My shocking and deadly sleep diagnosis (Part 3 of 3 on sleep)

If you’ve been following my posts over the last few weeks, you know that poor quality or short sleep predisposes you to weight gain, and that I personally struggle with insomnia. For me, it’s been ongoing at least 5 or more years and seemed to get worse after I had Graham 3 years ago and simultaneously started to have my first hot flashes, signaling the beginning of perimenopause (women start to have hormonal shifts and can experience hot flashes as early as ten years before they actually arrive at menopause!). To be clear, Graham started sleeping through the night at 8 weeks old, so it wasn’t the usual sleep struggles that a new mom experiences routinely. I DID get up every night for an hour around 2am to pump breast milk as he slept, but by the time I returned to work about 3.5 months after he was born, I had adjusted my pumping schedule to 3 times a day and could wait until 5:00am. Despite a sleeping baby and no obviously external disruptions to my sleep, I continued to struggle with middle of the night awakenings and often had difficulty returning to sleep. When you can fall asleep easily (me!) but awaken earlier than desired, it’s called maintenance insomnia. I talked to my primary care doctor about it, and we both suspected anxiety may be playing a role (I’d also felt somewhat more anxious than usual in the year or two after Graham was born). She prescribed an antidepressant called Lexapro (which can also be used for other mood disorders like anxiety). I gave it a try, finding that it was maddeningly activating for the first 1-2 weeks (meaning, it kept me awake as if I’d had 4 cups of coffee before bed), but I knew that it can take weeks to adjust so I kept at it. By the 6 week mark I found that Lexapro did absolutely nothing for me, neither improving my sleep nor seeming to have any effect of my mood or anxiety. So I quickly tapered off it. I then spoke to my OB-gyn about it, because it really felt hormonal to me. Just as I’d started to notice a few hot flashes, I’d been experiencing the increase in anxiety – and I noticed a significant worsening in my tossing and turning in the days leading up to my period, and unusually sound sleep in the days following my period – suggesting that hormones might be a big player. She prescribed a low estrogen birth control pill for me to help “smooth out” my hormones. I stayed on them for three straight months, unfortunately finding that they did get rid of the rare hot flashes, but did nothing to improve my sleep (if anything, I lost the good quality sleep that I’d been noticing in the week after my period). So, I stopped those, too. I finally saw a sleep specialist at the George Washington University as a last ditch effort. Pondered whether I might have narcolepsy because I do have this weird thing called “cataplexy” when my muscles suddenly lose strength sponge to strong emotion (I even almost fell off a treadmill while running due to sudden leg weakness when I was suddenly overcome with joyous laughter watching Steve Carell in “The Office!”) — narcolepsy is often associated with cataplexy. But our suspicion was low because I had never actually fallen asleep during the day. He gave me some advice based in cognitive behavior therapy for insomnia, or CBTi (no more looking at the clock, get out of bed and go do something mindless if you can’t fall back to sleep within ten minutes). I had a few nights of somewhat better sleep when I employed these methods, but over the year that followed still had pretty profound trouble with multiple awakenings. 

I started to worry more and more about my sleep, because I felt like my own cognitive function was starting to falter (especially forgetting names, and having more trouble paying attention to anything that I didn’t care a lot about). Well-meaning doctor friends reassured me it was normal, that I was in my mid 40s when we ALL start to forget names, and that I had simultaneous “mommy brain” with a baby at home. But my deep seated fear that I was in the very early stages of Alzheimer’s disease (given my own young mother’s diagnosis), and my knowledge that adequate and good quality sleep is critical for the brain to heal itself kept me searching for ways to improve my sleep. 

One day about 4 months ago, I was watching a TED Talk about sleep in which a slender-appearing gentleman spoke about his own disrupted sleep and how he would often get up multiple times to urinate as if something else was waking him up. DING DING DING!!! This was me! I would awaken and visit the bathroom usually three times during my fragmented night, but when I peed it never seemed like much. Certainly my bladder was never full enough to have woken me. So what WAS waking me?? 

Well, this man was diagnosed the obstructive sleep apnea (OSA) — a sleep disorder in which the soft tissues in your airway relax and collapse during sleep, thereby blocking your airway and preventing you from breathing. In the 15 minutes that it took me to watch his talk, it suddenly dawned on me that *I* could have OSA. The weird thing was, I was very low risk according to the usual screening questions: I was not overweight (anymore), didn’t snore (at least not loudly enough for Kevin to notice), didn’t have high blood pressure, and although I definitely felt tired during the day, I was never sleepy enough to fall asleep sitting in a lecture or stopped at a red light. But man, the disrupted sleep and especially my own subjective sense of cognitive impairment sure could be explained if I had OSA. So, I contacted that sleep specialist again (about a year and a half after I met with him) and asked if he would order a sleep study for me to rule it out.

Because my BMI was in the normal range, my insurance company would only pay for a home sleep study (rather than the gold standard polysomnogram that you have in a sleep center). I completed the test at home on November 8, 2019. I never heard from anyone about the results. About 6 weeks after the study I had a follow up appointment in the sleep clinic…. 

“You were right: you have moderate sleep apnea.”

WHHHAAAAAAA????!!!!

I was actually shocked. I thought it would be a negative study. Even *I* didn’t think I actually had OSA, since my body weight was normal. I always thought of it as a disease that plagued people with obesity. Obviously, so did my primary care doctor, my OB-gyn, AND the sleep specialist I went to! It turns out that I was having a respiratory event (either partially or completely obstructing my breathing) on average 23 times per hour. That’s once every 2.6 minutes. No WONDER I was awakening multiple times each night and feeling tired every day! (The sleep study also showed that I do indeed have “intermittent snoring” — I guess it was just never loud enough to bug my ever-tolerant husband!)

So, I needed autoCPAP — a machine to blow air into my nose/mouth while I sleep to keep my airways from collapsing and blocking my breathing. I had to wait a couple of weeks for the new machine to be delivered, but I’ve since been faithfully wearing my mask every night. Honestly, the first week or two was rough — getting used to having a lamprey attached to my face took a while. I am still sorta getting used to it, although I must say it’s getting way more “normal” feeling… and the good news is, I am sleeping a lot better already! I still wake up once or sometimes twice, but I have a much easier time getting back to sleep. Last night I slept 7.5 hours and woke up feeling fresher this morning, and more than 7 hours was essentially unheard of for me before I started treatment for my OSA! I do still notice that I sleep a lot worse leading up to my period and much better right after, so there are certainly also other factors at play with my sleep… but I feel such a huge sense of relief to finally have a diagnosis that explains my crappy maintenance insomnia that nothing seemed to help. And thankful beyond belief that I advocated for myself and asked for the sleep study even when my doctors didn’t think I was really at risk.

Why is figuring out whether you have OSA important? Because when left untreated, it’s deadly: it causes car accidents caused by falling asleep at the wheel, difficult-to control high blood pressure, heart disease, stroke, diabetes, depression, and perhaps most importantly to me personally, cognitive impairment and Alzheimer’s disease. OSA is extremely common, affecting more than 22 million Americans including up to 23% of women and 49% of middle-aged men, and the prevalence increases with age (and with peri/postmenopausal status in women). Despite it being this common, it’s extremely underdiagnosed: estimates suggest that 80% of men and 93% of women with moderate to severe OSA have not been diagnosed. Being overweight is a risk factor, but I was shocked to learn that about 20% of sleep apnea cases are in people of normal weight! People with a normal BMI who have OSA tend to be more easily aroused from sleep, and may have a family history of OSA, suggesting genetic predisposition. Indeed, both my father and my brother have OSA. 

Treatment is generally with an AutoCPAP machine like the one I am now getting used to, but in people who can’t (or aren’t willing to) tolerate wearing a mask to sleep, there are other treatment options, including dental appliances that change the way your jaw sits thereby opening your airway to stop the snoring and the blocked breathing, and even surgical implantation of a nerve stimulator that moves your tongue out of the way when you sleep!

When I took the standard “STOP-BANG” screening questionnaire, I answered yes to only one question and was told I was at low risk for OSA – yet I was actually suffering from moderate OSA that was bad enough to require treatment. So with that in mind, I have taken this standard screening questionnaire and added a few of my own symptoms and risk factors here to create my own invalidated-but-valuable Dr. Jen Kerns’s Sleep Apnea Screening Tool:

1.     Do you snore?

2.     Do you often feel tired, fatigued, or sleepy during the daytime? 

3.     Do you generally fall asleep within 2 or 3 minutes when you lie down to sleep at night?

4.     Has anyone observed you stop breathing or choking/gasping during your sleep, or have you ever woken up feeling like you are choking?

5.     Do you have or are being treated for high blood pressure?

6.     Is your body mass index (BMI) more than 27 kg/m2? Calculate your BMI here.

7.     Are you older than 50?

8.     Is your neck size (measured around the Adam’s apple) 17 inches/43cm or larger if you’re a biological man, or 16 inches/41cm or larger if you’re a biological woman?

9.     Is your biological gender male?

10.  Do any of your first degree relatives (parents, siblings, or children) have sleep apnea?

11.  Do you have fragmented sleep and wake up more than once or twice at night without an obvious cause?

If you answer “yes” to 3 or more of these questions, I strongly suggest that you ask your primary care provider to order a home sleep study for you to rule out sleep apnea. Untreated sleep apnea has been shown to increase your risk of death by almost 4-fold. If you have it, treating it could truly save your life. 

Until next week, sleep well! 

Jen

Strategies to improve your sleep (Part 2 of 3 on sleep)

Last week we explored a bit about how important sleep is to health and life. (5 word recap: it’s as important as water.) This week in part 2 of a 3 week series on sleep, I get into the details of many of the various strategies I’ve explored in an attempt to improve my own sleep. As I was preparing to write this post, I started jotting things down… and realized it could turn into a 100 page treatise. So in this post I’ll try to keep it as concise as possible, and then can go into a lot more detail for a few of these strategies in future posts for those of you who are interested in more of the scientific evidence behind them.

My med school friend Al Chun joked last week about expecting me to tout the benefits of cutting back on caffeine and alcohol, and indeed, he was correct:

1.     CAFFEINE. After you wake for the day, a chemical called adenosine starts to slowly build up in your brain, gradually slowing down your neuronal firing until you fall asleep and the adenosine is washed away. Caffeine decreases the soporific effects of adenosine by competing for its receptors in the brain, thereby speeding up neuronal firing and leading the pituitary to sense an emergency and trigger you adrenaline (thus the feeling of shakiness or cold hands from blood vessel constriction if you overcaffeinate). This can obviously disrupt your sleep. (Caffeine also disrupts the architecture of your sleep even if you are able to fall asleep after having that after dinner espresso.) Common wisdom suggests that you avoid caffeine after noon, but I would go farther than that and suggest that you should avoid caffeine for a full 12-14 hours before your intended bedtime. (!) Yes, that means that if you want to go to sleep at 10:00pm, you should avoid caffeine after 8:00am. The reason is that caffeine has a half life of 6 hours — meaning that a full 25% of the caffeine dose that you ingested this morning is still coursing through your veins 12 hours after you drank it. Cutting out caffeine entirely might be even smarter, but I don’t dare take away your morning joe, you coffee addict.

2.     ALCOHOL. While many people believe that a night cap helps ease them into sleep, alcohol actually has a very detrimental effect on sleep. While it can indeed induce the onset of sleep, it disrupts your sleep architecture dramatically and ruins the quality of your sleep by depriving you of much-needed restorative REM sleep. In addition, as you metabolize the alcohol, you can go into a mild period of alcohol withdrawal which includes stimulation of your brain and circulatory system. If you want to drink responsibly with minimal effect on your sleep, have a single drink if you’re a woman (1.5 ounces of hard liquor, 5 ounces of wine, or 12 ounces of beer), or no more than two drinks if you’re a man, a full 2 hours or more before bedtime. 

Beyond caffeine and alcohol, there are many other things that impact sleep quantity and quality:

3.     LIGHT: First of all, a bedroom that isn’t dark enough can seriously ruin your ZZZs. Blackout shades and/or a sleep mask can make a world of difference. Also, avoid bright and/or blue light for several hours before bed. Exposure to light in the blue spectrum after sundown is getting more and more common (with compact fluorescent and LED bulbs becoming ubiquitous and our iPhone and Android screens being ever-present in our lives) — this suppresses the production of sleep-inducing melatonin. This keeps you awake and shifts your circadian clock to create a false jet lag in your brain. Use the function on your phones and tablets that turns the light color to an orange hue (with Apple products it’s under Settings -> Display and Brightness -> Night Shift), avoid TV in the hour before bed, and turn down the lights in your home. If you want to get really geeky about it, you can even buy these sexy blue-blocking glasses.

Interestingly, I personally found that I was usually exhausted by 7 or 8pm and could fall asleep easily once I let myself get into bed, but often woke around 3:00am with a surge of warmth and adrenaline, as if my cortisol (which usually peaks around 6:00am) were peaking early. So for me, blue light in the evening wasn’t impairing my ability to fall asleep, but rather I seemed to have the opposite problem. So I started wearing these blue blockers in the early morning hours if I got up before 5:00am to help prevent my brain from thinking it was already daylight out. Similarly, I bought a cheap bright light therapy box to shine into my eyes around 7pm when I was fading early, to try to adjust my own circadian rhythm to a slightly later schedule.

Strategically using and/or blocking blue light to your advantage might be a useful part of a comprehensive sleep overhaul.

4.     NOISE: Ensure your bedroom is extremely quiet. If you’re unable to create a quiet environment, I highly recommend playing white noise to block out random sounds — there are many free white noise apps available. I own several and like to play a rain/shower sound — without it, even the sound of the aircraft onditioning unit outside our window turning on and off wakes me up! Sleep with a partner who snores but who themselves can’t stand to hear white noise? Buy a set of sleep headphones that are more comfortable for side sleepers than ear buds – if you put them over your eyes instead of your forehead, they can even double as a light-blocking mask.

5.     TEMPERATURE: Make sure your sleeping environment is cool. For optimal sleep, it turns out that the room temperature should ideally be about 65 degrees Fahrenheit. Sleep relies on the cooling of your core body temperature, so a warm room can hinder this. I invested in a pricy product called the chiliPAD™ (I bought a refurb and waited for 25% off!) which goes underneath your sheets and pumps water throughout the night to regulate the temperature of your bed anywhere from 55 to 115°F — I have mine set for 64 degrees. (Side bonus for my 40/50-something lady friends out there – the chiliPAD™ can eliminate the middle-of-the-night hot flashes that so commonly disturb the sleep of perimenopausal women!)  Taking a hot bath or sauna before bed can help by warming your body up enough to dilate your surface blood vessels, which can then help dissipate heat from your core more quickly as you slide into bed in your cool room. Wearing a pair of warm socks (or placing an old school hot water bottle at your feet) has the similar effect of warming your extremities and allowing your surface blood vessels to dilate more, thereby helping you sleep more soundly. 

6.     MENTAL CHATTER: We’ve all probably lay down to go to sleep, or awoken in the middle of the night, only to start ruminating about the big presentation we have to give the next day, or what you wish you had said during that argument, or simply your long To Do list looming over your head. There are several strategies that might help. One is keeping a notebook next to your bed and brain dumping all of your worries out onto paper before you go to sleep. (Jotting down the thing that pops into your head at 3:00am can also help you release it and go back to sleep.) Similarly, avoid mentally engaging with anything that might be stressful in the hour or so before bed, such as watching the evening news or reading potentially annoying work emails. Starting a meditation practice can also do wonders. There are several popular apps out there. I personally like Headspace (which has a great “mindful eating” course in addition to several courses on sleep, by the way); I’ve heard many people tout the benefits of Calm, and if you think meditation is froofroo, Ten Percent Happier is another popular meditation app which is geared toward people who might approach mindfulness and meditation with a bit more reluctance. I found that with practice (just 10 minutes of guided meditation each afternoon), I was able to more easily tap into that relaxed head space in the middle of the night and clear my mind, meditating myself back to sleep successfully as often as not. I also suggest trying the “military method” of falling asleep, which focuses on muscle relation — since incorporating it (especially focusing on relaxing all of the muscles in my face), I’ve had a much easier time drifting back off to sleep than I used to.

7.     NAPS: No matter how tired you are, if you’re not sleeping well at night, try to avoid napping. Remember adenosine, which we discussed above under caffeine? Well, a long enough nap will discharge the adenosine that’s been building up in your body and thereby worsen your nighttime sleep. If you do need to nap, keep it to 20 minutes or less to refresh your mind without discharging all that sleep-inducing adenosine. 

8.     FASTING: Don’t eat or drink within the two hours before bedtime. Having your digestive system actively processing that big dinner or late-night snack when instead it should be resting has been shown to impact sleep negatively.

9.     SUPPLEMENTS: I could write an entire blog post solely on potential supplements to use for sleep, so I won’t get into all of the evidence (weak or strong) behind these here. But a few supplements that I personally have incorporated are low-dose melatonin (it has a very short half life so will help you fall asleep, but won’t really help you stay asleep - I sometimes take a physiologic 300mcg dose when I awake at 2 or 3am), ashwagandha 300mg twice a day, GABA 100mg at bedtime (it doesn’t cross the blood-brain barrier to make you sleepy, but may relax the peripheral nervous system), and L-theonine 100-200mg at bedtime (btw to simplify things, Jarrow Formulas makes a single supplement called “GABA Soothe” that contains GABA 100 mg, theanine 100 mg, and ashwagandha 225 mg). I also take my daily magnesium supplement (Magtein) for cognitive preservation/function in the evening since some people claim that magnesium relaxes them and makes them sleepy. Two kiwi fruit an hour before bed, as well as sour cherry juice, have been studied and are potentially promising as well. The gut Microbiota can affect the architecture of our sleep, and certain prebiotic fibers have been shown to improve sleep in rodent studies - specifically, these fibers are contained in the supplement Bimuno Daily, which was touted as an effective supplement in a BBC documentary entitled “The Truth About: Sleep.” I put a sachet of Bimuno in my coffee every morning just for kicks. 

I recommend AGAINST using sedative-hypnotics such as Ambien (zolpidem), as they adversely affect sleep architecture and have been associated with a higher risk of mortality even in people who use them only occasionally. Similarly, the use of antihistamines (such as Benadryl or diphenhydramine, Unisom or doxylamine, and meds containing these antihistamines such as Tylenol PM or Advil PM) has been associated with a significantly increased dose-dependent risk of dementia (attributed to the anticholinergic effects).

10.  DIVORCE: Did I get your attention? Ha. But seriously, I feel strongly that a “sleep divorce” might do wonders for your and your partner’s sleep. A hot topic recently covered by the New York Times and the Today show, the “sleep divorce” simply entails partners sleeping in separate rooms. This can make a huge difference if either or both of you are disturbed by the other, whether from snoring, different bedtime and rising times, movement in the bed, the sleep disorder of one or both partners such as restless legs syndrome or obstructive sleep apnea, or different temperature preferences. It turns out that up to 40% of people, when surveyed anonymously, admit to sleeping separately from their partner, and the sex lives of these people may actually be better than those with disturbed sleep… because who wants to get busy when you’re exhausted?? Indeed, a sleep divorce might help prevent a real divorce!

I know this was a long one, guys, but hope at least some of it was new and helpful to you! Let me know in the comments below whether you’ve had success with any of these methods, or plan to try one or more of them. And if any of my posts have been interesting or helpful to you, please do share with others you think might be interested — sharing really helps me spread the wisdom more effectively!

Next week in Part 3, I will cover one more critical topic in the realm of sleep, and reveal my own shocking (and life changing) sleep-related diagnosis! Until then, sweet dreams!

Love, Jen

How your insomnia is making you fat (part 1 of 3)

Sleep is a critical biological process that allows brain energy stores to rebuild and allows for the clearance of waste products (including beta amyloid, the accumulation of which is implicated in the development of Alzheimer’s Disease) through the “glymphatic” system. If you don’t believe me when I tell you that sleep is as important to life as water, you have only to read the macabre scientific studies from the 1980s in which total sleep deprivation in rats led to death within a matter of weeks.

Over the past decade or two, the intersection between sleep and obesity has gotten increasingly complex. A simple Google search on “sleep and obesity” today yields over 85 million results, and sleepiness has been suggested as the new “6^th vital sign” that should be checked by healthcare providers. If you’re an American, a quick visit to the CDC’s website

can tell you how prevalent inadequate sleep is in your region of the country. In my hometown of Bethesda, Maryland, a DC suburb, 32% of adults report short sleep duration (less than 7 hours per night). I am one of those adults: I have been struggling with early awakenings, or “maintenance insomnia,” for years now – waking in the middle of the night several times, sometimes getting up for the day as early as 3am when unable to go back to sleep after tossing and turning a bit. (One middle-of-the-night awakening is normal if you get back to sleep, but more than that isn’t.)  I typically get between 6 and 7 hours of sleep on a normal night, and usually wake multiple times within that 6.5 hours, so my sleep architecture is somewhat fragmented, too.  A personal quest for better sleep (mostly driven by my intense interest in delaying my own potential onset of Alzheimer’s Disease, but also by the wish to just feel better) led me down the rabbit hole of sleep research. In next week’s post I’ll talk about the various strategies I’ve adopted in an attempt to improve my own insomnia, but this week I’d like to scratch the surface of how short sleep and/or disrupted sleep promotes weight gain and obesity.

I heard the basic physiological effect of inadequate sleep on bodyweight described elegantly in a podcast interview of Dr. Matthew Walker, a sleep researcher at Berkeley and author of the bestseller “Why We Sleep.” He explained that for the vast majority of human evolution, we were hunter-gatherers who did not have organized agriculture, let alone the industrialization of food and a 24-hour convenience store on every corner. Our bodies evolved to intentionally create a physiologic state of wakefulness if we were starving. This wakefulness had the effect of allowing us to go travel farther to find food more effectively (after all, if we fell asleep while we were starving, we’d be more likely to continue starving and eventually die). He explained that the opposite is true, as well — that just as when our bodies are experiencing starvation, we will naturally experience insomnia, when our bodies are experiencing insomnia (or intentionally disrupted or short sleep), our brain misinterprets this to mean we must be starving. This triggers a myriad of mechanisms designed to increase our appetites and make us more likely to eat. 

One such mechanism is a decrease in serum leptin levels that occurs in response to inadequate sleep. Leptin is a hormone produced by adipocytes (fat cells) that, when high, signals that the body is well fed, and when low (as naturally occurs when there are few fat stores to produce it), signals that the body is starving and acts to lower satiety and lower energy expenditure. This basically makes you eat more and move less. Not only do leptin levels drop with poor sleep, but acutely inadequate sleep (meaning just a single night of poor sleep) leads to an increase in the potent hunger hormone ghrelin, which is released primarily by the stomach. (Anyone ever thoroughly enjoy a breakfast at a greasy spoon diner after a night out drinking and subsequent poor sleep? Check.) Researchers not only found these changes in appetite regulating hormones that promote overeating, but also found that participants with an average nightly sleep of 7.7 hours were the thinnest, and participants with less sleep than that had significantly higher BMIs.   

I personally believe good quality sleep for 7-9 hours per night (in adults) is actually more important for overall health and the maintenance of a healthy bodyweight than is exercise, though certainly, I am a huge fan of each!. If you don’t even know how much you’re sleeping, the first step is awareness: start keeping a sleep journal and record your bed and wake times to estimate it each day (or look at the data from your Apple Watch, Fitbit, or Oura ring). If you, like me, are getting less than 7 hours of sleep on any given night and/or have fragmented sleep, join me next week for part 2 of this 3 part series and I’ll get into the nitty gritty of potential solutions and the various changes I have personally made in my own quest for better sleep. 

Please leave me comments below, feedback (positive or negative!) and topics you’d like for me to cover in upcoming blog posts would be great. I’m all ears!

Until next week – sleep tight!

Jen