By Franz Gliederer, MD, MPH and the pH health care professional team

Sleep is a big deal! The average person spends 25 years of life sleeping, and a good night’s sleep is absolutely essential for good health. Therefore, it’s no surprise sleep quality and health has attracted a lot of attention in recent years. Many of us aren’t  getting the sleep we need because of  sleep apnea, which is on the rise in the United States. Many cases of sleep apnea go undiagnosed and untreated, and this is a public health hazard.

With sleep apnea, a person has episodes when their breathing stops during sleep. It is commonly observed in people who snore, are overweight and people who have conditions that partially obstruct their upper airways. It can affect people of all ages but is more prevalent among middle-aged adults to senior citizens as well as among males. It is estimated  3-15 percent of the general population may have sleep apnea. When also considering  mild sleep apnea, rates may spike up to 62 percent in certain communities over age 65. Among children, it’s not as common -- around 7 percent are affected.

Pauses of breathing during sleep were reported as far back as 2,000 years ago. Ground-breaking research became possible after the introduction of technical devices that monitor and record breathing disturbances during sleep. These devices have been around since 1965. By the late ‘70s and ‘80s, research on sleep apnea was fully established and continues to expand today.

Today’s polysomnography or “sleep study” is the standard for sleep apnea evaluation. However, there is also increasing demand for portable sleep-monitoring devices to use at home. Keep in mind, at-home testing is not quite as sophisticated or accurate as a supervised polysomnography in a lab.

What happens in the body with sleep apnea?

Pauses in breathing cause decreased oxygen levels. For a healthy person, normal oxygen saturation levels are typically between 97 and 100 percent. During episodes of sleep apnea, oxygen may drop to 90 percent or lower. This is the equivalent to a moderate asthma attack or moderate pneumonia. At some point, the brain registers low oxygen levels and sends out signals to initiate breathing muscles to work again. This explains the gasp or choking sound followed by a deeper breath after a prolonged pause in breathing. The person may or may not wake up when this occurs. Breathing pauses can last seconds or minutes. Sleep apnea symptoms may vary daily and can change due to environmental conditions.

Breathing during the night may not necessarily stop completely but gradually change into shallow breathing. When air flow decreases to the lungs, this causes similar chronically intermittent lack of oxygen throughout the body. The intermittent lack of oxygen may lead to early temporary dysfunction in cells especially in oxygen-sensitive organs such as the brain or heart.

Frequent intermittent periods of low oxygen can disturb your sleep quality and make you feel chronically tired. Sleep apnea causes difficulty concentrating, decreased memory and decreased overall energy levels. If the condition persists and progresses, chronic diseases such as hypertension, cardiac arrhythmias, heart disease, stroke and diabetes can develop.

Risk factors for sleep apnea

Risk factors for sleep apnea include advanced age, being male, obesity, high central fat distribution, family history, menopause, craniofacial (bones of the skull and face) abnormalities, allergies, impairment of nasopharyngeal pathways, chronic runny or clogged nose, an underfunctioning thyroid and certain health behaviors such as cigarette smoking and heavy alcohol use and taking certain medications (including sedatives).

Types of sleep apnea and breathing disorders during sleep

1. Obstructive sleep apnea: This can be caused by being overweight, which makes it harder for the respiratory muscles to expand the lungs due to excess belly fat. Excess or laxity of pharyngeal soft tissue can partially obstruct upper airways, causing impaired airflow to the lungs. Nasal congestion due to infections, allergies or polyps may also interfere with breathing during sleep.

2. Central sleep apnea: Brain respiratory centers control breathing. Problems occur if the brain does not register declining blood oxygen levels adequately or does not activate the respiratory muscles in a timely fashion unless the oxygen levels drop very low. Central nervous system-depressing drugs or alcohol can decrease activity of the respiratory centers in the brain, decreasing the rate and depth of breathing during sleep. Both obstructive and central sleep apnea can overlap.

3. Other lung conditions: If someone already has a lung condition such as COPD or asthma, this can amplify sleep breathing problems. Air pollution is also linked to increased occurrences of sleep apnea. Although not fully understood yet, this may have to do with the stiffening, loss of elasticity and recoiling of the lungs. Air pollution has shown to increase premature aging and narrow blood vessels. Blood vessels in the lungs are vital, because they are needed to allow optimal oxygen uptake into the bloodstream and therefore the whole body.

What are the symptoms of sleep apnea?

• Headaches in the morning

• Exhaustion and fatigue

• Difficulty concentrating

• Night sweats and frequent urination

• Dry mouth when waking up

• Waking up during the night with increased heart rate

How can you get diagnosed with sleep apnea?

There are two common tests used to screen for obstructive sleep apnea. The Epworth Sleepiness Scale is useful in assessing clinical symptoms but does not identify all cases. Epworth Sleepiness tests assess daytime sleepiness scores such as dozing off while sitting, watching TV, sitting in a public place, lying down in the afternoon, sitting and talking to someone, sitting quietly after lunch and sitting in a car while stopped in traffic for a few minutes.

The Berlin Questionnaire is highly sensitive to detecting obstructive sleep apnea, which means it can detect the condition at a high level. However, it can misidentify people who end up not having sleep apnea at all. The Berlin Questionnaire considers height/weight/BMI as well as whether snoring occurs and how frequent and loud it is. Other observations include breathing pauses in the person’s sleep, if the person feels tired after sleep, nods off while driving or has high blood pressure.

Often, sleep tests occur at specialized testing facilities where patients check in. The patients are attached to wires to various recording devices to monitor breathing rates and depth, heartbeat (ECG), brain waves for assessment of depth of sleep (EEG), oxygen saturation, limb movements and abnormal sounds while sleeping. A trained sleep technician monitors the patient, adjusts settings or assists with nasofacial oxygen in case of severe oxygen deprivation. The data is then analyzed and an Apnea/Hypopnea Index (AHI) is assigned. The AHI essentially corresponds to clinically significant episodes of low oxygen and breathing pauses per hour.  

What are abnormal results?

After data recording, a physician trained in sleep medicines assesses the AHI and clinical data and gives a final report on scores and clinical interpretation.

Breathings pauses lasting longer than 10 seconds are abnormal. The AHI corresponds to the number and extent of sleep apnea episodes. An AHI less than five per hour is considered normal. AHI between five and no higher than 15 suggests mild sleep apnea. AHI 15 to 30 is moderate. Lastly, a score greater than 30 is considered severe sleep apnea.

What are the consequences of abnormal sleep apnea testing?

If a sleep study result verifies moderate or severe sleep apnea, the doctor will recommend another sleep study test and apply positive air pressure devices, which help assist with artificial breaths when breathing stops. The device is attached to the mouth and nose and delivers air/oxygen to the lungs. This effectively improves sleep apnea symptoms and daytime fatigue. When someone needs this type of device, it is usually for life. Stopping treatment causes sleep apnea to resume.

Persistent untreated sleep apnea can cause the following illnesses, which may shorten life span and decrease quality of life:

• Hypertension: Blood pressure during sleep tends to be 10 percent lower than during the daytime. However, sleep apnea can produce surges in blood pressure during the night, which can persist through the following day. Intermittent lack of oxygen due to impaired breathing from sleep apnea increases the sympathetic nervous system tone, oxidative stress and arterial cell dysfunction. This combination leads to persistent hypertension. Sleep apnea is present in 30 percent of people with hypertension and in 80 percent of refractory (difficult to treat) hypertension. Therefore, treating sleep apnea may be an integral part of hypertension treatment and prevention in the future.

• Heart disease and stroke: Not surprisingly, heart disease, heart attacks and strokes are more frequent and come earlier as a consequence of high blood pressure and sleep disturbances. There are also strong links between development of cardiac arrhythmias and sleep apnea. Initially, blood pressure may just elevate during the night, daytime blood pressure may still stay normal.

• Overall death rates increase: Severe obstructive sleep apnea has markedly increased death rates from 4-6 fold, and moderate obstructive sleep apnea most likely carries a 2-3 times risk of death.

• Abnormal glucose metabolism: Research suggests sleep apnea can negatively affect glucose metabolism and lead to the development of diabetes. In return, diabetes worsens sleep apnea. Sleep apnea is present in about 23 percent of diabetics, and 58 percent may have some type of sleep breathing disorder.

• Weight gain: Less oxygen means a person’s metabolism cannot work as effectively. This implies a slowed metabolism, which contributes to weight gain.

• Daytime sleepiness and fatigue: Sleep apnea interferes with sleep quality as evidenced by waking up drowsy or fatigued, which may resolve as the day progresses or persist.

• Neurocognitive impairment: Several studies have shown obstructive sleep apnea has an adverse effect on inductive and deductive reasoning, attention span, vigilance, learning and memory. People with obstructive sleep apnea may develop mild cognitive impairment an average of 10 years earlier than those without sleep breathing problems, according to the American Academy of Neurology.

• Depression. People with sleep apnea may be five times more likely to have clinical depression. An American Academy of Sleep Medicine study found continuous positive airway pressure (CPAP) therapy reduced symptoms of depression in people with sleep apnea.

Treatment for sleep apnea

Continuous positive airway pressure (CPAP) delivery is an effective treatment. This can be administered by a variety of devices including nasal, oral or combined devices worn during sleep. Once the first sleep study confirms the presence of clinically significant sleep apnea, a second study is needed to fit positive air pressure devices to the patient and adjust them to individual needs to optimize breathing during sleep.

Despite effectiveness of naso-oral breathing devices for sleep apnea, they are not comfortable for everyone. Therefore, a number of patients are noncompliant with the treatment or stop it altogether.

In some cases, your doctor may recommend upper airway surgery, a dental appliance to reposition the lower jaw or even a type of nerve stimulation.

Currently, there is no known effective drug regimen.

Increased cardiovascular breathing exercises may counteract sleep apnea severity, but current findings are inconsistent.

Nutrition may not be the first thing you think of with sleep apnea. A study published in the European Respiratory Journal found following the Mediterranean diet for six months combined with exercise was effective in reducing the AHI score (used for diagnosing sleep apnea).

The Mediterranean diet

Many major scientific organizations endorse the Mediterranean diet as a proactive way to prevent major chronic diseases. The diet is based on traditional cooking styles of the countries bordering the Mediterranean Sea and includes staples such as olive oil and a glass of red wine!

According to the Mayo Clinic, additional staples and rules of the Mediterranean diet include:

• Mostly plant-based foods such as fruits and vegetables, whole grains, legumes and nuts

• Olive oil and canola oil (instead of butter)

• Herbs and spices (instead of salt for flavor)

• Limiting red meat to a few times per month or less

• Eating fish and poultry at least twice per week

• Enjoying meals with family and friends

• Getting plenty of exercise

• Drinking red wine in moderation (optional)

In addition to the benefits for someone with sleep apnea, additional benefits of the Mediterranean diet may include lower LDL cholesterol (the “bad” kind that builds up in your arteries) along with a reduced risk of heart disease, cardiovascular-related death and overall death; and reduced rates of cancer, Parkinson’s disease and Alzheimer’s.

Since a person with sleep apnea may also have other diseases and increased risk factors for diseases, talking to your doctor about the Mediterranean diet is a good idea!

Vitamins and minerals for sleep apnea

Spectracell Laboratories offers micronutrient testing through companies such as Proactive Health Labs and others across the country. Click here to view their graphic about sleep apnea and nutrition! Keep in mind, while research may link certain nutrients with sleep apnea, your best bet is to talk to a health care professional about nutrient testing. Testing can help you identify any deficiencies or imbalances and choose the appropriate dosage. Like anything, too much of a good thing can be a hazard to your health!

Cysteine - Oral supplementation with cysteine, the precursor to glutathione, has therapeutic potential for sleep apnea. Snore time and duration were significantly reduced for patients treated with N-acetyl cysteine compared to untreated sleep apnea patients.

Antioxidants - It is well documented  sleep apnea patients have both reduced antioxidant capacity and higher levels of oxidative stress than controls.

Vitamin C - Improves endothelial function (blood vessel health) in sleep apnea patients to levels seen in people without sleep apnea.

Vitamin E - Mitigates the oxidative stress seen in sleep apnea patients; Works synergistically with Vitamin C.

Vitamin A - Sleep apnea patients have low retinol (vitamin A); Retinol suppresses the growth of vascular smooth muscle, a process that causes blood vessels to clog, linking low vitamin A levels to the cardiovascular complications seen in sleep apnea patients.

Vitamin D - People with sleep apnea have a high prevalence of vitamin D deficiency; The worse the apnea, the more severe the deficiency; Evidence suggests low vitamin D worsens sleep apnea's negative effect on heart disease risk.

Selenium - In one case report, selenium supplementation completely stopped snoring caused by non-obesity sleep apnea; Selenium's role as a potent antioxidant may reduce the oxidative stress seen in sleep apnea patients.

Copper - Considered a strong predictor of oxidative stress in sleep apnea patients; Copper's role as a key cofactor in the powerful antioxidant superoxide dismutase (SOD) explains this; SOD is very low in apnea patients.

Other minerals - The trace minerals zinc, copper, magnesium, manganese and selenium are critical cofactors for the major antioxidant enzymes, which are important in repairing cellular damage caused by hypoxia (lack of oxygen) in sleep apnea.

Glutathione - Low levels linked to sleep apnea; This powerful antioxidant helps repair liver damage caused by sleep apnea.

Overdiagnosis and underdiagnosis

Sleep apnea may be underdiagnosed according to a Centers for Disease Control and Prevention study published in the journal SLEEP. In fact, more than 80 percent of the people who reported classic symptoms of sleep apnea such as snorting or gasping for breath most nights had never received an official diagnosis.

Mild sleep apnea, however, may not necessarily produce significant clinical symptoms and could be overdiagnosed. (You can read more about new guidelines for sleep apnea screening here).

Be proactive!

Learn more about how minerals can affect your sleep and energy levels in our new book, Minerals - The Forgotten Nutrient: Your Secret Weapon for Getting and Staying Healthy! Find it here.

Enjoy Your Healthy Life!

The pH professional health care team includes recognized experts from a variety of health care and related disciplines, including physicians, health care attorneys, nutritionists, nurses and certified fitness instructors. To learn more about the pH Health Care Team, click here.