The Sleep Apnea Spectrum and What You Can Do About It
It’s estimated that 18 million people — mostly men — are affected by sleep apnea. Many people associate sleep apnea with obesity, age, and poor habits including smoking and overindulgence in alcohol. All of these may be true, however, there is growing evidence that this sleep disorder may have its roots in childhood, vitamin deficiency, or hormonal changes.
Most people think sleep apnea is a brief pause in breathing during sleep. Yet it’s actually much more complex than that. According to Dr. Jerald Simmons, a triple board-certified expert in neurology, epilepsy, and sleep medicine, and founder of Comprehensive Sleep Medicine Associates, while it’s accurate to say that people with sleep apnea are physically prevented from getting a restful night’s sleep, their breathing may not pause completely.
Fortunately, once we understand sleep apnea, there’s a lot we can do to stop it before it starts or to eliminate the cause if you do experience sleep apnea. In this article, I’ll briefly explain why sleep is so important and how sleep apnea can affect your health. Then I’ll go into detail about the sleep apnea spectrum and what may land you there. I’ll also cover prevention, testing, and treatment of this sleep disorder so that you can get all the information you need for a good night’s sleep.
Why Do You Need Sleep?
During sleep, your body is performing some critical functions. These include repairing muscle tissue, purifying your brain from toxins, and even processing memories and emotions. The benefits of a good night’s rest abound. Sound sleep:
• Boosts immunity; you get sick less often due to less inflammation.
• Helps maintain a healthy weight because the hormones ghrelin and leptin that regulate hunger remain at an ideal level.
• Improves mental clarity and the ability to make decisions.
• Lowers your risk for diabetes and heart disease.
• Reduces stress and improves your mood.
How Does Sleep Apnea Affect Your Health?
According to Dr. Simmons, breath-related sleep deprivation in children is a major cause of ADD and ADHD. In fact, between one-third and one-half of all cases of ADD and ADHD may have their roots in sleep disorders that arise from breathing problems. Other serious and long-lasting issues include:
• Complications with medications and surgery
Obstructive sleep apnea can cause complications with medications and surgery such as general anesthesia.
In a recent study, 50% of those who had fibromyalgia also experienced sleep apnea. Further study is needed to identify if one disorder causes the other.
• General fatigue
Interrupted sleep patterns prevent you from getting enough rest, disrupting circadian rhythms and causing extreme fatigue. This can lead to inattentive driving and poor performance in school or work.
• Heart problems
Sleep apnea may increase the risk of heart attack, stroke and abnormal heartbeats. This is because the cardiovascular system is strained from the drop in blood oxygen levels due to intermittent breathing.
• Hypertension or high blood pressure
Sudden drops in blood oxygen levels that occur during sleep apnea increase blood pressure (hypertension).
• Impaired apoptosis.
While you sleep your body removes certain cells including some pre-cancerous cells and ones infected with viruses. Apoptosis maintains the balance of cells in the human body and is especially important in the immune system, lipid metabolism, and blood clotting.
• Increased inflammation
Seven different inflammatory markers are significantly elevated in those who have sleep apnea compared to those who don’t; inflammation is one of the root causes of autoimmune disease.
• Intermittent hypoxia
This is a deficiency in the amount of oxygen reaching your body’s tissues. It affects all parts of your body on a cellular level and creates a state of inflammation.
• Liver problem
The liver is more likely to show signs of scarring in those with sleep apnea than in those who don’t.
• Mood disorders
These are quite common and include extreme irritability and depression. Children and adolescents with sleep apnea exhibit behavior problems.
• Type 2 diabetes
Having sleep apnea increases your risk of developing insulin resistance and type 2 diabetes.
• Reduced cytokine production
Your body releases these proteins that target infection and inflammation while you sleep so that you can heal.
How Does Sleep Apnea Affect Your Breathing?
When you breathe, air flows in and out of your airway, creating negative pressure, or a vacuum. This is called the Bernoulli effect. The smaller the space, the greater the negative pressure. You create this vacuum with every breath you take.
Have you ever noticed your shower curtain pulling in toward you during a shower? That’s the Bernoulli effect in action.
When you fall asleep, the muscles around your throat relax. Your airway naturally gets a bit smaller. In addition, your jaw falls back and your tongue, which is connected to your chin, also relaxes and falls backward. This increases the airway pressure, drawing the tissue into the airway.
Think about that shower curtain pulling in. That’s what’s happening to the tissue in the airway. In some people, the tissue vibrates with each breath. That’s what you hear as snoring.
If the pressure becomes too great, the airway will collapse completely. Your brain will sense this and wake you up to take a breath Yet, sleep disturbances can be the result of the airflow decreasing down your esophagus just to the extent that your brain must make adjustments to ensure you’ll get enough oxygen. That means while you don’t awaken, your brain is much more active than it should be, preventing you from getting the deep rest your body needs.
What Is the Sleep Apnea Spectrum?
Picture a horizontal line with arrows at both ends. This represents the sleep apnea spectrum. The arrow on the left is pointing to normal breathing during sleep that results in complete rest. The arrow on the right is pointing to full-blown sleep apnea that causes repeated awakening during the night.
These are the three types of full-blown sleep apnea and one related disorder:
Obstructive Sleep Apnea
This is the most common form of sleep apnea. It occurs when the muscles surrounding the throat relax and restrict your airway. When your brain senses you’re not getting any oxygen, it rouses you just enough to take a breath. This can happen as many as 30 times in an hour.
Central Sleep Apnea
A less common form of sleep apnea, it occurs when your brain doesn’t send proper signals to the muscles that control breathing, possibly as a result of stroke or narcotic use. Your breathing lapses for a short period of time and you awaken abruptly with a shortness of breath.
Complex Sleep Apnea Syndrome
This form of sleep apnea occurs when someone has both obstructive sleep apnea and central sleep apnea. This sleep disorder seems to develop in people with obstructive sleep apnea who use a continuous positive airway pressure device (CPAP) to keep their airways open. Researchers believe this may be an initial reaction that subsides after several weeks of treatment, however, more study is needed.8
Upper Airway Resistance Syndrome
In between the two arrows are degrees of difficulty in breathing that can cause disrupted sleep. Sleep apnea that is not severe enough to completely rouse you from sleep to take a breath is called Upper Airway Resistance Syndrome. Rather than waking you, your brain may instruct your body to take some other steps to open your airway, resulting in disrupted sleep.
There are many people who fall into this category of sleep apnea and yet very few people — even healthcare professionals — are aware of the issue. Those who experience this sleep disorder may simply feel they are not getting enough sleep, while others describe it as “breathing through a straw.”
However, recent research is uncovering some surprising information. In fact, it appears that this syndrome affects more women than men (56%) and that those of East Asian descent may be particularly vulnerable.
Signs You Could Be on the Sleep Apnea Spectrum
Nearly all of these symptoms can happen from time to time, especially if you are under stress or have a cold. However, if these common signs and symptoms of sleep apnea persist, you may be on the sleep apnea spectrum:
• Bruxism, or grinding or clenching your teeth
• Dry mouth upon awakening, pointing to mouth breathing
• Difficulty staying asleep
• Episodes in which you stop breathing during sleep (as reported by another person)
• Excessive daytime sleepiness
• Extreme shifting of position during sleep
• Falling asleep at inappropriate times
• Gasping for air during sleep
• Loud snoring
• Morning headaches
• Mouth breathing, also known as rescue breathing
• Problems focusing
• Stuffy nose that clears soon after awakening, another sign of mouth breathing
How Do You Get on the Sleep Apnea Spectrum?
As I mentioned earlier, risk factors for sleep apnea do include being overweight, aging, smoking, as well as alcohol or drug consumption. Yet these may not be the root cause. Instead, there are some surprising factors that can land you on the sleep apnea spectrum, especially if you have more than one of them.
Congenital Physical Structure
Some people are born with certain physical abnormalities that can put them on the sleep apnea spectrum. Those with an unusually high and narrow hard palate, an abnormally small intermolar distance (the distance from your front teeth to your molars), or a thin soft palate with a short uvula may find themselves in the middle of the sleep apnea spectrum. Having no wisdom teeth or having them extracted early may also play a role.
Those with hypertrophic tonsils and adenoids, craniofacial abnormalities, neuromuscular diseases such as cerebral palsy, or Down syndrome are at increased risk for development of obstructive sleep apnea.
I can personally attest to the fact that bone structure issues can lead to sleep apnea. Initially, because my husband, Xavier, was snoring, he was tested for sleep apnea. I’d been waking up during the night and we assumed it was because Xavier was snoring. However, when I was still experiencing disrupted sleep after his issues were resolved, I realized I might have a problem.
I consulted with my biological dentist (akin to a functional medicine practitioner) and then with Dr. Simmons. We discovered my jaw is very narrow, one of the common physical structure issues that can place people on the sleep apnea spectrum. I should have had braces as a child, which we could not afford. This could have stopped the problem before it even began.
However, according to Dr. Simmons, one of the reasons sleep apnea is more common is “because our mouths have actually gotten smaller. Processed foods and bottle feeding have led to smaller mouths since the industrial revolution because our jaws are less challenged.”
Furthermore, childhood behaviors such as thumbsucking, the use of a pacifier, and bottle-feeding rather than breastfeeding can have an affect on physical structures. All of these factors can lead to a diminished airway, narrow dental arches or jaws, changes to the breathing pattern, and difficulty swallowing. They can also cause a deviated septum and create unusually large turbinates, the long, narrow passageways that help to warm and moisten the air that flows in through the nose, both of which can cause or worsen sleep apnea.
Changes in structure can lead to improper positioning of the teeth and an abnormal resting position of the tongue. If the tongue does not have enough room in the mouth because the dental arches have not developed properly, it can slide back into the airway, causing sleep apnea. The longer these behaviors continue, the more likely the structure of the jaw and palette will be affected.
While more men than women are affected overall by this sleep disorder, the chance of a woman experiencing sleep apnea increases during menopause. Estrogen and progesterone are stimulating hormones that help keep airways open by maintaining muscle tone in the throat.
As these hormones decrease during menopause, the chances of sleep apnea increase. This also played a role in my sleep apnea. Further, the weight gain and redistribution of body fat that may accompany menopause can cause disrupted breathing and sleep disorders.
Vitamin D Deficiency
Another surprising factor is vitamin D. Several recent studies have shown a connection between Vitamin D deficiency and risk of sleep apnea. Further study is needed to explain exactly why, however, we do know that every single type of tissue in your body has receptors for vitamin D. Your bones, heart, brain, muscles, immune system — you name it — all require sufficient vitamin D to function optimally.
Regardless of the cause of sleep apnea or where you fall on the sleep apnea spectrum, there are natural ways to prevent and even eliminate the symptoms.
How Do You Test for Sleep Apnea?
Finding out where you are on the sleep apnea spectrum is the key to treating this sleep disorder. Many people see their primary healthcare provider first about fatigue or sleeplessness. Others are surprised when their dentist questions them about their sleep habits, based on the structure of their jaw or palate.
Regardless of where you begin your journey to better sleep, you may need to visit a sleep specialist, many of whom are psychiatrists, pulmonologists, neurologists, or ear, nose, and throat specialists. Look for a board-certified sleep specialist who is affiliated with a sleep laboratory that’s been accredited by the American Academy of Sleep Medicine at aasm.org.
Your practitioner will question you closely and may wish to speak with your sleep partner as well. He or she may use tools such as the STOP-BANG questionnaire or the Kushida Index to assess your symptoms. To be diagnosed with obstructive sleep apnea (OSA) or central sleep apnea, your healthcare professional may suggest you undergo a sleep study. She or he may order at-home testing or a clinical test.
What’s the Difference Between At-Home or Clinical Sleep Apnea Studies?
With an at-home test, you’ll receive a kit with various probes that you’ll attach to your body that send messages to a small computer. Those probes will track your breathing, oxygen levels, breathing effort, and sometimes your sleep position. With an at-home test, you are usually asked to record the data for two nights. The results will be sent to the doctor who ordered the test.
Your doctor may opt instead for a sleep study to be conducted in a clinical setting. This will also uncover any related sleep disorders such as restless leg syndrome (RLS). You’ll stay overnight in observation to undergo a test called nocturnal polysomnography. You’ll be hooked up to equipment that monitors your heart rate, lung, and brain activity, breathing patterns, arm and leg movements, and blood oxygen levels while you sleep.
I opted to undergo a sleep study at a sleep lab here in Austin. I know many people are uncomfortable with the idea of spending the night in a sleep clinic. However, it’s not at all scary and doesn’t hurt a bit. In fact, every effort was made to ensure my comfort, including letting my husband, Xavier, spend the night in the room with me on an air mattress!
However, a typical study like mine may not determine if the Bernoulli effect — the narrowing of your airway that I discussed earlier in this article — is the cause of your disrupted sleep. To assess the pressure in the airway, a technician may insert a catheter through your nose to determine what’s happening in the airway below the esophagus while you’re asleep.
What are the Treatments for Sleep Apnea?
Here’s where the really good news begins! Depending on the underlying cause of sleep apnea and when it’s discovered, there are many very effective treatments. Often, a combination of factors leads to sleep problems, so a combination of solutions may be what’s needed. There are natural treatments, devices and medications, and surgical options.
I recommend working with a healthcare professional to determine the optimal treatment for you. After all, sleep is absolutely essential to your physical and mental well-being.
Natural Treatments for Sleep Apnea
Among the first things your doctor will assess are your lifestyle and risk factors. Excess weight, particularly around the neck, is a major contributor to sleep apnea. Losing weight can change the pressure on your throat by reducing fatty deposits, thus opening up your airway. It can also reduce hormonal issues involving insulin.
Smoking can damage upper airway muscle function and increase mucus congestion in the upper airway, worsening sleep apnea. If you smoke, your doctor can set you up with a plan to help you quit. You’ll also be advised to forgo alcohol. It doesn’t cause sleep apnea, however, it can make it more difficult for you to awaken if your breathing pauses.
Taping the mouths shut with surgical tape can provide some relief for those who are not very far down the sleep apnea spectrum. Of course, only do this if your nasal passages are clear and there’s no risk of choking!
Others find that tape strips across the bridge of the nose (Breathe Right™ is one brand) open nasal passages enough to keep you from breathing through your mouth at night. There are also plastic, winglike devices that you can insert into your nostrils at night to hold your nasal passages open.
For children, the least invasive technique is myofunctional therapy. This series of simple exercises works the muscles of the face, mouth, and tongue. Over time, the therapy can reverse the effects of thumbsucking and encourage the proper positioning of the tongue at rest.
Some people also find relief from sleep apnea with a technique called Rolfing®. This is a type of deep-tissue massage to realign the fascia, or connective tissue within your body. The goal is to lengthen and stretch the connective tissue to realign your body into vertical alignment,
Adults can participate in positional therapy to adjust the way you lie in bed to improve airflow. While this retraining is in process, you may benefit from cognitive behavioral therapy to help manage the symptoms of sleep apnea such as impaired decision-making and depression.
Several recent studies have shown a connection between Vitamin D deficiency and risk of sleep apnea, although no one is exactly sure why. We do know that it helps regulate neurotransmitter balance in the brain. We also know that Vitamin D is the only vitamin that also functions as a hormone in the body.
This makes it even more important to be sure you’re not one of the 41.6% of adults in the US who are deficient in this critical nutrient. Nanoemulsified Vitamin D3-K2 contains 1000i.u of super bioavailable Vitamin D3 (as cholecalciferol) per drop in an easy-to-take liquid form.
Medical Devices and Treatments for Sleep Apnea
A continuous positive airway pressure machine is a device with a tube and facemask that you wear during the night. It creates a positive pressure that keeps your airway open so you can breathe continuously. While this treatment has a great success rate when it’s used properly, studies show that even compliant sleep apnea patients only use it 50% of the time.16 Patients cite noise, feelings of claustrophobia, stuffy nose, dry mouth, and skin irritation from the CPAP mask as reasons they don’t want to use their CPAP machine.
Dental Appliances for Adults
Your doctor may prescribe a dental appliance that is worn at night for your sleep apnea. The most common is a MAD. or mandibular advancement device. It resembles an orthodontic retainer or sports mouthguard and moves the jaw forward to prevent the airway from collapsing. There are also devices to lift the tongue or to lift the palate, though these are less common.
Your dentist will determine the appropriate device and custom fit it to your mouth. You can find a dentist who specializes in sleep disorders by contacting the American Academy of Dental Sleep Medicine. There are a few biological dentists who also specialize in appliances for sleep apnea.
Dental Appliances for Children
Doctors and dentists alike are becoming increasingly aware that the bone structure of the head, particularly the jaw and palate, may be the primary cause of sleep apnea. In children particularly, patients with certain physical conditions such as the enlargement of tonsils and adenoids, bone abnormalities in the face and jaw, and neuromuscular diseases such as cerebral palsy, or Down syndrome are at increased risk for development of obstructive sleep apnea.
However, because the bones of young children are very malleable, pediatric dentists and orthodontists can intervene with dental appliances that actually widen the palate, provide more room for the tongue, and improve airflow. They can also prescribe devices similar to the ones adults use for sleep apnea.
These require a periodic assessment to ensure your child’s palate, jaw, and teeth are growing properly. You can get help finding the appropriate dental professional for your child’s sleep disorder by contacting the American Academy of Pediatric Dentistry.
Estrogen and progesterone are stimulating hormones that help keep airways open by maintaining muscle tone in the throat. As these hormones decrease during menopause, the risk of sleep apnea in women increases. Further, the weight gain and redistribution of body fat that may accompany menopause can cause disrupted breathing. Your healthcare professional may prescribe hormone replacement therapy to boost muscle tone.
Is Surgery for Sleep Apnea an Option?
Most healthcare professionals will try other methods before suggesting surgery for sleep apnea. However, in children, facial bone structure abnormalities may be addressed surgically as the primary treatment. In other cases, children may undergo the same types of surgery as adults however, the first surgery that is often tried is to remove both the tonsils and the adenoids. Another common surgery for children with sleep apnea is the pharyngeal flap, which entails transferring muscle tissue from the back of the throat to the palate to narrow the nasal opening.
For adults, there are seven types of surgery to address sleep apnea:
1. Hyoid advancement
The hyoid bone is a small bone in the neck where the muscles of the tongue base and pharynx attach. It can be surgically repositioned to expand the airway.
In a relatively new technique, a device called Inspire is surgically implanted in a patient’s chest. The patient turns it on by remote control each night at bedtime. It delivers mild stimulation to the nerve that controls the tongue, keeping the muscles and soft tissues from sagging and blocking the airway.
3. Nasal surgery
The most common nasal surgical procedure consists of straightening the septum and reducing the turbinates, the long, narrow passageways that help to warm and moisten the air that flows in through the nose.
4. Soft palate implants
This technique involves the placing of three polyester rods into the soft palate. These rods initiate an inflammatory response that ultimately stiffens the soft palate.
5. Tongue advancement
This procedure involves moving one of the main tongue muscles forward so that it’s ability to fall back during sleep is limited.
6. Tongue base reduction
The tissue at the tongue base can be reduced by shrinking it with radiofrequency waves over the course of several treatments. The same effect can be achieved surgically in a single procedure.
UPPP (uvulopalatopharyngoplasty) is the most common sleep apnea surgical procedure. Excess tissue from the soft palate and pharynx removed, as are the tonsils if they’re present.
While you work to address your sleep issues, getting enough Nanoemulsified Vitamin D3-K2 and implementing the four pillars will help you take back control of your health — including a good night’s sleep! In addition to the following article, lifestyle changes including losing weight, stopping smoking, and limiting alcohol will all improve your chances of getting the sleep you need.
Dr. Grace - Founder of The Gut Institute