Sleep Apnea

Sleep apnea is a disorder characterized by the cessation of breathing or in some cases underbreathing during periods throughout sleep. Apnea is a Greek word that literally means “without breath.” Apnea results in the afflicted individual suffering from reduced oxygen levels (hypoxia). Sleep apnea is one of the least thought about reasons for a variety of health concerns that at first glance seem unrelated to sleep disorders and is a common reason for fatigue. The disorder also has been shown to be life threatening, increasing morbidity and mortality.¹ In the U.S., it is estimated that obstructive sleep apnea is responsible for 38,000 cardiovascular deaths per year.²

Sleep apnea is a very common problem among my patients. Although obesity is a risk factor for sleep apnea, I have found that even some of my normal weight patients test positive for this condition. As a matter of practice, I test all of my heart disease patients for sleep apnea, due to the strong connection between the two conditions.

A Hidden Epidemic

The National Institutes of Health estimates 12 million Americans have overt sleep apnea,³ including 1 out of 25 middle-aged men and 1 out of 50 middle-aged women. The incidence also increases with age, with at least 1 out of 10 people over the age of 65 developing the disorder. Women are much more likely to develop sleep apnea after menopause.³

It is thought that the occurrence of sleep apnea is much more widespread than the estimates show since many people who have the disorder go undiagnosed.⁴

In men over age 40, obesity, smoking and alcohol use increase the risk for obstructive sleep apnea⁵ and the condition occurs more frequently in African-Americans than in Caucasians.³

Obesity is the strongest risk factor. As body mass index increases by 1 standard deviation, the obstructive sleep apnea risk increases fourfold. Another strong risk factor is neck circumference, an indication that upper body or central weight gain puts people more at risk than overall obesity.⁶ Other risk factors for sleep apnea includes hypothyroidism, menopause and andropause and anatomical abnormalities.^7-9

Although people who have sleep apnea may not have any of these specific symptoms, common symptoms of sleep apnea include fatigue, excessive daytime sleepiness, headache (especially in the morning), restless leg syndrome symptoms, impaired thinking, chronic snoring, waking up abruptly with shortness of breath, episodes of breathing cessation during sleep, sore or dry mouth upon awakening, insomnia, depression and personality changes.¹⁰ In children, symptoms include attention deficit disorder, decreased intelligence, hyperactivity and aggressiveness.¹¹ Depression, insomnia and hypothyroidism are more common in women with sleep apnea than men.¹² I routinely observe more premature hormone cessation in both men and women with apnea, presenting with earlier menopause, andropause and adrenal fatigue.

Different Types of Sleep Apnea

There are three types of sleep apnea: obstructive, central, or mixed. In obstructive sleep apnea (OSA), which is the most common, patients upper airways are obstructed, causing airflow to stop during sleep despite respiratory effort. In central sleep apnea, there is a lack of central nervous system initiation, causing complete or partial lack of respiratory drive combined with at least 10 seconds of absence of breath during sleep. Only 10 percent of patients with sleep apnea have central sleep apnea;¹³ however, central sleep apnea syndrome is seen in approximately 40 percent of patients with congestive heart failure.¹⁴ Mixed sleep apnea is a combination of lack of respiratory effort and upper airway obstruction.

Health Concerns Associated with Sleep Apnea

Sleep apnea predisposes sufferers to a number of health concerns:

Cardiovascular Conditions

Sleep apnea elevates inflammation markers such as C-reactive protein, higher levels of which are linked to atherosclerosis and coronary artery disease.¹⁵ Individuals who have OSA also show increased platelet activity and aggregation (where blood cells clump together, clogging the arteries), higher levels of fibrinogen (a clotting factor) and a decrease in fibrinolytic (clot breakdown) activity.¹⁶

Furthermore, cardiac arrhythmias including premature ventricular contractions (PVCs) as well as both bradycardia and tachycardia are increased in sleep apnea.^17-18 Approximately 50 percent of individuals with OSA also have high blood pressure, which may be related to the fact that many OSA patients are obese.¹⁹ Research has shown that OSA severity is directly linked to severity of both sleep apnea and daytime hypertension.²⁰ Researchers also have determined that obstructive sleep apnea is an independent risk factor for strokes or transient ischemic attacks.²¹

Blood Sugar Concerns

Individuals who have sleep apnea are at a greater risk for abnormal glucose metabolism, insulin resistance and type 2 diabetes.^22-23 Treatment with a positive airway pressure device in individuals with OSA and type 2 diabetes resulted in an increase in insulin sensitivity and a decrease in levels of HbA1c, a marker for high blood sugar.²⁴

Gastroesophageal Reflux (GERD)

Those suffering from GERD experience an increased risk of OSA. Studies show that GERD becomes worse when the Apnea-Hypopnea Index (AHI) increases.²⁵

Decreased Mood and Well-Being

In veterans with sleep apnea, researchers noted a significant increase in mood disorders, such as depression, anxiety, dementia, psychosis and post-traumatic stress disorder.²⁶ Treatment with a positive airway pressure device, meanwhile, can reduce symptoms of depression.²⁷

Diagnosing Sleep Apnea

To test for the presence of sleep apnea, physicians will commonly either send patients to a sleep lab or monitor the patient with an at-home oximeter unit or portable cardiorespiratory device. Once the presence of sleep apnea is confirmed, conventional physicians may either suggest surgery or have the patient use positive airway pressure devices (CPAP, BiPAP, APAP), or oral appliances designed to open the airway during sleep. Positive airway pressure devices, which supply air pressure to force the respiratory passages open during sleep, are prescribed for more severe forms of sleep apnea while oral appliances are generally used in mild-to-moderate sleep apnea.

While these devices are effective at clearing the obstructed airway during sleep, they do not fully address the primary cause behind the sleep apnea nor the complications associated with the disorder.

Natural Support

The first approach I use with my sleep apnea patients is to monitor their hormone levels through a salivary hormone test (Comprehensive Hormone Panel) to check for imbalanced levels of cortisol and other hormones due to the increase in sleep apnea after menopause and andropause. Sleep apnea patients also have been found to have high cortisol levels and normal cortisol levels have been restored after CPAP treatment.²⁸

I find that supporting the health of my sleep apnea patients with various natural substances can be especially helpful. If cortisol levels are found to be high, I suggest using Cortisol Control, which is a combination of Relora®, a proprietary blend of Magnolia (Magnolia officinalis) bark and an extract from Phellodendron (Phellodendron amurense), and Sensoril®, a patented Ashwagandha (Withania somnifera) root and leaf extract. Relora and Sensoril lower cortisol levels and reduce the detrimental effects of stress.^29-30

N-acetyl cysteine (NAC) may help with the intermittent hypoxia (low oxygen) that occurs during obstructive sleep apnea. When animals were given NAC, the deleterious effects of intermittent hypoxia on respiratory muscle function were blocked, likely due to NAC’s ability to increase glutathione levels.³¹ NAC also protected heart cells of animals against the damaging effects of low oxygen conditions.³²

Melatonin is another natural substance that counteracts the damaging effects of hypoxic conditions. When researchers exposed hamsters to low oxygen conditions, the animals developed high blood pressure, fasting hyperglycemia, elevated levels of damaging compounds known as Reactive Oxygen Species (ROS) and narrowing of the blood vessels (vasoconstriction). Melatonin decreased blood pressure, blood glucose and ROS and widened the blood vessels (vasodilation).³³

Green tea also is emerging as a substance that may stop the side effects associated with sleep-apnea-related hypoxia. In an animal model of sleep apnea, green tea stopped some of the cognitive dysfunction that occurs during hypoxic conditions.³⁴

L-Tryptophan is another nutrient I use to support the health of patients during sleep. In one study, 12 subjects with obstructive apnea and 3 with central apnea were given an average dose of 2,500 mg L-tryptophan at bedtime. L-tryptophan resulted in significant improvement in the obstructive sleep apnea patients, who experienced the most dramatic improvement in non-REM sleep.³⁵

Due to the oxidative stress that occurs in sleep apnea, I have found that antioxidants such as vitamin C and vitamin E can be very helpful. In a study of obstructive sleep apnea subjects, lipid peroxidation (which occurs due to free radical damage to the lipids in the body) was significantly increased compared to normal subjects and levels of the antioxidant glutathione were significantly reduced. CPAP therapy as well as vitamin C and vitamin E given for 45 days reduced the lipid peroxidation and restored the glutathione concentrations in OSA subjects. After antioxidant intake, OSA patients slept better with decreased Epworth sleepiness scores and the number of sleep apnea episodes, and they spent more time in stages 3 and 4 sleep. Additionally, the optimum CPAP device pressure was significantly lowered after the subjects consumed the antioxidants.³⁶

Conclusion

Sleep apnea is an underdiagnosed problem and can be the overlooked culprit behind a number of concerns, including coronary artery disease. It not only affects the person suffering from the sleep apnea, but also sleeping companions who experience sleep disruption due to their partner’s nightly snoring or worry about the one they care about.

After testing determines patients have sleep apnea, I have found that monitoring cortisol and hormone levels with a salivary hormone test and supporting their health with Cortisol Control (if levels test high), NAC, melatonin, green tea extract, L-tryptophan and vitamins C and E can have profound effects on their health. These supplements are not intended to be used as a substitution of conventionally accepted apnea therapy, but rather as adjunctive support. Sufficient oxygen is essential for the performance of every cell within your body; therefore, any changes to current or future pressure of a positive pressure device needs to be adjusted by one’s attending sleep specialist provider.

References

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