleep-related breathing disorder is involved. The important aspect of snoring, which I don’t see enough written about, is the effect it can have on bed partners. One person’s sleeping affects the person they share a bedroom with. So if you look a one person’s breathing, he or she may or might not have sleep apnea, but their snoring can still be negatively affecting the person next to them physically, emotionally, and spiritually.

Q

Does sleep position play a role?

A

Some people have what is referred to as positional sleep apnea: Many people find when they are on their backs, they don’t breathe as well. While in this position, your tongue, tonsils, and other soft tissue fall back, causing possible obstruction. If you turn your head or sleep on your side, you may breathe easier. A classic example is that person who is snoring on their back, and their bed partner gives them a little poke to roll onto their side, which stops or reduces the snoring. There are various ways to train people to sleep on their side, as well as different sleeping devices and pillows. Dental appliances can be very helpful for positional apnea.

Q

Any lifestyle changes that can make a difference?

A

There are many lifestyle choices that can play a factor in preventing or treating sleep apnea:

  • Being mindful of alcohol consumption: Ever notice that people snore a little more after a nightcap? Many people drink to try to relax, but this causes the airway muscles to relax as well, which can induce a form of apnea or worsen a current apnea. So—not trying to be a killjoy—I tell my patients to enjoy their beer, wine, or spirits, but not close to bedtime.

  • Maintaining a healthy weight.

  • Honoring our mental, emotional, and spiritual health: What we do during the daytime affects our nighttime sleep. So it’s important to move, eat well, honor our emotions, and have a healthy ritual before bed. This is why there always needs to be a complete conversation to help people optimize their sleep and get them the right treatment. Getting at people’s stories, finding out who they are day in and day out, and helping them shift mentally, emotionally, spiritually is what makes a real difference. We’re not our cholesterol number, our blood sugar number, or our AHI number; we are our connections to our family, our passions, and our emotions. To help people get to sleep and stay asleep, we need to honor all those levels of who we are.

Dr. Param Dedhia is a physician, weight loss program leader, and the director of sleep medicine at Canyon Ranch in Tucson, Arizona. He went to Canyon Ranch from Johns Hopkins University, where he served as a hospital-based internist and as an assistant director at both the Johns Hopkins Weight Management Center and the Johns Hopkins Geriatric Education Center. He received his medical degree from Michigan State University’s College of Human Medicine, where he cultivated his passion for internal medicine along with nutrition and exercise science. Param is board-certified in internal medicine, sleep medicine, and obesity medicine and is fellowship-trained in geriatric medicine and integrative medicine.

The views expressed in this article intend to highlight alternative studies and induce conversation. They are the views of the author and do not necessarily represent the views of goop, and they are for informational purposes only, even if and to the extent that this article features the advice of physicians and medical practitioners. This article is not, nor is it intended to be, a substitute for professional medical advice, diagnosis, or treatment and should never be relied upon for specific medical advice.

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