Monday, September 15, 2008

Commitment And Consistency

One of my greatest frustrations is when I reveal to a patient that a major cause of his or her underlying medical issues (such as high blood pressure, dieabetes or weight isues) are from untreated obstructive sleep apnea. Most people are ecstatic about finally finding an answer to many of their medical problems and are excited to find how how to go about treating it. But there are some individuals that give me a blank stare, with a glazed over look in their eyes. Some are even adamant that they know that they don't have obstructive sleep apnea.

At this point, I go over again all the reasons I think they have sleep apnea, but only some are convinced. The rest go on treating their end-stage symptoms such as migraines and chronic throat pain with either pain medications or acid reflux reducers, which may help temporarily, but the problem usually comes back. Many of these same people will come back months or years later after worsening of their problems, admitting that "you were right."

This phenomenon reminded me of a psychology book I read a while ago called Influence: The Psychology of Persuasion, by Dr. Robert Cialdini. One of the principles that he describes is commitment and consistency. He states that humans prefer to think the same way, act the same way, and take comfort in the consistency of their ways. In their minds, they've already committed themselves towards repeating the same steps every time.

For example, if you've been taking high blood pressure medications for 20 years, and you're suddenly told that it was actually obstructive sleep apnea that caused it in the first place, how would you respond? If you've suffered from migraines all your life, how would you respond to being told that not sleeping efficiently due to partially obstructed airways can aggravate migraines? Being told something that completely refutes the daily actions (taking pills) you've taken for 20 years. It also conflicts with what your doctor said about your health.

If you were told something by your doctor that completely went against what you've revolved your life around for years, how would you respond, and how do you think your doctor should handle this situation? I'd like your feedback.

Saturday, September 13, 2008

Snoring May Cause Strokes

We’ve always known that that heavy snorers are at increased risk for stroke. But a recent study from Australia showed that carotid artery narrowing in the worst snorers was 10 times higher than those who snore the least. In typical scientific journal fashion, a much larger sample size was said to be needed to establish a casual relationship. You can read a layman’s summary here from the New York Times. The authors proposed that perhaps vibrations themselves can damage the thin inner wall lining, leading to plaque buildup and eventual narrowing.
There are many more published articles that associate snoring with stroke. We know that a significant percentage of people who snore will have obstructive sleep apnea, and sleep apnea is strongly linked to stroke. The frustrating thing is that despite regular reports like this that warn of the the dangers of snoring, people continue to equate snoring as something to be laughed at and doctors continue to treat the end effects of obstructive sleep apnea (such as hypertension, diabetes, depression, anxiety, heart disease, heart attack and stroke). At least once per week, I see a younger snoring patient that tells me that his (or her) father snored heavily and suffered a stroke or a heart attack in their 40s or 50s. The frightening thing is that we know now that you don’t even have to snore to have obstructive sleep apnea.

Do you have a parent that snores heavily, and if so, did they suffer from a stroke or a heart attack at a relatively young age?

Wednesday, July 2, 2008

Can Obstructive Sleep Apnea Lead to Alzheimer's?

Sleep apnea and Alzheimer's are not commonly known to be associated, but a recent study in the Journal of Clinical Sleep Medicine reported that the greater the severity of one's sleep apnea, the greater the chance that you'll have what are called lacunar infarcts in your brain on an MRI study. Lacunar strokes (or infarcts) occur when small vessels supplying a specific part of the brain gets blocked and can show up on an a CAT scan or MRI as multiple small lesions. These areas correlate with small areas of dead brain tissue in the distribution of small arteries. In the study, 54% of people with severe OSA, and 12% with mild OSA, were found to have lacunar infarcts. All these people were asymptomatic neurologically at the time of testing. Their conclusion was was people with severe OSA have a higher incidence of silent cerebrovascular lesions than their counterparts with less severe OSA.

An interesting finding, in light of the fact that Alzheimer's is now thought to be a disease of small vessels in the brain. There's still a lot of controversy about the clinical significance of incidental lacunar infarcts on an imaging study, but I think you would agree with me that having dozens or hundreds of these small areas of dead brain tissue is not good for your memory. Add to this all the research studies that show that people with OSA are more likely to clot due to increased inflammation in general. Others studies have shown that people with lacunar infarcts have a higher incidence of heart disease. Over 80% of people with OSA are not diagnosed in this country. OSA is known to be strongly linked to heart disease. The links go on and on.

Do you think this is a valid association that's worth further research, or am I taking the sleep-breathing paradigm a little too far?

Friday, June 20, 2008

What You Must Know About Sinus Headaches

Many of my patients come to see me for their severe sinus headaches with pain, pressure, sinus congestion and pure misery. Most are surprised, if not shocked, when I tell them that their sinus headache is really a variation of a migraine attack in their sinuses. Some don't believe me at all. Many of these same patients can also have mild nausea, light or sound sensitivity. Some have none of these other symptoms. The true test lies in their response to an anti-migraine medication, whether an OTC or prescription medication. Some of my patients respond very well to Excedrin Migraine, a common OTC medication. Others respond to prescription medications for migraine, such as Imitrex.

A recent paper presented at the 111th meeting of the Triological Society's Combined Otolaryngology Spring Meeting, showed that a class of migraine aborting medications (tryptans) brought relief to more than 80% of sinus headache sufferers. They gave these people with normal CAT scans a 40 mg dose of eletriptan and another dose two hours later if not improved. Overall, 31 out of 38 patients achieved 50% or greater relief of symptoms, and another 8 went on to respond to a different type of tryptan medication (82% response total).

The study's findings mirror what I've been seeing in my practice for the past few years. What the presenters don't explain, however, is why these sinus headaches (migrianes) are happening. Again this is another example of covering up a symptom, without getting to the root cause of the problem. What I've found is that almost every one of these patients have problems sustaining deep sleep due to poor breathing at night. By helping them breathe and sleep better, helping them adjust their eating habits and timing, and by calming and relaxing the stress responses that builds up, patients overall feel much better.

Do you suffer from sinus or migraine headaches? If so, how much does it affect your life?

Wednesday, June 11, 2008

SLEEP Meeting 2008 Summary

I spent all day yesterday at the SLEEP 2008 national meeting in Baltimore. I  went to qualify various home testing options (I have three to choose from), but I wanted to mention in this blog a few interesting companies and products that I  saw.

Cure for Insomnia?
For people with severe insomnia, I've mentioned cognitive behavioral therapy or CBT. It's been found work better than sleeping pills, and many people can stop taking these pills as well. The problem has been that it's very labor and time intensive. I was pleasantly
surprised to see an online version of CBT, developed by a Harvard insomnia researcher. Check it out here.

Elephant CPAP Mask
I was walking by a booth and I did a double take, as I thought I saw an elephant's nose. I turned around and saw this device in the picture below. It's made of a soft fabric and it allows you to sleep on your side with no rigid tubing or plastic mask to get in the way. You can find out more information or order it here
Football Helmet for Sleep Apnea?
Many people hate CPAP because they can't sleep on their stomach, face down. The mask and the tubing comes off when this is attempted. A device that I saw looks almost like a football helmet but on closer inspection is a light plastic helmet with  thick rounded bars (like a face mask) in front of the face to accommodate for the CPAP mask and tubing. It's patent is pending and may take another 1-2 years to become available. You can see the design at

After many hours of walking, my tired feet took me to a company called "Happy Feet." Not the penguin movie, but a shoe insert that's filled with glycerin that massages your feet when walking. I bought a pair and so far so good. You can check them out here.

Thursday, May 29, 2008

An Important Reason to Breathe Through Your Nose

In an article about the importance of form and function with regard to the face, one interesting point that was made was the fact the our noses (mostly our sinuses) make nitric oxide (NO), a gas that acts as a powerful vasodilator. When inhaled into the lungs, it promotes oxygen uptake. This is why we're told when running to inhale through your nose and exhale through your mouth. What this implies is that if you're a chronic mouth breather, you may be depriving yourself of oxygen.

Searching further on Pubmed revealed an interesting study: humming increased nasal production of NO 15 fold as compared with quite breathing. They hypothesized that oscillating nasal breathing as a result of humming could explain this process. It's also interesting to note that rapid short nasal breathing taught in yoga classes may have a similar effect.

I strongly recommend that you read the entire article (it's a little long). It's an interesting read about how poor development of our facial bones could be leading to many of our medical ailments today. I can't agree with everything stated in the article, but I do agree with most of the article and the basic fundamental arguments. It parallels and supports all the major concepts that I discuss in my forthcoming book, Sleep, Interrupted. It also references Dr. Weston Price's book, which I use as a one of the foundations for my book.

Saturday, May 3, 2008

Why Women Can't Sleep in Menopause

An article in WebMD reports on a research study showing that difficulty sleeping was the most common complaint among post-menopausal women. The study recruited 110 women and asked them to rate the severity or persistence of the following symptoms: hot flashes, day sweats, night sweats, vaginal dryness, sleep difficulties, mood issues and forgetfulness. Trouble sleeping came in as the most common complaint, followed by forgetfulness, hot flashes and irritability. Based on what I’ve been talking about from my sleep-breathing paradigm, this is not too surprising. I’ve always said that many of the common symptoms of menopause are sleep-breathing disturbances. The one missing link in all the studies, commentaries and articles on menopause is the inability for women to breathe properly at night as a direct result of increasing tongue muscle relaxation during menopause.

Progesterone is one hormone that has been shown to promote tongue muscle tone, and the slow decrease during the menopause years can produce the common symptoms of menopause. So it’s not a direct result of dropping menopause levels, but worsening upper airway patency leading to more frequent micro-obstruction and arousals, preventing deep sleep. I’ve written in the past about young men coming to me complaining about night sweats, hot-flashes, mood swings, irritability, weight gain and insomnia. These men were slowly gaining weight, progressing up the sleep-breathing continuum. The gradual narrowing of their upper airways due to increased fat deposits in the throat can lead to a generalized nervous system reaction, leading the night sweats, hot-flashes, mood-swings, etc. So as you can see, many of the common symptoms of menopause are not exclusive to women.

Thursday, May 1, 2008

Migraines Linked to Stroke and Heart Attacks in Women

An interesting study in the January 2008 issue of Cephalagia revealed that women who had migraines more than once per week had nearly three times higher risk of ischemic stroke and 1.5 times more risk of heart attack as compared to women without migraines. Even having migraines once per month or less was associated with a 1.5 times increased risk of stroke or heart attack. The authors state that further research is needed to determine if migraine prevention reduces the risk of cardiovascular diseases. 

My feeling is that even if migraines were controlled with aggressive dietary modifications and pharmacologic agents, there will be minimal to no improvement in the incidence of the risk of heart attack or stroke. My logic is as follows: Migraine is a common feature in people with sleep-breathing disorders. It's especially more common in women (and men) who have upper airway resistance syndrome (UARS), which is a variation/precursor of obstructive sleep apnea (OSA). Obstructive sleep apnea is known to be linked to high blood pressure, heart disease and stroke. In my experience, allowing people to sleep better (by breathing better at night) usually improves migraines, as well as the effects of OSA. So covering up a migraine headache with medications will not address the cause, which is inefficient sleep due to breathing problems at night. I discuss the reasons for this in detail in my forthcoming book, Sleep, Interrupted.

Monday, April 21, 2008

When You Hear Ringing, and It's Not the Phone

Temporomandibular joint disease, or TMJD, is a very common disorder that affects millions of people in this country. The most common symptoms are ear pain and headaches. Other less common symptoms that are described are ringing, buzzing, ear fullness, sound sensitivity, popping and clicking. A paper published in April, 2008 issue of Archives of Otolaryngology - Head & Neck Surgery described a relatively high incidence of theses "aural" symptom in patients seen in an academic TMJ clinic. They reiterate and agree with other authors' hypothesis that local inflammation of the jaw joint, due to it's proximity to the ear structures, can aggravate all these problems. In the end, no one really knows why these symptoms occur. As in all scientific papers, they can only show association, but never prove cause and effect.

Let me propose one possible cause for these effects: People with sleep-breathing disorders (obstructive sleep apnea and upper airway resistance syndrome) all have various degrees of nasal inflammation with ear and sinus pressure problems, TMJD, and headaches. If you have nasal inflammation with partial blockage of the tube that connects the back of the nose to the middle ear (Eustachian tube), then you can imagine that you may feel ear fullness, hearing loss, popping or clicking. If your senses are heightened due to a physiologic stress response due to inefficient breathing during sleep, then you can hear noises in your ear or be sensitive to certain sounds or voices. Neurologic stimulation of the various structures can aggravate jaw muscle stimulation and spasm, or even ear or sinus fullness. This is similar to what occurs in a migraine attack. Various papers have suggested that a migraine attack can occur in any part of the body that has nerve endings, so in theory you can have a "migraine" attack anywhere in your body.

This is one of many papers that describe observations between one specific condition and it's symptoms. Their findings and observations are accurate, but when viewed from the more holistic perspective of the sleep-breathing paradigm, you may be able to make sense of all of these various interpretations all that much more. After all, there's really no point in looking at all this research without having an overall perspective to interpret it from.

Friday, April 18, 2008

Insomnia and the Blues

A new study published in the journal Sleep reveals that people with insomnia are more likely to develop depression later in life. The traditional thinking is that insomnia is a symptom of depression, but the authors argue that insomnia may come before depression.

My take on this is: "So what,this is old news". However, if you were to look at insomnia from a sleep-breathing paradigm which I describe in my forthcoming book, Sleep, Interrupted the issue becomes a lot more complex and all that more meaningful.

In the book I propose that both insomnia and depression are manifestations of interrupted breathing while sleeping that deprives you of deep, restful, restorative sleep. This process begins in early childhood, and is affected by multiple factors, including anatomic issues, diet, infections or stressful situations.

The beauty of my sleep-breathing paradigm is that it doesn't contradict what's out there in insomnia knowledge and research. Instead, it suggests a revolutionary approach on thinking about medical concepts that we take for granted. For the most part, it even agrees with and supports the evidence in insomnia research. My theory is that it's not important which comes first (insomnia or depression), but that both can coexist together. If this is so, what can cause both to occur?

This is another example of the peculiarities of medical research when you try to isolate and correlate one variable against another. Yes, you'll get some interesting results, but more often than not, you'll end up asking more questions as a result, or end up with multiple conflicting results. Once you look at humans as a complex interaction of innumerable processes, by looking at the "big picture," things just make more sense. This is one of my overriding themes in my book.

Get Less Headaches – Raise Your Blood Pressure

A recent study published in the journal Neurology showed that the higher your blood pressure, the less likely you're going to have chronic daily headaches symptoms. This is an interesting finding since the authors conclude that headaches may result from stiffening of the arteries as one develops high blood pressure. In the end, the authors' weren't sure why this happened but were perplexed as to its paradoxical implications.

This finding is not surprising at all if looked at from the sleep-breathing paradigm which I describe in my forthcoming book, Sleep, Interrupted. People with upper airway resistance syndrome (UARS) are typically young, thin, don't snore, and are chronically tired, no matter how long they sleep. They also tend to have cold hands or feet, and have normal or low blood pressure with bouts of lightheadedness or dizziness when standing up suddenly. These people also tend to suffer from various headache syndromes, like tension, migraine, or TMJ associated headaches. They'll also have frequent sinus pain and pressure, usually misdiagnosed as a sinus infection. Typically, one or both parents will snore heavily, who frequently have high blood pressure, depression, or heart disease.

Later on in life, about 20-40 years later, UARS patients are more likely to be overweight, with no more cold extremities, dizziness or light-headedness, but now snore and have high blood pressure. At this stage, they are likely to have the classic features of obstructive sleep apnea (OSA).

We know that OSA is a major risk factor for high blood pressure, but patients with high blood pressure are almost never screened for OSA. Instead, they are treated for one of the signs of OSA, which is hypertension. One of the major root causes of high blood pressure is almost never addressed. There are even scientific thinkers that propose that OSA is the main reason for most cases of undiagnosed high blood pressure.

The study authors also commented on other studies that show that increasing blood pressure is linked to lower amounts of chronic pain throughout the body. In sleep research, sleep apnea patients are thought to have diminished autonomic nervous system sensitivity, thus the longer breathing pauses.

Unfortunately, in most cases, we wait for the end result of a disease process (high blood pressure) before starting treatment, rather than preventing it from happening in the first place. In the latter scenario, helping people breathe better at night so that they can sleep better can not only alleviate much of the headaches when they're young, but it can prevent progression into high blood pressure and other cardiovascular complications later in life.

Thursday, April 10, 2008

Moans in the Night

An interesting article in a recent sleep medicine journal describes a rare condition where women moan intensely while sleeping. Contrary to what you may have been thinking, these women were not moaning due to either pain or erotic dreams. These seven women sought treatment at Stanford's sleep clinic due to a condition which has been coined catathrenia. They were all embarrassed by their condition, as well as having family members who were alarmed by the strange noises. Catathrenia has been classified in the parasomnia category, which are disturbances that occur during sleep-wake transitions, in contrast to sleep-breathing problems such as obstructive sleep apnea. This condition is typically seen in younger, premenopausal women, who are relatively thin.

When these women underwent an overnight sleep study, none were found to have obstructive sleep apnea. However, they all had in common the typical feature of multiple breathing pauses with arousals, leading to inefficient sleep. All these women also had in common smaller jaw sizes and a history of dental extractions for crowding or orthodontic problems. Many also complained of chronic fatigue symptoms as well.

This article caught my attention because of the nature of the cure for this condition. All the women were essentially cured with treatment that's normally given for people with obstructive sleep apnea. Yet, they didn't have obstructive sleep apnea. What they really had was upper airway resistance syndrome (UARS). As I've described at length in other articles, UARS is a variation/precursor to obstructive sleep apnea, where people have narrowed upper airway anatomy that causes brief obstructions and breathing pauses that are not severe enough to be called obstructive sleep apnea.

To receive a diagnosis of obstructive sleep apnea, you have to stop breathing completely or partially for 10 seconds or more, at least 5 times every hour while you sleep. But if you stop breathing 15 times every hour, but wake up after 2-3 seconds each, then your apnea score is 0 and you're told you don't have obstructive sleep apnea. These UARS patients are constantly tired and suffer from various other chronic conditions such as recurrent sinus pain or infections, low blood pressure, cold hands or feet, various gastrointestinal symptoms, anxiety/depression, and almost invariably, prefer not to sleep on their backs.

The lead author of this article (Dr. Guilleminault at Standford University) was the first to describe UARS as well. In his original UARS paper, he treated these constantly tired people with CPAP, or continuous positive airway pressure. This is a device that delivers gentle air pressure through the nose, thereby keeping their breathing passageways open. For the most part, they all did well, but in the long term, they could not continue sleeping with masks and hoses attached to their faces. Most UARS patients, due to heightened sensitivities, are unable to tolerate this device.

In this current study describing catathrenia, many of the patients tried CPAP as well, which worked, but they all refused to use it continuously. Most of the patients subsequently underwent various surgical procedures of the throat, and were reported as being "cured."

It's amazing how often I find studies that link common and uncommon medical conditions to sleep-breathing disorders. Knowing that sleep-breathing disorders (obstructive sleep apnea or upper airway resistance syndrome) may be linked to depression, anxiety, cold hands, migraines, irritable bowel syndrome, chronic fatigue syndrome, polycystic ovarian syndrome, obesity, ADHD, TMJ, diabetes, high blood pressure, high cholesterol, heart disease, heart attack and stroke, could a breathing problem during sleep be the common link? I've even seen multiple articles linking obstructive sleep apnea to epilepsy and cluster headaches. In my forthcoming book, Sleep, Interrupted, I propose that the this may be a possibility. It may be a bit of a stretch to say a definite yes, but I'm confident that in 10 to 15 years, the answer to the above question will be more clear. This just goes to show that what we generally take for granted my have an alternate explanation.

Saturday, February 16, 2008

Sleep Better With Duct Tape

I happened to go into my son Devin's room, to check on something after he went to bed. To my surprise, a very bright neon-blue light emanated from beneath his bed, like those cars from the 80s. It lit up his entire room and I wondered how he could sleep with the room so brightly lit. 

When I looked underneath his bed, I realized that I had recently placed a powerstrip to connect his aqaurium next to his bed. The blue LED light on the powerstrip was so powerful that it lit up the entire room. I quickly got some black electrical tape and placed it over the light, and the room was dark again. (Duct tape would have worked as well.) 

I've noticed over the years that with more efficient LED lights on electronic appliances, our bedrooms can be lit up to the point of preventing a good night's sleep. In our bedroom, I taped off our air purifier (5 different places), our wireless phone (which was really bright), our humidifier, and had to turn upside-down our two cell phones as well. Not only are individual LEDs much more powerful than a standard night light, a typical bedroom can have 3-5 bright lights, which can prevent someone from falling asleep. Even my new alarm clock is MUCH brighter than my old one.

There's been much written about how the invention of the light bulb really disturbed our sleep patterns in this century, and the proliferation of more and more powerful LEDs are definitely taking it up another notch. Lack of light is what signals our brains to produce signals to initiate sleep. Besides all the other distractions that prevent us from getting proper sleep (such as televisions, cell phones, internet, etc.), we don't need more lights.

So take a few minutes and survey your bedroom, as well as your children's bedroom. Make sure you give your eyes a few minutes to adjust to the darkness. Then cover anything that emits light with a small piece of black electrical tape or duct tape. 

Another option, of course, is to tape your eyes. But you could get an eye mask instead.

Saturday, February 2, 2008

The New York Deli Phenomenon

One of my biggest pet peeves is whenever I order a deli sandwich, the deli guy sometimes forgets one or more of my requested ingredients. For example, if I order a roast beef on a roll with lettuce, tomato, mayo, mustard, onions and sweet peppers, the last few ingredients are typically left out. Usually, it's the ingredients listed at the end, never the first few items. Ever since I noticed this, I watch the sandwich maker like a hawk. I hate it when they have to turn their backs to me to make a sandwich, since I can't see what they're doing. Every time I let my guard down, I always regret it.

You may be asking by now what this has to do with sleep and breathing and medicine in general. Unfortunately, too much.

When it comes to medical diagnoses, many physicians are guilty of the same phenomenon. For example, when I had to learn about obstructive sleep apnea in medical school, I had to memorize a long list of signs and symptoms. Usually, they're listed in order of importance. By the time you get to the 39th or 40th sign and symptom, your brain can't memorize any more. Most multiple test exams in medical school test you on the more common signs or symptoms, and rarely an unusual one. So by default, we tend to memorize the items higher on the list.

But this is where the problem starts. For example, going back to the obstructive sleep apnea example, the most frequent findings that are mentioned in textbooks or in a lecture are: older, obese, snoring, male, and big neck. Since these were the features first described in obstructive sleep apnea, no wonder. But if you read further down the list or look at published studies on this condition, you'll find dozens or even hundreds more common and uncommon features that no one has time to list out when asked about this condition. So lecture after lecture, I've seen the same description about obstructive sleep apnea: typically seen in older, snoring, obese men, and untreated, can lead to diabetes, high blood pressure, heart disease, heart attacks and strokes. It still continues to this day, even with numerous studies showing that obstructive sleep apnea can occur even in young thin women that don't snore. Of course, in a young thin woman complaining about sinus infections or fatigue, sleep-breathing problems are near the bottom of the list.

Despite the facts that doctors know about obstructive sleep apnea in the typical patients, they forget about the second part: the link with heart disease, heart attack and stroke. It's shocking to me how many people I see that have suffered from heart attacks or strokes that are found to have significant obstructive sleep apnea when eventually tested. The same can be said about sinusitis, throat infections, ear infections, etc. Too often, ear pain alone with no obvious infection is treated with antibiotics.

It's obvious that a human being is not a deli sandwich. To label a person with "sinusitis" is like saying, remember to add nasal congestion, yellow pus, fever, facial pain, poor sleep, ear fullness, or post-nasal drip. The problem is that this list gets whittled down to yellow pus and facial pain. Or that obstructive sleep apnea patients snore and are overweight, Yes, the majority of people with these symptoms will have the respective conditions, but you're missing out on many other patients that only have poor sleep or ear fullness for sinusitis and post-nasal drip for obstructive sleep apnea.

So if you have post-nasal drip, and are treated for allergies, no wonder the medication didn't work. Without getting a full and complete medical history and thorough physical exam, it's hard to get a complete picture of what's going on. In this age of managed care and rushed doctor's visits, it's no wonder that we end up treating the symptoms only and almost never the true cause of the illness, leading to missed diagnoses and incorrect treatment regimens.

Unfortunately, the New York Deli phenomenon will continue, with doctors making diagnoses and prescribing treatment based on incomplete pictures. Just as an incomplete sandwich just doesn't taste right, an incomplete history and examination can lead to an unsatisfying outcome.

Friday, January 25, 2008

Sleep Position Matters

I just saw a young man who complains of many months history of right-sided throat pain and swollen glands. Past medical history is significant for anxiety issues. He noted that he usually sleeps on his back. He also mentioned that he's had a nagging right chest, and shoulder discomfort, which started around the same time as his throat problems. When asked how he slept prior to his problems began, he stated that he normally slept on his sides. He also complains of chronic post-nasal drip, throat clearing, and coughing. He also has a relatively small lower jaw. He eats late and complains of being tired all the time, no matter how long he sleeps. 

His exam reveals severe tongue collapse when on his back with swelling and inflammation of the back of his voice box, consistent with a sleep-breathing, throat acid reflux problem aggravated by suddenly sleeping on his back. I recommended sleeping on his left side, not eating late, and practicing relaxing breathing exercises. 

Thursday, January 24, 2008

Bad Advice from the American Academy of Dermatology

About once per week, I see mostly female patients who come in for recurrent sinus or throat problems who also have severe and chronic fatigue. When asked if they sleep on their backs, they'll say yes. But when I question them further, they'll tell me that when they were younger, they always slept on their stomachs, with their face on one side of the other. Then I asked about when they began to sleep on their backs, and not too surprisingly, it's about the same time that they began to feel more tired and started to have various illness such as sinus infections, throat pain, etc.

When asked why they began to sleep on their backs, the most common answer usually is, "my dermatologist said sleeping on my face could aggravate wrinkles" (read the article from the American Academy of Dermatology here). What the dermatologist does not appreciate, however, is that these people MUST sleep on their stomachs so they can breathe well when sleeping at night. The reason for this is that many people (to various degrees) have a tendency for their tongues to fall back slightly when lying on their backs due to gravity. When you add deep sleep, all the muscles begin to relax, and the tongue may collapse completely, which causes a temporary obstruction and arousal. This prevents people from getting deep sleep. This is what I talk about in my book, Sleep, Interrupted.

If you have this condition, you probably realized this subconsciously when much younger and slept on your side or stomach to compensate pretty well. But when you start to sleep on your back, then you can't compensate very well anymore and you will have multiple micro-obstructions and arousals, preventing you from achieving restorative, deep sleep. So in a sense, this will age you more in the following manner: inefficient sleep causes a low grade stress response, constricting blood vessels to nonessential organs such as your gastrointestinal or reproductive organs, skin and hands or feet. If you don't get enough blood flow. your skin cannot heal and repair itself properly, this "aging" faster. Plus you also feel tired and lousy.

This situation can also apply to people who are admitted to the hospital after operations or after an accident, but in these situations, the consequences can be much more severe. Others have to sleep on their backs due to an shoulder injury or neck pain, which prevents stomach sided sleeping. Some people ABSOLUTELY cannot sleep on their backs. Something to think about.

My First Post

I just got back from the annual Integrative Healthcare Symposium, and I thought what I learned would be a good subject for the inaugural entry in my blog. As you may or may not be aware, my passion is to help people live more fulfilling lives by allowing them to breathe better while sleeping. This is why I wrote my forthcoming book, Sleep, Interrupted. It’s about a new way of looking at health and disease in general from a sleep-breathing perspective—based on the premise that all humans are susceptible to breathing problems while sleeping, to various degrees.

During the one-year process of writing this book, I’ve traveled a great journey. What I discovered is that to treat isolated conditions such as sinusitis or middle ear infections, you must treat the whole person, including their overall medical status, diet, lifestyle, stresses, and emotional state of mind. Going to the Integrative Healthcare Symposium only solidified my suspicions that you must treat the entire person first, before treating a symptom or medical condition.

In a sense, this journey has been a healing process for me as well, as I’ve learned to take the time to re-examine the way I value my own health, my relationships with others, and my goals and priorities in life. I have to admit that when I first started writing my book, I was somewhat overwhelmed with the added time commitments, financial burdens, and strains on my relationships with my family and friends. Slowly but unexpectedly, as I researched and read through the material needed for my book, I saw a small but significant change in myself for the better. I seem to be less stressed or worried, I’m eating healthier, I’m running competitively again for the first time in 20 years, and my relationship with my wife and children has improved. All this from simply writing a book. Most of it was through great guidance and coaching from my book authoring mentoring program. Through goals-setting exercises, time blocking, and transformational mind-shifts, I found that I had more time to accomplish more activities more effectively.

The symposium was truly eye-opening. In contrast to the typical medical conferences that I usually attend, there was so much more hope, excitement, and enthusiasm than I’m used to seeing. There was much less statistical analysis and academic pontification, and much more practical and empowering information that I could implement immediately in my practice. For the first time ever after a meeting or conference, I was excited about what I learned and was confident about making significant positive changes in the fundamental way that I practice medicine: not focusing on better medicines or surgical techniques, but to focus on significantly improving doctor-patient relationships, and improving the overall health and wellness of the patient as a human-being, not just a person with sinusitis.

I have to admit that the very first keynote talk that I heard was very nerve-racking. One example had to do with known toxins and carcinogens that are required to be applied in all mattresses in the US as a flame retardant due to fires from unextinguished cigarettes, but was never rescinded even after self-extinguishing cigarettes came out. This material was banned in Europe, and is still found in certain mattresses, even infant crib mattresses. Another example is the effect of environmental toxins that mimic estrogens that are causing an epidemic of early puberty, with one study citing 27% of African-American girls in the US developing pubic hair and breasts by age 7, and 48% by age 8, and in White girls, the numbers were 6% and 14%, respectively. The shocking number was that 3% of African-Americans and 1% of White girls had pubic hair and/or breast development by age 3. Obviously, I was somewhat paranoid by the end of this talk.

I then got into the meat of the sessions, with a number of great lectures on nutrition and the concept of nutrigenomics, which is the ability of foods to modify to various degrees the amount of our innate gene expression. After these talks, I was pretty convinced that our country’s SAD diet (Standard American Diet) is a major part of what’s making us one of the sickest countries in the developed world.

I could go on and on about the other talks, but I do want to mention some of the vendors that I came across in the exhibition area. I’m normally not into vitamins and nutritional supplements, but I happened to come across a new type of grain called Salba which had some wild claims: ounce per ounce, Salba had 8x more omega-3s than salmon, 15x more magnesium than broccoli, 3x more iron than spinach, 1.1x more fiber than bran, 3x more antioxidants than blueberries, and 6x more calcium than whole milk. The reps claimed that it was the choice of the ancient Aztec runners for energy and stamina. With these incredible claims, and having just signed up for the Bronx ½ marathon in 4 weeks, I ordered a one month supply to test it out. Stay tuned for my results.

I also underwent acupuncture for the first time. I got 5 needles in each ear for stress reduction and relaxation. I have to admit, after the first few minutes of mild irritation, I was soooooo relaxed, I lost total track of time. My arms and legs were so heavy, and I felt like I was in a trance in the middle of a very busy and noisy convention floor. Despite that fact that acupuncture’s theories are completely different from that of Western medicine, it’s been shown in multiple studies that the needles affect your nervous system, realigning the imbalances in your body. So if you have too much of the stress response (sympathetic nervous system), then acupuncture can lower this part and raise the relaxation portion (parasympathetic) of your nervous system.

Not surprisingly, many western physicians are somewhat skeptical of the validity of many of these complementary and alternative medicine (CAM) methods. Our model or definition of the usefulness of any intervention has to be shown in a large randomized, double-blinded, placebo-controlled, prospective studies that shows statistical significance. So if you have enough numbers to show that the “drug” is 10% better than a placebo with statistical significance, then it can get FDA approval.

One of the major criticisms of CAM medical models is that there are no convincing large-scale studies proving that they work. Although there are a number of smaller often conflicting studies out there, there are no “landmark” studies that are convincing enough for the traditional allopathic community.

However, people in the CAM fields would argue that that’s not the point. Statistics and studies are important, but what’s more important is to look at the person as a whole, not just a number in a large-scale study. They would argue that if you used CAM’s definition of “success”, Western medications and interventions would fail miserably for certain chronic conditions such as heart disease, diabetes, cancer or obesity. Yes, for acute conditions such as certain bacterial infections or major trauma, Western medicine is great. CAM practitioners define wellness very differently from Western practitioners. A Western doctor thinks you’re well if she cured your sinus infection with an antibiotic. A CAM practitioner thinks you’re well, once your entire mind, body and spirit are in balance, and that what predisposed you to getting the bacterial infection is addressed, as well as how your body responds to infections is optimized, with minimal to no side effects. Unfortunately, in Western medicine, complications and side effects are more the rule than the exception.

Don’t get me wrong—I’m not crossing over completely into CAM. What I’ve found over the course of the last year writing my book is that all the journal reading, conference attending and test ordering has not made significant improvements in my practice. What has made a big difference is when I got to know the patient by taking time to really know the patient en toto, as a whole person, that’s when great things started to happen. I still believe firmly in the original goals of Western medicine; it’s just that we’ve lost our focus and clarity in light of the obstacles and hurdles that we doctors have to face dealing with administrative hassles and overwhelming paperwork. But that’s no excuse.