May 16, 2015
Podcast from https://bengreenfieldfitness.com/2015/05/a-hidden-sleep-killer/
[02:16] About Dr. Joseph Zelk
[04:45] The Sleep Medicine Group
[06:57] In-Home Sleep Monitoring
[09:24] Wearables Versus Home Sleep Monitoring
[12:01] Using A Pulse Oximeter To Quantify Sleep
[16:17] The Ideal Scenario For The Amount Of Time Spent In Deep Sleep
[20:26] Healthy People with OSA
[25:47] Blood Tests and Sleep
[32:19] Strategies Used To Address OSA
[44:04] Dr. Zelk's Personal Sleeping Habits
[54:16:1] End of Podcast
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In this episode of The Ben Greenfield Fitness Podcast:
“When you're having apnea, you're basically closing off your throat unconsciously, and then unconsciously you're trying to breathe against an obstructed airway until finally, you big surge of adrenaline.” “So you should feel a good chunk of delta sleep or deep sleep. And typically, if it's an accurate unit, it'll show you that most of your deep sleep is happening in the first hour to two of your whole sleep period. And then as the night goes on, you should get longer and longer REM episodes until all of your last hour of sleep is mostly REM.” “That's part of the insurance reimbursement. This is a valid therapy that most insurance companies cover.” “Don't wait for your kids to be twelve to do braces if they have narrow jaw or crooked teeth. Get in there early and go to a functional orthodontist.”
Ben: Hey, folks. It's Ben Greenfield here, and a few weeks ago I actually got a really interesting e-mail from a podcast listener. And the e-mail was a little bit cryptic, but it was basically about, or a response to something I had mentioned regarding tracking sleep and improving sleep on a podcast. And this e-mail contained the following quote, it said: “you could improve sleep also by a simple screening of oximetry to rule out OSA in your adrenal fatigue clients.” And then the e-mail went on to talk about something called “OSA” and some issues that this individual who was a certified sleep specialist had actually observed in many of the folks that they've worked with regarding this sleep disruptor that I was actually unfamiliar with.
So I wrote back to this guy, this board-certified sleep specialist, and we kind of went back and forth about blood oxygen saturation, and something called obstructive sleep apnea syndrome, and a lot of other things regarding sleep, and how sleep can get disrupted, and some of the things that kind of fly under the radar when it comes to insomnia, jet lag, disrupted sleep, narcolepsy, and other sleep disorders. So I figured that I should actually get this guy on the podcast to talk about this stuff with us, and so I did. He's here with us now. His name is Dr. Joseph Zelk. And Dr. Zelk is the medical director of something called “The Sleep Medicine Group“, which you'll hear all about in this podcast. But if you've ever wanted to get better sleep, or fall asleep faster, or get deeper sleep, or beat insomnia, or manage jet lag a little bit better, this is going to be a really good podcast for you to listen into. So Joe, thanks for coming on the call, man.
Joe: Thanks, Ben! Good to be here! Love the podcast.
Ben: Awesome, awesome. Well, it sounds to me like you've got this sleep thing figured out, so I'm pretty happy to get you on the show 'cause we get questions about sleep all the time. And I guess my first question is I've never actually heard of The Sleep Medicine Group and don't really understand or know what you do. So can you give a little bit of your background and what exactly The Sleep Medicine Group actually is?
Joe: Sure. Sleep Medicine Group is an interdisciplinary sleep disorder center. We have, surprisingly, a dentist who's board-certified in something called dental sleep medicine, believe it or not. I'm bored-certified sleep specialist. We have an ear-nose-throat surgeon who is available to assess the nasal flow and do less invasive surgical procedures for soft tissue. We do diagnostic testing. We used to be an in-lab facility where you'd go spend the night and do what, everyone's probably heard of a polysomnogram or a PSG, where it takes an hour to hook you up, and go through the whole process, and hopefully pray to fall asleep. Or we'll just give you a little sleeping pill to force you to go to sleep.
But nowadays I've gotten into, and very early on in the technology of a diagnostic psych, I went into home sleep testing where you can actually assess sleep staging, and oximetry, and of course breathing disruption in sleep in the comfort of your own home. And so we do that as well as provide home diagnostics consulting on insomnia, primary sleepiness disorders like narcolepsy, and of course the most prolific which is obstructive sleep apnea where the airway tightens up on you. And we provide dental appliances, which are essentially retainers that go on the upper and lower teeth to hold the jaw slightly forward to avoid airway collapse, auto-adjusting CPAP devices, or the abbreviation is for Continuous Positive Airway Pressure. Basically you're ballooning the back of the throat open throughout the night so your airway doesn't collapse on it. And of course, less invasive, what we call phase one soft tissue reduction procedures. There's lots of surgeries you could do on your quest to cure your sleep apnea, but many of them have not panned out to be very consistently effective.
Ben: So this in-home sleep monitoring that you just mentioned, what exactly is that? How does that work?
Joe: Yeah. So there's different channels of data that you collect when you're looking for sleep disorders. And in the sleep laboratory, there's fifteen channels, there's electroencephalograms, TED, electrooculograms, so your eye movements, [0:07:13] ______, ECG for cardiac rhythm, what we call inductive plasmatographic bands, which are basically bands over the chest and the abdomen to see what your breathing pattern is, and a whole slew of things which is overkill for the vast majority of people who just want to stay on top of their game and are not just really chronically ill. So home testing does a limited version of that, anywhere from two to sometimes five or even more channels of data. And typically it's looking at, depending on the unit you have, a limited level of what we call a montage or an electroencephalographic configuration where you do with just a couple sensors to look for sleep staging. You look at airflow through something that looks like an [0:07:59] ______ canula, but it's actually a nasal pressure canula. It looks at airflow limitation as you breathe in and out through the nose. Oxygen levels, so we're looking at pulse oximetry to see how the red blood cells are saturated with oxygen.
And of course there's also plasmatography where with some of the sensors, we can actually see when the blood vessels, the small venules of the terminal portions of the veins actually bulge during a sleep apnea event. And the reason when they would do that is when you're having apnea, you're basically closing off your throat unconsciously and then unconsciously you're trying to breathe against an obstructive airway until finally you get a big surge of adrenaline to do what we call fragmented sleep or cause what's an arousal where the brainwave activity gets from a slower wave to a faster wave where you can actually tone up the muscles and breathe again. Mostly, you would know about. The vast majority of patients have no clue. They're like, “Oh I'm, wait, I happen to be snoring and peeling the paint off the wall and people can hear me in the next room, but I sleep great.” And that's the interesting…
Ben: So when you're doing this kind of home sleep monitoring, how does this compare to a lot of the apps and the wearables that are out there that are giving sleep data? I mean, have you ever compared the data that you're getting to the data that a lot of these wearables are giving? Or is this completely apples and oranges?
Joe: I'm so glad you asked that. Don't get too involved in the technology that's in the abstract now. They're very limited. Very few have actually been clinically validated. The only one that I know actually has any decent data on it is the MyBasis Watch by Intel. Most of them are just going to give you a really limited actographic movement. And if you don't have anyone in the bed, or no dogs, no family members, they can give you a fairly decent amount of data feedback on if you're moving a lot throughout the night, or if you're just simply doing the most common problem in America, which is insufficient sleep syndrome, just not getting enough sleep. If you track that and you see that your average for the week is below, say, seven and a half hours of sleep, then obviously you know that you're not at your peak game. And if you're tossing and turning a lot, that might be a little bit of a data plug, but you really don't want to go by…
Ben: How about the deep sleep phases versus the light sleep phase? Is that something that a lot of these wearables will tell you when you wake up? They tell you sleep latency, how long you're in deep sleep, how long you're in light sleep. Is the system that you're using different than what they're using as far as like accelerometers and things of that nature?
Joe: Yes. Definitely different. So when you use home testing that has an electroencephalographic waveform observation, you're looking for those changes from beta to alpha, to changes and muscle tone with REM along with heart rate variability.
Ben: So are these actual, these electroencephalographs, you're actually wearing electrodes that are hooked up to you as you're sleeping?
Joe: Yeah. There's one really great small unit called the ARES unicorder that basically is a headband with a computer the size of a small box. And it has two electrodes on the frontal, basically on the frontal part of the forehead there, and a little oxygen sensor that reads your blood oxygen through a sensor, a non-invasive sensor on your skin, and it has a nasal pressure canula. So you're literally looking at the brain wave activity in some of these units. Now not all of them do that, but many of them do.
Joe: Which is pretty cool.
Ben: So why is it that you would want to measure, and this kind of leads into why you first wrote me, right? You mentioned using a pulse oximeter upon waking. Can you explain just really quickly, I think some people understand pulse oximetry, some don't, so explain what that is and why you would want to actually use something like that as a way to measure quality of sleep?
Joe: So you are really into quantifying health, and I love this about a lot of the latest up and coming health podcasts is they love that you're getting information on exposure to heavy metals, and heart rate variability, and advanced biomarkers. Those are really great tools. But we're really missing the boat here if we don't look at the most common disorders that can rob us of our highest performing state of health. And so, if you don't look at the one-third part of your life that you are totally unaware of, you're missing a big part of your performance. So oxygen saturation can easily be robbed from you when you're unconscious. And it's extremely prolifically just out there. A ton of people have this. And so like I talked to you before, a ton of people have airway disruption and snoring. It's not just a social problem. You're actually depriving yourself of good oxygen flow. You're becoming hypercapnic, or because you ventilate, you're getting higher carbon dioxide levels in the blood, which makes you acidic. So then you're obviously not metabolizing well. So if you cause unconscious arousals or fragments of sleep, you won't get the performance that you need. So the easiest and simplest way to rule out at least a significant problem, like a moderate level of apnea or a severe level, because you're unaware of it, is to buy some of these lower cost oximeters to wear at night, at least for a few nights, to at least get a good peace of mind. And that will let you know if you are having any of these oxygen dropping episodes. And a lot of these oximeter on Amazon, or even the one I like is SPO Medical, which is actually a wrist band, it has a very fast oxygen sampling rate.
Ben: That's a wristband?
Joe: Yeah. It's a wristband oximeter. It's got a computer in it, and you can plug it into, it's a little bit more expensive, it's probably a couple hundred dollars. But there's another one on Amazon, I forget the name of it, it's like D5 of something, super cheap…
Ben: And this one's called an SPO Medical?
Joe: SPO Medical is the manufacturer. And there are several manufacturers that make really good quality ones.
Ben: So what we're looking for is an oximeter that's able to actually keep track of your pulse oximetry, or your blood oxygenation levels, during the night. So it's not just give me a one-time snapshot when you wake up, but you're somehow able to download the data that you've gotten during the night?
Joe: Yeah. And you can download it, and you'll see it throughout the night if you're having any oxygen changes. And you can see, if say most people who are younger and healthier might start finding the apnea creeping in when they end up on their back unconsciously, or maybe when REM happens, REM sleep, and let's talk about that a little bit, sleep comes in cycles, and I think you've talked a little about this in the past in some of your other podcasts, it goes into a what we call N1, or non-REM 1 sleep, very unrefreshing, very short period when you first go to bed. Then it goes to N2, which is stage two sleep, kind of intermediate. And then you'll get a big surge, if you're younger, of delta sleep, or deep sleep. And that's when you get your growth hormone surges. You do a lot of gluconeogenesis in the liver, and lipoprotein metabolism in the liver in that period of time. Plus you get healing in the muscles in the body. Most people dream when they're in REM, and that will recur every 60 to 90 minutes throughout the night for about four or five cycles. So when you have REM, muscles relax throughout the body, so you don't do something freaky like act out your dream and whack the person next to you.
Ben: Now a lot of times when you're using these type of sleep quantification devices, like I've used the Move x20 by Timex for example because I raced for Timex. I have one of these that they sent me, and when I wake up in the morning after using this, I'll get a graph of time spent in deep sleep versus time in light sleep versus time in REM. Is there a standardization? Should we be looking for an ideal scenario in terms of the number of deep sleep phases that we go to or the amount of time spent in deep sleep?
Joe: Sure. The standard cycle should be around four to five cycles. So you should see a good chunk of delta sleep or deep sleep early in your night. And typically if it's an accurate unit, it'll show you that most of your deep sleep, or we call slow wave sleep, with delta waveforms is happening in the first hour or two of your sleep cycle. Your whole sleep period, sorry. And then as the night goes on, you should get longer and longer REM episodes, until like your last hour of sleep is mostly REM sleep. So if you see that sort of textbook sleep graph, or we call hypnogram, then you can feel confident that you have a pretty accurate unit, very likely, if there's no one else in the bed with you, if there's no dogs, no children. It's all based on accelerometer movement and actography. If you have these confounders, it's going to totally throw off what those units say to you.
Ben: Okay. Gotcha. So you recommend, in addition to looking for those cycles when it comes to sleep phases, some kind of an oximeter, and I'm taking some notes here, by the way. For those of you listening in, if you go to bengreenfieldfitness.com/sleepdoctor, that's bengreenfieldfitness.com/sleepdoctor, I'm taking some notes on the oximeter that Dr. Zelk recommends along with some of the other things that we're talking about here. So you need an oximeter that will take a good sampling rate and something that you can download data from in the morning, and you're going to look for a drop in oxygen saturation when you look at that oximeter. Does that oximeter actually measure anything related to heart rate as well? Like does it measure if your heart rate speeds up or slows down?
Joe: It does. Pulse oximeters look at pulse variation, and you can see what we call a tachy-brady pattern where when your airway's being closed and you're having problems breathing, it's where you basically get a vagal nerve stimulation, and that will cause an artificial lowering of the heart rate or bradycardia. And then as the airway opens and you get the arousal, you'll get oxygen flowing in the body, and adrenaline surging through the body, and you'll see what we call a tachy, or a faster heart rhythm. And if you see that sort of tachy-brady syndrome, even if you don't have a whole lot of oxygen deprivation, which milder cases of apnea do not necessarily have, oxygen pulse oximetry drops yet, you're pitching it way early, you might see that in these what we call tachy-brady episodes, or brady-tachy.
Ben: Now what happens to, I know these don't measure your heart rate variability, but what would technically be happening to heart rate variability if you were also keeping an eye on that or are measuring that during these periods of obstructive sleep apnea?
Joe: So what you'll typically find in the morning if you are using a HeartMath unit or one of those other units for heart rate variability is you'll find that if someone's having brady-tachy or tachy-brady, whichever you want to call it, or apnea problems where you're in a high level of oxidative stress, you typically will find a reduced heart rate variability upon awakening. So that might be kind of a clue to if you're doing everything right and you're sleeping fine or your sleeping duration that are appropriate, and your heart rate variability is not in the nice zone of variability and it's less variable, you might want to think, “Oh, I should be looking into my sleep quality. What's affecting my sleep quality.”
Ben: Gotcha. Okay. So in terms of obstructive sleep apnea, I got to tell you that in most cases I have seen this associated with things like obesity and a sedentary lifestyle. What can be said in terms of healthy folks, which is really a lot of the people listening to this show are relatively healthy, they're fit, they're exercising, they're not struggling with huge amounts of obesity. What about people who are fit and lean? Are you seeing OSA, this obstructive sleep apnea in these folks and why would that be?
Joe: Oh, I love it that you ask that. One-third of patients who have obstructive sleep apnea are within what we considered essentially a normal body mass index, around 25 thereabouts, of standard deviation. And those folks won't know about it unless they hear the prevalence on a well-informed show like this. I'll give you my case for example. I'll share with you, I have obstructive sleep apnea. I don't know if you saw the pic I showed you from my before and after when I started doing less carbohydrate, but even at my highest, I was at 27 body mass index. Even one or two standard deviations can dramatically, of body mass index, could dramatically change your level of not having sleep apnea or having sleep apnea. So if you're within that 25 to 28 BMI, which you kind of look at yourself and say, “Oh, I'm pretty great. Typically normal, great.” You might have apnea more prevalently than if you were at say, even at a peak performance weight of like 23, 24. But a ton of folks have it even at a very lean body mass, and I was telling you about my picture. Even on my follow up picture where I was 9% body fat, I still had an obstructive sleep apnea score of seven. And my typical at my higher weight, 27 BMI, which was not heavy, is 19.
Ben: Can you explain those scores real quick? Just for people who need to get their heads wrapped around how you're quantifying this?
Joe: Yeah. So the way you quantify obstructive sleep apnea is you look at your breathing disruption episodes, and the minimum criteria, the 10 second sensation of breathing while you're asleep. Almost no one has 10 seconds. Typically they would be 25, 30, 40. I've seen some minute-long episodes where you're not breathing. This isn't, “Oh, I'm holding my breath. I'm just going to take a big gulp of air.” This is you're slowly exiting air flow out of your throat involuntarily. So a fancy word for suffocating is apnea. So if you think of sleep suffocation, now all of a sudden, you can say, “Whoa. This would obviously affect performance.” So if you want to grade how it's going to affect you, at least cardiovascularly and part of an oxidative stress sort of spectrum, you want to see how many times per hour your airway is relaxing on you. And you can do that through, like I said, with a pulse oximeter, with an oxygen desaturation index. How many times per hour does your oxygen level drop? At least three or four points of pulse oximetry, which is pretty significant. So if you have…
Ben: So that's what you're looking for, is three of four points.
Joe: And you're also gonna have frequency, right? So less than five would be considered normal. You're allowed to have up to five suffocating episodes for 10 seconds and still be normal, which is weird to me. But that's sleep. If you pass that and you go five to 15 times per hour, that is considered a moderate level. And when you pass 30 basically, not breathing every two minutes for at least 10 seconds, but usually 30 seconds at that point in time, that's a severe case of sleep suffocating. And that's why I want to get on the airwaves here and talk to you. We need to really take away all this confusing medical mumbo jumbo and make it into something that people can really identify with. And so if you have an 80% undiagnosed problem that's affecting a huge swath of the population, you need to start unwrapping some of the confusing aspects that would leave us not willing to look into this problem. So one-third of us have no weight issues causing sleep apnea. 70%, as you gain weight, you can definitely develop sleep apnea. And the way you think about this is anatomically.
The tongue is a big part of the obstruction of the airway. Since we can speak we're a unique animal where we have to have phonation and have a very flexible pharynx, and larynx is the cartilage supported area, but the pharynx is very, very collapsible. And right above the epiglottis, you have what we call the hypopharynx, where the biggest part of the tongue is situated. And as you gain weight, your little fillet mignon lean tongue base starts to turn into a juicy rib-eye steak basically, if you want to think of it in those terms. And now as you're gaining weight, your little bitty airway that's only about 12 millimeters when it's really, really wide is slowly but surely encroaching on itself, nine, eight millimeters, even less. And so when you fall asleep and your airway naturally relaxes a little bit, if you lose that dimension, you're going to have a dramatic change in the way you don't breathe basically when you're sleeping. And it sneaks up on you. You don't have to be the guy crawling, even though they may be very significantly impacted with oxidative stress due to high frequency of not breathing, which is what sleep apnea is.
Ben: Okay. Gotcha. So in terms of pulse oximetry in some of these home sleep monitoring systems that a professional sleep organization like yourself would kind of send someone home with, what about blood testing? Are there ways that you can recognize via blood and biomarkers issues that might be affecting your sleep? Like if you don't sleep well and pulse oximetry seems to be affected and you're not quite sure why, what can blood tests tell you?
Joe: So to get the gold standard, and I think that's where you try to look at is you want to look at the physiology of the problem is. So first and foremost, if they want to go get an oximeter, great. If they don't want to do that and they want to get the gold standard, have them get ahold of a sleep doc who doesn't want to just rush him into an in-lab test which is super expensive. Have him talk to a sleep doctor who's open to more home testing, and then get that done first. So that's very simple. Like our group, we're doing more and more online consultation, and basically FedEx mailing of home testing, and that type of stuff.
Ben: So you're actually doing that? Like someone could call you up, you could send them this unicorder, and the electroencephalographs, and all this jazz, they put it on, they sleep with it, and then they send it back to you?
Joe: Exactly. And that's where this is progressing. And this whole internet connection makes a lot easier to have access to someone who is expert at this, they can give you a lot of information just like you're say, doing with Wellness f(x) and advanced biomarkers, but on a sleep focus there.
Ben: But I'm just curious, just to interrupt you real quick before you keep going. How much does something like that cost?
Joe: It varies widely. Some practices are just barely getting into home sleep testing, and they're really, and I can't speak for everybody but across the nation it could be anywhere from, in my practice I charged 200, 250 dollars depending on the unit. That includes the consultation and the interpretation of the study. And some practice could charge you for the same unit, as high as [0:27:25] ______. So be a good consumer of your sleep diagnostics and try to do a little window shopping.
Ben: Yeah. Does insurance actually cover stuff like this?
Joe: Many insurance companies do, and that's the other really cool thing that I've tried to commit to in my practice is we work really hard to grab the insurance information, verify it, see what the benefits are. And whether it's a diagnostic assessment, consultation, or even an intervention where you want to do an oral appliance, or a dental, or a photic, or a CPAP machine, or look into a surgical referral, or even just nutritional recommendations for any options that might help out, that's part of the insurance reimbursement. So this is a valid therapy that most insurance companies cover.
Ben: Interesting. Okay. So you were getting in to some of the blood and biomarkers.
Joe: This is pretty exciting stuff. Again, you guys nerd out really well on this on the show and I love it. I love it, to be honest. So don't apologise to anyone listening when you start nerding out 'cause I think a lot of us who are listening to you love it. So keep doing it. And again, I can nerd out a little bit on some of this sleep insufficiency stuff and how it's affecting inflammatory markers.
So what we're looking at, we're looking at inflammatory markers, okay? So when you're looking at advance biomarkers, if you're looking at someone who's got a high Apo B, or a marker on their lipoprotein to Apo A ratio, that could be an indirect marker. It's not 100%, but it's something to get you thinking about whether that might be an oxygen deprivation problem, or what we call intermittent hypoxic episodes, or low dropping of oxygen below 90% of oxygen where you want to be. Your brain is an A student, it wants [0:29:19] ______. And more importantly, it would love 95% because you breath slower and more shallowly in sleep, so you're not going to have 98, 99.
There's also APOE. So if you have the APOE4 gene, there was a study done out of Stanford where 28% of patients with moderate to severe obstructive sleep apnea had a positive APOE4 gene. So it's not 100%, but if you found that, that could lead you to want to look into whether you had a genetic susceptibility. If your oxygen levels are really dropping down and you're having significant frequency, like 30 times, 40 times, 50 times, I've seen a 112 times in one hour where a 37 year old guy and had severe sleep apnea, it was totally wiped out. That's wild. You'll see it proBNP, which is a peptide that's spilled off in the left ventricles when they're exposed to very high intraneural pressures. So when you're holding your breath, and your oxygen levels are dropping, and the heart is being injured, it will start spilling this out. You've probably seen some articles where some guys after Ironman will see elevated troponin levels, or you would see proBNP as well.
Troponin I is also something that will be in the blood sometimes. Interleukin 6, interleukin 10, those are inflammatory markers, cytokines that are telling you there's something going on with the endothelium. That can be elevated and there's more and more data showing that if those are elevated, you should be looking into sleep apnea. Tumor necrosis factor Alpha, TNF Alpha, is also, if that's elevated, if you see all three of those elevated, there's a very high possibility. There's even a urine test that looks at the [0:31:09] ______ where you just do basically a urine catch. And if that's elevated, you're basically beating your body up from the inside out. High-sensitivity C-reactive protein, that with interleukin 6, interleukin 10, and TNF Alpha, if those are elevated, start looking for apnea because oxygen's spilling.
Ben: Gotcha. This gets me thinking. A lot of these are inflammatory or oxidative biomarkers.
Ben: By addressing inflammation from a dietary standpoint, like a low inflammation diet, or a diet low in refined sugars, caffeine, high amounts of commercial dairy, red meat, et cetera, or by including traditional natural anti-inflammatories like curcumin, or antioxidants, or vitamin C, or things of that nature, are these actually strategies that you use when you see obstructive sleep apnea or are you relying more upon kind of like the biomechanical manipulation of facial features, like the implants, and the mouth guards, and things like that?
Joe: It depends on where the patient's at mentally. If there's an obesity problem when their body mass index is greater than 30 and they want to address that nutritionally and with antioxidants, absolutely I want to try to address that with ways to improve nitric oxide. Maybe they need to take l-arginine. Maybe they're low in their minerals. A lot of sleep apnea patients are low in selenium and copper. Those are signs of oxidative stress. A lot of folks with obesity and sleep apnea tend to have lower testosterone levels. So things that we can do to try to improve those and to try to mitigate it with antioxidants, absolutely. Great idea. You're only doing part of the job. You're not 100%. If you don't open the airway up and you're just using nutritionals, I haven't seen these studies where it actually reverses the problem. So you might be trying to mitigate it, but you got a look at the underlying problem which is supporting the airway when you're unconscious. Think about it with CPR. If I cram 'em full with glutathione in the IV and I give a bunch of IV solution and I don't do anything for the unconscious person whose airway's obstructed, I don't open their airway and breathe for 'em, how well am I going to save 'em?
Ben: Yeah. So how do you open the airway? How's this work?
Joe: Alright. So there's several tasks. So the first one is, and this is going to kind of go a little bit aside from just sleep problems, but since we are interdisciplinary, we have dental sleep medicine as well as sleep disorders, I understand more facial development. So you can start really, really early if you try to treat children, and I know how really avid you are about being an avid parent, being more present for 'em and nutritionally being more responsible, if you can monitor kids and look for a couple things. First thing, this might sound a little weird, “Sleep apnea, breastfeeding, what do you mean?” If your tongue is functioning against the palate of the mouth, you're going to get 80% of facial development within the first year of a child's life. And if you can have that tongue through that hard effort of breastfeeding, you're going to help grow the mid portion of your face or your maxillary bone. And a lot of modern humans for the last 50 years, we know that there's a smaller maxillary and mandibular bone. And I think it's several folds. It might be more prolific allergies, so kids are more mouth breathing instead of nasal breathing when they're sleeping, less breastfeeding, obviously a higher exposure to xenoestrogens might be an issue. But the bottom line is if you can get you know facial development to get back on track, you might be able to head off some of the sleep apnea at these dimensions.
So that's one thing. Now in an adult, you really only have three options. The most commonly used one is continuous positive airway pressure where you take a mask, you put in on the face, and you just turn the pressure up, and it starts blowing the airway open. That's CPAP. Most commonly used, probably not the most liked by patients. If you look at research back from 1988 or thereabouts, if you ask the patient do they want to wear a retainer or put a mask on their face, 80% said, “I'd love to do a mouthpiece. Let me try that first.” Well what's currently happening in the current practice patterns is every guy's like, “Hey, it's good to give you a box and just slap the mask on, and I'm good. I got you covered.” But I look at it differently. I think that we need to erode some of the barriers. And so if you just have a little mouth guard that's very portable and supplied by someone who knows how to do it so your jaw can't get sore, your teeth don't get hurt, like these snore guards online, and then you'll start getting more people motivated into looking into the snoring problem. So like I said, but the mandibular advancement device, or a fancy word for two retainers that hold the lower jaw from falling backward, is the second treatment.
And of course the oldest treatment out there, which is kind of lost a lot of its favor, is this soft palate reduction or tonsilectomy. Now tonsils are very important in children because they're at their largest between the ages of five and, say, 9 or 10. And because we have smaller jaws, guess what our tonsils are going to act like? They're going to act larger, and they'll stop and they'll obstruct good breathing patterns. So you want to get that fixed. But in adults, tonsils pretty much shrink in just about everybody because it's part of your immune system, you're trying to generate immune memories. So your thymus gland, and your adenoids, and your tonsils will pretty much shrink to almost nothing in, say, 80% of the population by the time you're 25.
Ben: So are the tonsils actually necessary for anything in your opinion? Like is a tonsilectomy going to be, in the long run, damaging?
Joe: You have to weigh the pros and cons. So the tonsils there, if they're not obstructing you and causing you not to breathe, and affecting sleep disruption, or reducing your immune capacity by totally ruining your sleep quality, yeah, they're really important there. They're there to kind of be the sentinels. They're looking for that virus, and that bug, and that parasite, and that bacteria. And then it shuttles it to the spleen and to the bone marrow, and you're able to find and catalog with antibodies, what that was. And so when you get exposed to it in the future, you'll be able to attack it faster. But if you're not breathing, sleeping, you can't get to that immunological cascade. So you have to balance it out. So in my opinion, if the kid's mouth breathing and they're not breathing well through the nose or they have allergies, look for those tonsils, they're hyperactive, they're not doing as much good as they could have if you had plenty of room in the airway.
Ben: Okay. Gotcha. Is there anything else that you do to fix something like obstructive sleep apnea?
Joe: Yeah. With the pediatric realm here, there's a cool movement. Orthodontics is an extremely young specialty. And I think, without taking airway development into perspective, you miss out on what the actual most appropriate treatment is. So I would highly recommend don't wait for your kid's 12 or so to do braces if they have narrow jaw or crooked teeth. Or if you have a history of braces in your family, or extracting your bicuspids a very common thing where your premolars get extracted as well as your wisdom teeth when you're older, and then you wire down your jaw and make it smaller. Get in there early and go to a functional orthodontist right around facial development time. By the time you're eight, 90% of your facial development's done right. Or age of 10 basically. That's why a lot of orthodontists wait 'til you're 12. But if you can identify airway problems, tonsil problems, nasal allergy problems and treat those very aggressively through nutritional modifications like avoiding inflammatory foods like high carbohydrates, and processed foods, and the like, and that helps, great. If they're having environmental allergens, get that looked at right away. And if the tonsils are huge, what we call a palate expander, if you go to a functional orthodontist, they'll actually look at that airway and they'll help guide that jaw development as young as, say, five, six, seven, eight. And you might actually correct a lot of that facial, what we call maxillary insufficiency or retrognathia where the lower jaw's too far back, and that's my problem. I was a kid who had allergies that grew up in Florida, and I sounded like this my whole life because my whole nasal passage was absolutely obstructed and I was constantly mouth breathing. So again, at 9% body fat, I have sleep apnea right.
So if allergies aren't treated, your facial type becomes either too long, you feel a longer facial type, it's called dolichocephalic, that means you have less space side to side. And of course, if you can get people who are obese to lose weight, that will very much reverse much of the sleep apnea. But once the fat issue is applied in that upper airway, it's usually the last place to be applied and the last place to be removed. So typically, once you get to a significant body mass, like 30, or 35, or even, god forbid, 40 body mass index where you could be up to 80 pounds overweight, when you're lose a significant amount of weight, you're still going to have a significant amount of left over. You probably won't totally resolve it, but you'll definitely make it less of a problem. And so that's really my practice, and it's very unique. I think a lot of sleep docs go, “Hey, here's a device! Let's treat it.” Or, “Here's a surgery. Let's do that.”
If I see a patient where I can get them feeling immediately better by treating their sleep quality by improving their oxygen, I want to take that motivation. And if there's any weight problems, I'm going to throw in a good panel of anti-oxidants. I'm going to get them on appropriate dietary intake and help them get the tools to take that better metabolism that now is working because they're oxygen's better and help them be more successful in that weight loss. Because if you tell someone who's overweight to lose weight and they have obstructive sleep apnea causing their sleep process to be so poorly, they're fatigued constantly and their metabolism is shot, they're leptin levels will be off, they'll be leptin resistant. So their hunger levels are through the roof, their ghrelin levels are up as well, and they're carb addicted to that point as well, you really have to give them every tool possible to be successful.
And again, you don't have to be wildly overweight. You can simply be a 28 BMI. And again, if you look at my picture, my Hawaii picture shows me at 28, and then it looks significantly less healthy than my 9%, but it's average. That's the average for the average human being. And this is one more really cool effect we can think about. In 1990, when they first started looking at obesity rates, only 10% of the population was over a body mass index of 30, which is considered morbid obesity. In 2010, which is the last CDC state charts where they did this survey, it was almost 30% of the population, and over 27 BMI, which is considered overweight. So the obesity epidemic, even if we're not severely obese, is dramatically increasing the prevalence of breathing disturbances in sleep.
Ben: So I'm curious about your own personal kind of habits, knowing as much as you know. And we really only scratched the surface on some of the research that you sent over to me as far as like cancer, and insulin insensitivity, and blood sugar, and appetite dysregulation, all the nasty things that happen with sleep deprivation, and perhaps at some point in the future we can talk again, or maybe I can even twist your arm into a guest article to go into some of that stuff because it's fascinated. But I'm curious about like your own personal sleep habits. Do you have specific evening habits or morning habits that you use in addition anything else that we've just discussed to actually optimize your sleep?
Joe: I try to practice what I preach. So the first thing is I've treated my sleep apnea with a dental appliance for the last 10 years. I feel like that was a good hack right there. And I'm not even a snorer. I'm just more of a mouth breather type patient, which is another misnomer. You don't have to be a loud snorer to have an airway disruption. What I also do is I try to avoid working up until the last minute. I try to give myself seven and a half hours of sleep time in bed because the average person only sleeps about 85% of the time they're in bed. So if you give yourself, the average American only sleep six, six and a quarter hours. So if you give yourself seven hours in bed, you're only asleep in six and a half hours. So if give yourself seven and half or eight, then you'll probably sleep at least with decent amount, which is about seven, which is a good middle of the bill. You're probably going to help most folks get their optimal performance.
I am big about taurine at bed time. Also if I have an issue, I have a sublingual spray I like to use. It's got l-theanine in it, a little bit of melatonin, tart cherry, it's got some lemon balm, and Valerian root, and passionflower in it, which is really cool. And since it's sublingual, it absorbs very quickly. I'm not a bad sleeper so I don't have to worry about the insomnia problem. But if someone did have an insomnia problem, they really want to be wary of some that dirty electricity that you guys are talking about, being exposed to there, I'm a big believer in that radiation, that Bluetooth radiation. Turn off your WiFi at night time. I think it's a great idea.
Ben: Now what about these sleep kits that you send out? Do those have Bluetooth or electronic signals, or are those simply because they're being used temporarily, not really a big deal?
Joe: Right. They're temporary. You're not being exposed chronically over time. You don't have unknown amounts of chronic radiation that you're being exposed to. That's probably, again, not a big significant problem because it's the chronicity of issues that give you a problem.
Ben: Gotcha. So it sounds like you're using many of kind of the traditional sleep nutrients that we've talked about in the past on this show. And then taurine is not something that we've discussed too much, but you're using taurine as like an amino acid prior to sleep?
Joe: Oh, it's great because I typically don't have time to work out until the evening, and I'm a strength trainer, I don't do a lot of cardio as far as running, but I keep the pace up. And so sometimes you just need a little taurine for a little amino acid use. ‘Cause again, it's not essential, but if I'm from utilizing it and I'm exhausting it, I want to replace it. And plus to get a little bit of a calming effect. If I was having issues, I'd probably go for a little 5-HTP. I have tried the GABAwave, the phenibut, which has some research on it, and sleep disorders medicine. But again, because it's so significant, and we can get really geeked out on neurotransmitters, and there's newer neurotransmitters like orexin, not just GABA. Adenosine is the biggest driver for slow wave sleep, and we block that every day with caffeine. Caffeine is an adenosine blocker. You can inject adenosine into and you turn into a deep sleeper in slow wave sleep and get growth hormone, but no one's doing that.
Ben: Is that safe though? Has that been looked into as far as like the use of adenosine as a supplement or as an injection? I mean, would that technically shut down your own endogenous production of adenosine or anything like that?
Joe: Adenosine breaks down so quickly. No one does that. It's just like for experiments with animals with basic science for neurophysiology. But it just shows you that in the brain, neurotransmitters work very different than in the rest of the body. Like histamine. Histamine is the most profound alerting neurotransmitter. No one's talking about that. But everyone uses a version of that over the counter with Unisom, with diphenhydramine, which is Benadryl. That's an antihistamine that crosses the blood-brain barrier, and the way it makes you sleeply is it blocks histamine. Again, there's so much more than just GABA and [0:48:37] ______ precursors, and I'm just trying to be part of that whole functional medicine, root cause, natural medicine. Again, the whole reason why I'm excited about talking to you on this podcast is not does it get out to people who are proactive in their health, but you get a lot of functional medicine practitioners and chiropractors who are functional medicine, and naturopaths, and they're probably not even taking this into their differential diagnosis for why they're treating fatigue and other problems with patients.
Joe: If they understand that there's this one other area that they're missing, man, we can get so many more people at their optimal level of performance.
Ben: Yeah, it makes complete sense. And it sounds to me, like for people out there who are experiencing adrenal fatigue or sleep issues, I mean for me personally, doing something like a quantitative analysis of sleep using something like one of these kits that you send out or hooking up with something similar to what you do in the local area and literally doing like a sleep study that gets a little bit more deep into the data than something like, whatever, Beddit, or the MyBasis watch, or any of these other sleep tracking devices, and then also looking at pulse oximetry, all of that sounds like you would be pretty prudent in a case like this. And this does indeed sound like something that kind of flies under the radar, this obstructive sleep apnea issue.
So first of all, I realize that we didn't get a chance to go into like half the stuff that you're an expert in, and so we either have to have you back on the show, or like I mentioned, perhaps if you're listening in, you could look for a guest article or something like that at some point in the future to go into this a little bit more. And second of all, I'm going to put resources to the stuff that we talked about, including your website over at sleep, I'm sorry bengreenfieldfitness.com/sleepdoctor if you want to look into Dr. Zelk and what he does as part of The Sleep Medicine Group, the pulse oximeters we talked about, et cetera. And then Dr. Zelk, thank you for coming on and for sharing some of this stuff with us.
Joe: Hey, Ben, thanks for everything you're doing out there. It's really opened up my practice. I don't want to just run to writing prescriptions anymore. This functional medicine movement's been great, and this quantitative self is really super. And by the way, I'm still wearing my encoder band. You've got me all paranoid about EMFs, and so that and structured water.
Ben: Those encoder bands that can really be used quite well, I've got actually two on my desk and then I wear one on my wrist, they're great for mitigating EMF. Unfortunately, those got so popular that a) they're completely out of stock, and b) I still found that the wild little lifestyle someone leads, including like obstacle racing, and open water swimming, and stuff like that, these things still, in my opinion, could be engineered to hold up even better under the rigor of those type of activities. So that's why you can't get them right now. If you own one of these encoders, congratulations. If you don't own one, I believe if you go to superhumanencoder.com, there's like a waitlist or something like that, but I'm probably six to eight weeks out of, I've got somebody actually over in India working on a newer version that's really able to hold up to rigors and also has a little bit more added to it in terms of like copper tubing and some other kind of cool features. Total rabbit hole, but yeah, I'm glad you brought that up because I know a lot of people who've been asking about these wrist bands and when they might be able to get them again. So soon, hopefully, at some point in the next year.
Joe: And just one last thing, on earth, I'd highly recommend you do a podcast on that whole earthing movement. It's got some interesting stuff. I don't know if you're thinking it's a big woo-woo thing, but I think Dr. Sinatra, that functional cardiologist, dig into that heart rate variability.
Ben: Yeah. I'm definitely into earthing. I use the Earth Pulse that I sleep on, and then the biomat that I use has some of those same features. And then of course, I walk around outside barefoot. And I've got earthing sandals, and I've talked about the earthing, or the grounding movie before on the show but I don't know if we've done a full podcast episode on it. So we'll have to that sometime too. So many different avenues to pursue when it comes to living the optimized healthy lifestyle.
Anyways though, this is great information that you've provided. So thanks for coming on. And again if you're listening in, you can go to bengreenfieldfitness.com/sleepdoctor to access some of the resources that we discussed during this show. So Dr. Zelk, thanks for joining us.
Joe: Keep up the great work. And thank you again for having me on. I really appreciate it.
Ben: Alright, folks. This is Ben Greenfield and Dr. Joseph Zelk from The Sleep Medicine Group signing out from bengreenfieldfitness.com. Have a healthy week.
A few weeks ago, I received an interesting email from a podcast listener, who cryptically stated…
…”you could improve sleep also by a simple screening of oximetry to rule out OSA in your adrenal fatigue clients. 30% of OSA patients have OSA unrelated to obesity. Me included and I am 9% body fat. Just something to consider since you are doing a lot of cool but out of the box sleep recommendations. This coming from a fan and a board certified sleep specialist.“
I have to admit that I did not, off the top of my head, even recall what OSA was, and that it had been some time since I'd personally used a little finger pulse oximeter to measure my blood oxygen saturation. I was also intrigued about the fact that many people who don't sleep well, are constantly tired, or experience adrenal fatigue don't seem to know about this issue, so I asked him what he meant.
He wrote back and clarified:
“Relating to OSA, I was referring to Obstructive Sleep Apnea Hypopnea Syndrome. I like a more accurate description “sleep suffocation”. The issue is totally ignored by Primary Care Physicians, let alone the guys that should be investigating it which should be the cardiologists. 30 percent of OSA patients have no obesity contributing to the problem but have craniofacial development deficiencies. The other 70 percent or so end up developing “sleep suffocation” as obesity sets in. Nearly 80 percent of moderate and severe OSA cases are undiagnosed. This is the lion's share of what the sleep specialists deal with every day. The insomnia cases, ASPS, DSPS, jet lag, RLS, PLMD, narcolepsy and the other sleep disorders take a back seat to this OSA issue. You can't address sleep issues thoroughly without thoughtful discussion regarding OSA.”
Wow. Now that's something that needed some further digging, so I decided to get this guy on the podcast. His name is Dr. Joseph Zelk and he is the Medical Director of the Sleep Medicine Group, which you'll learn more about in this show. In this episode, you'll also discover:
-Why many sleep monitoring devices and wearables simply aren't accurate, and how you should really be measuring your sleep…
-What a sleep cycle should really look like when it comes to deep sleep vs. light sleep…
-Why you should use a pulse oximeter upon waking, and what can it tell you…
-How you get OSA, especially if you're a lean active person who eats healthy…
-Why more people don't know about OSA, especially physicians…
-What you can do to fix OSA…
-Are there ways/technologies to measure pulse oximetry all night while you're sleeping?
-Which nutrient deficiencies can cause this issue…
-And much more!
Resources we discuss in this episode:
–The Sleep Medicine Group
–Pulse oximeters that can measure oximetry while you're asleep
Do you have questions, comments or feedback about this hidden sleep killer that flies under the radar? Leave your thoughts below!
Finally, for customized, cutting-edge sleep tracking and testing, a one-on-one sleep consultation via Skype, screening for obstructive sleep apnea or any other your other sleep enhancement or insomnia fixing needs, visit www.sleepmedicinegroup.com. Mention “Ben Greenfield” on your e-mail intake form or when you speak to a representative, and get a $25-100 discount on any sleep testing or sleep consulting services.