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Sleep Apnea: The Apeiron Life Perspective

Updated: Oct 24, 2022


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What it is:

Sleep apnea is a common condition in which breathing becomes impaired during sleep. This causes intermittent hypoxia, or a drop in oxygen, that prevents a person from getting deep, restful, continuous sleep.

Shallow breathing leads to snoring and pauses between breaths, which can cause a person to wake up choking or gasping for air.


When the body relaxes into deeper sleep, the airway muscles can narrow, leading to inadequate airflow in and out of the lungs. To remedy this, individuals with sleep apnea wake up repeatedly to resume normal breathing. Sometimes these awakenings happen every few minutes or even more. Chronic sleep disturbance results in impaired daytime performance and elevated cardiometabolic disease risk.



The purported claims:

Untreated sleep apnea is associated with:

  • Metabolic dysregulation

  • Weight gain

  • Hypertension

  • Diabetes

  • Inflammation

  • Heart failure

  • Excessive daytime sleepiness

  • Hormone dysregulation

  • Chronic headaches

  • Impaired memory

  • Mood disturbance

  • Sexual dysfunction


What the science says:

There are two types of sleep apnea. The first is obstructive sleep apnea (OSA), which is the most common type and happens when the airways relax and narrow during sleep, preventing adequate airflow. Obesity, a large neck circumference, large tonsils, or a small jaw can all increase the risk of OSA.

Central sleep apnea (CSA) describes a neurological impairment in breathing. In other words, the brain does not trigger the right instructions to breathe during sleep. CSA can either be genetic or caused by certain drugs.

Sleep apnea is diagnosed by assessing how many pauses in breathing (apneas) or shallow breaths (hypopneas) a person has per hour of sleep. Together, these are reported as an apnea-hypopnea index (AHI). The greater the AHI, the more severe the case of sleep apnea.

Mild OSA – 5-14 AHI

Moderate OSA – 15-30 AHI

Severe OSA – 31+ AHI

These values tend to be lower when diagnosing OSA in children.

OSA is thought to affect up to a third of the population, with moderate and severe cases affecting between 6 and 17%. The risk is much higher for older and obese individuals. There are also notable differences between men and women, with women generally diagnosed less often than men. While men may report the more classic symptoms to their doctor, such as snoring or waking up gasping for air, women may instead complain about insomnia, depression, or fatigue – symptoms that aren’t necessarily associated with sleep apnea at first glance.

Women also experience changes in OSA risk as a result of hormone fluctuations. Progesterone is a potent respiratory stimulant. For young and midlife premenopausal women still experiencing a monthly menstrual cycle, the risk of OSA is generally lower, especially during the phase between ovulation and menstruation (known as the luteal phase) when progesterone is highest. Postmenopausal women have lower levels of both estrogen and progesterone; therefore, the risk of OSA increases in older age. Hormone replacement therapy has been shown to reduce this risk.

While hormone levels can increase or decrease the risk of OSA, the relationship is bidirectional. This means that OSA itself can disrupt the levels of hormones in circulation. One of these important hormones is testosterone which depends upon circulating levels of luteinizing hormone (LH) and follicular stimulating hormone (FSH) – the same hormones that play a role in female sexual health.

Testosterone levels are generally higher during the first half of the day and decrease as nighttime approaches. In individuals with OSA, the sleep disturbances caused by impaired breathing disrupts the chain of command that starts in the brain and ends in the release of testosterone from the testes (or ovaries in women.)

OSA also indirectly reduces testosterone by increasing systemic inflammation due to oxidative stress caused when airflow decreases. This oxidative stress can promote insulin resistance and fat gain. Any weight gain can reduce the levels of sex hormone binding globulin (SHBG) which plays an important role in carrying testosterone in the bloodstream. Low levels of SHBG can also increase the risk of insulin resistance and Type 2 diabetes in a somewhat vicious cycle.

Low testosterone levels can lead to sexual dysfunction through decreased libido and erectile dysfunction. Reduced testosterone is also generally associated with worse sleep quality and fatigue. Studies that administer testosterone replacement therapy to OSA patients have had mixed results. Sometimes, testosterone improves symptoms, while other times, it exacerbates them.

Sleep apnea results in systemic changes to the body. Targeting a single hormone is unlikely to address the often far-reaching effects of this disorder. Instead, it is best to address the restricted breathing itself.

Treatment for sleep apnea varies depending on the severity of the condition. For people with mild sleep apnea, reducing alcohol intake and changing from a back to a side sleeping position can be enough to reduce snoring and promote better airflow. Nasal dilating strips and decongestant sprays can also be helpful.

More significant interventions are needed in moderate and severe cases of sleep apnea. Mandibular advancement uses a device akin to a gum shield that improves airflow during sleep by moving the jaw and tongue forward. These devices are typically custom fitted by a qualified dentist to ensure optimum comfort.

If mandibular advancement does not resolve the sleep apnea or is not well tolerated, the next avenue is generally continuous positive airway pressure (CPAP). CPAP treatment involves sleeping with a facemask attached to a hose that delivers constant, steady air pressure during sleep to promote healthy breathing. It can take some getting used to and must fit appropriately to ensure the mask forms a good seal, but it is highly effective at combatting even the most severe cases of OSA.

Treating CSA can be more complicated and may involve changes to medications (such as opioids) that may be responsible for the breathing issues. Oxygen or carbon dioxide therapies, CPAP, or specific respiratory stimulating drugs are also effective options.




Our take:

Diagnosing and treating sleep apnea can be life-changing, but it starts with knowing what to look for in your breathing. Individuals who share a bed are likely to know if they snore or stop breathing in their sleep. It can be more challenging for those who sleep alone.

Apps like SnoreLab record you while you sleep, detecting whether you snore. Wearable sleep trackers, such as the Oura ring, can also pick up any fragmented sleep that might be too brief to perceive consciously, as well as oxygen saturation (SpO2) levels which will sharply decrease during apneas and hypopneas throughout the night.

If you suspect that you have sleep apnea, speak to your doctor. You can also try a home diagnostic testing device, such as the WatchPAT, which can detect OSA and CSA.



Will this benefit you?

Snoring is common, but it can indicate unhealthy sleep. Taking steps to improve your breathing has numerous positive benefits, including better heart health, mood, and lower levels of inflammation.

Nasal breathing has recently gained attention for how it promotes better health. By noticing how well you breathe through your nose during the day, you can take a decisive step toward improving your breathing at night. Allergies, poor air quality, and low humidity can stress the nasal cavity. Resolving any existing issues that affect daytime breathing will have positive ripple effects during nighttime sleep.



Still curious to try it? If you do, here’s what to look out for:

If you have tried a variety of minor interventions and nothing seems to be working, do not hesitate to try dental devices or CPAP. While both can take some getting used to and may change your sleep routine, combatting sleep apnea promotes better sleep, mood, performance, health, and longevity. Sleep researchers at the University of Utah and RAND Corporation are working on a novel couples-based intervention (aptly called “We-PAP”) to promote better CPAP adherence when one partner has OSA. We-PAP may improve sleep in relationships strained by sleep-disordered breathing by encouraging couples to use partner support, communication, and goal setting.

Treating OSA promotes a positive feedback loop, whereby better sleep reduces inflammation and leads to better sleep. Better sleep results in higher energy levels and increases the drive to exercise. It also boosts memory, focus, and mental health. If you have tried every trick in the book to improve your sleep and suspect OSA might be to blame, remember that by treating it, you have everything to gain.



References:

Comprehensive list of products for mild to moderate sleep apnea: https://pghomt.com/products-for-breathing-and-sleep/

Mandibular advancenment and CPAP: https://pubmed.ncbi.nlm.nih.gov/29129030/

Drs. Peter Attia and Matthew Walker discuss sleep apnea and other sleep-related topics: https://peterattiamd.com/matthewwalkerama2/



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