August 2016 - NON-MEDICATED LIFE
How Lifestyle Can Impact Sleep Apnea
By Paul E. Lemanski, MD, MS, FACP
Editor’s Note: This is the 72nd in a series on optimal diet and lifestyle to help prevent and treat disease. Any planned change in diet, exercise or treatment should be discussed with and approved by your personal physician before implementation. The help of a registered dietitian in the implementation of dietary changes is strongly recommended.
Medicines are a mainstay of American life and the healthcare system not only because they are perceived to work by the individuals taking them, but also because their benefit may be shown by the objective assessment of scientific study. Clinical research trials have shown that some of the medicines of Western science may reduce the risk of heart attacks, strokes and cardiovascular death while others may reduce certain types of cancer.
In the first 71 installments of the Non-Medicated Life, informed diet and lifestyle have been shown to accomplish naturally for the majority of individuals, many, if not most of the benefits of medications in the prevention and treatment of chronic medical conditions. When implemented by an individual, informed diet and lifestyle as a medical intervention may accomplish such benefits at lower risk for side effects, and may reduce the number and amount of medications, and may allow actual discontinuation of medication. Equally important, the benefits of a lifestyle approach in the treatment of chronic medical conditions may also reduce reliance on certain surgical procedures and devices. Sleep apnea is a case in point.
Sleep apnea or more exactly obstructive sleep apnea (OSA) is a condition characterized by a collapse of the upper airway during sleep with temporary cessation of breathing. Typically, the bed partner of the affected individual will first note progressively deeper snoring. The snoring is a result of partial airway collapse that occurs with an increasing loss of tone of the muscles of the throat as one enters deeper stages of sleep. At a certain point the muscles of the throat and upper airway become so relaxed that complete obstruction occurs and breathing stops. During the period of apnea carbon dioxide builds up in the bloodstream and oxygen falls, and the individual comes out of the deeper, restorative stages of sleep, gasps, takes a breath, rolls over and resumes snoring. This process may repeat many times during the night with significant negative consequences on health.
Unfortunately, denying an individual access to the deeper, restorative stages of sleep results in excessive daytime sleepiness as the body tries to recapture the sleep that has been lost. Individuals may fall asleep while driving or using machinery resulting in injury or even death. Additionally, those suffering from OSA may experience fatigue, poor concentration, cognitive dysfunction, memory problems, insomnia, mood changes, gastro-esophageal reflux, and morning headaches. The fall in oxygen during periods of apnea constricts blood vessels in the lungs and may, if severe, cause heart failure, hypertension, fatty liver, stroke, heart arrhythmias and even sudden death.
The diagnosis of OSA begins with a heightened index of suspicion based on the characteristic symptoms described above, especially when combined with established risk factors. Risk factors for OSA include obesity, a neck circumference greater than 17 inches in men and 15 inches in women, increasing age, male gender, the onset of menopause, abnormal nasal or throat anatomy, nasal congestion, smoking, and family history of OSA. The use of alcohol, narcotics, benzodiazepines or prescription sleep medications, while not definitively shown to cause OSA may exacerbate it significantly, if present.
Periods of apnea witnessed by a bed partner are very strong evidence for OSA. Screening questionnaires such as the Epworth Sleepiness Scale are validated tools for helping to identify OSA. Finally, home sleep apnea testing or the even more definitive in-lab sleep study allows the diagnosis to reliably be made.
While treatment for OSA has relied primarily on surgical procedures and devices, there are limitations with such approaches. The C-PAP (continuous positive airway pressure) device blows air into the nose and upper airway to counter the tendency for airway collapse during the deeper stages of sleep. C-PAP is an effective treatment although may not be tolerated long term by up to 50% of those who would benefit.
UPPP is a surgical procedure that trims tissue from the soft palate, and uvula, and removes the tonsils. UPPP makes the upper airway internal dimensions more open and thus less likely to collapse during sleep and is an effective treatment. It is nevertheless an invasive surgical procedure and as a consequence has associated risk.
For those with mild OSA a dental device, which repositions the jaw and tongue during sleep, may be an effective treatment. While seeming less invasive and problematic than the first two options mentioned, this one also requires consultation with a pulmonologist or otolaryngologist to determine appropriateness. Sometimes a repeat in-lab sleep study is required to prove efficacy in a given patient.
With the limitations inherent in surgical procedures and devices, a lifestyle approach to the management of OSA may offer a low risk, low cost alternative in less sever cases. Or such an approach, even if only modestly reducing the degree of obstruction, may allow a C-PAP device to be more efficient and better tolerated or may reduce obstruction sufficiently to allow a dental device to be used.
The lifestyle modification approach to treating OSA involves: weight loss (in those individuals who are overweight or obese), daily aerobic exercise, modification in sleep position, and the avoidance of alcohol and medications that can worsen sleep apnea. There is also some limited data that exercises of the tongue and muscles of the throat may also help reduce obstruction.
Weight loss in those with OSA who are overweight (BMI 25.1-29.9) and those who are obese (BMI > or =30) has consistently been shown to improve the OSA including lessening symptoms of excessive daytime sleepiness. A weight loss as little as five pounds may prove helpful with greater weight loss offering additional help.
Daily aerobic exercise may help contribute to weight loss and weight maintenance, and has shown to be effective in reducing OSA. However, daily aerobic exercise, even when it does not result in weight loss has been shown to be effective in reducing OSA.
Sleep position – Those individuals whose OSA is brought on or significantly worsened primarily by sleeping supine (face and torso up) may find significant improvement by simply choosing to sleep on their side. Sewing a tennis ball into the back of the pajama top may help in maintaining such a position throughout the night, and may be both an inexpensive solution and effective.
Alcohol should be completely avoided in all patients with untreated OSA because it may significantly worsen the severity of obstruction.
Medications – Drugs such as benzodiazepines, barbiturates, narcotics, sedating antihistamines and prescription sleeping pills should also be avoided as they also may worsen OSA.
In summary, OSA is a condition that is increasingly common and may cause significant, life threatening health problems. Typically, the condition is treated with either surgical procedure or device. Unfortunately, neither may offer a well-tolerated, nor effective long-term treatment.
A lifestyle approach to OSA may serve as a lower risk, lower cost alternative in less severe cases, or may allow the use of a device to be more efficient and better tolerated. As such, a lifestyle approach to OSA may reduce our over-reliance on risky surgery and expensive devices as well as improve outcomes in the management of one of our most significant healthcare problems.
Paul E. Lemanski, MD, MS, FACP (firstname.lastname@example.org) is a board certified internist at the Center for Preventive Medicine, CapitalCare Medical Group in Albany. He is medical director of the Department of Community Medicine and Population Health at CapitalCare Medical Group. Paul has a master’s degree in human nutrition. He is an assistant clinical professor of medicine at Albany Medical College, and a fellow of the American College of Physicians.