Sleeping with Darth

CPAP stands for Continuous Positive Airway Pressure. Lord Vader sounds like a man wearing a 20^th century CPAP device, and should you ever be trapped in a lift with a group of Star Wars obsessives (these are probably not the fans you are looking for), they will explain that Darth’s outfit does indeed provide CPAP, regulating his air pressure and helping him to breath.

Darth required CPAP because his lungs were charred when he fell into a lava pit on planet Mustafar, in the Atravis sector. This was an unusual case. Most folk use CPAP devices to alleviate obstructive sleep apnoea (OSA), and their numbers are increasing rapidly because the risk of developing OSA increases with bodyweight. A 10% weight gain is associated with a 6-fold increase in the risk of OSA (1), 

Accordingly, as populations continue to fatten on the industrial diet, OSA figures are rising (2, 3). They may now have reached as many as 13% of all US adults (3, 4), and are projected to grow higher as we grow wider.

As waistbands expand, fat deposits accumulate in the pharynx and abdomen. These block airways and reduce respiratory volume, making the upper airway more likely to collapse during sleep. If your partner is snoring, snurking and occasionally choking in their sleep, they probably have sleep apnoea. Ad if you wake up exhausted, depressed and irritable, with headache and dry mouth and throat, you probably have it too.

It’s a serious matter. Darth died with his boots on, but Princess Leia (Carrie Fisher) was killed by OSA complications plus a cocktail of street drugs on an LAX-bound Boeing (5). Sleep apnoea is dangerous because it contributes to a number of serious pathologies. 

OSA drops blood oxygen, raises carbon dioxide, and drives up the triad of cortisol, insulin resistance and glucose (6, 7). These shifts contribute to increased risks of diabetes, hypertension, atrial fibrillation, strokes, heart attacks and congestive heart failure. Elevated cortisol levels (6, 7) show that sleep apnoea is a significant stressor, and over the long haul they increase the risk of cognitive decline and dementia (8-13).

There is also plausible OSA / cancer link. 

OSA is strongly associated with obesity and ageing, substantial cancer risk factors in their own right and therefore confounding variables in the many epidemiological studies (14) which indicate a link between OSA and cancer.

These do not provide proof. However, the hypoxia, inflammation, impaired immune surveillance, sleep disturbances, dysbiosis and loss of insulin sensitivity triggered by OSA are all recognised as cancer-promoting mechanisms (ie 15-17); they increase carcinogenesis, tumour growth rates and cancer cell invasiveness (18).

A growing body of evidence suggests that OSA does indeed ramp up the risk of certain clinical cancers, including melanoma (19). A recent and very large meta-analysis (20) tends to support this idea. Further investigations are ongoing, but the case for CPAP is already very strong.

Wearing a CPAP device in bed is deeply unromantic (in my opinion), but it reduces many of the above risks (21-24). Any subtle changes in facial structure caused by long-term nasal CPAP (25, 26), aka ‘Smashed Face Syndrome’, will be outweighed by reduced signs of sleep deprivation. And in the morning, you will feel more rested.

This is why CPAP, which started out as a man, a pug and a vacuum cleaner (27), is now a $10 billion industry. It is not, however, the whole solution; as you might expect, nutrition plays a role too. Part of this is simply trying to help OSA patients to lose weight, but there is more. Relatively new research underlines the importance of chronic inflammation in OSA. 

The abrupt nocturnal changes in oxygenation cause oxidative stress, which overlaps with inflammatory stress (28). Blood levels of various inflammatory cytokines correlate well with OSA severity (ie 29-32), and it is reasonable to characterise OSA as a disorder with a significant inflammatory component. This seems to be particularly implicated in hippocampal and cortical brain damage (8-13, 33), and downstream cardiovascular endpoints (22-24, 34).

Chronic inflammatory stress may precede OSA (35), with both issues being primarily by obesity (35), but the fact that CPAP reduces inflammatory markers (ie 36-38) demonstrates that OSA does indeed cause inflammation. This in turn helps to explain why CPAP reduces mortality (39), although this reduced risk only emerges after 6-7 years of use.

Positive biochemical and clinical effects (ie 21-25) tend to emerge earlier, at around 4-6 months. If we were to use additional anti-inflammatory nutritional tools, clinical experience with these leads me to expect biomarker changes and symptomatic improvements in many cases within 2-3 months. Furthermore, the overall health benefits should be substantially greater.

I think this would be worth trialling. If there is any substance in this argument, supplementation with omega 3 HUFA’s and amphiphile polyphenols could be a useful low-cost entry-level intervention, particularly in those who do not enjoy wearing a CPAP device in bed.

There are likely to be additional benefits. A significant number of cases of treatment-resistant hypertension have underlying OSA (41-42), and I have seen the omega 3 HUFA / amphiphile polyphenol combo reduce BP in many patients with essential hypertension. This potentially dual response makes the potential use of CPAP plus pharmaco-nutrition in OSA even more interesting. There is evidence that an anti-inflammatory diet reduces the risk of OSA (43), although the weight loss associated with this diet is another likely mediator.

Gut dysbiosis also appears to be involved in OSA-associated hypertension, and may be mediated via neuroinflammation (44, 45). Blended prebiotic fibers therefore constitute another pharmaco-nutritional tool which could be tried in such cases. 

There is a more general and more important point, which I have made in previous posts. OSA is linked to obesity, chronic inflammation, dementia, dysbiosis, cancer, NIDDM, NAFLD and resistant hypertension (ie 12, 13, 17-20, 42, 44, 46, 47). While researchers all over the world are trying to dissect out the links, this is not the most effective use of research funds.

In those living the modern life, all these pathologies interact with and reinforce each other, but they are symptoms of the same malaise; they are largely driven by the same dietary and lifestyle factors creating chronic inflammatory stress, Type B malnutrition, dysbiosis and glycemic mis-match. 

I was taught at medical school to address patients’ fundamental problems, where possible, in parallel with symptomatic management. This is why I recommend the heath protocol as part of any risk reduction and management strategy.

Palatal exercises, nasal strips, tongue stabilizers, mandibular adjusters and even surgery provide alternatives to CPAP (50), and recently iNAP (49) has been introduced as the latest and best iteration of this ageing technology. These mechanical fixes may provide symptomatic relief, but in my opinion they continue to fail to address the basic problem.

Eat better may mean that you sleep better (50). Over the long haul, you will likely breath better and live better too.

Next week: The importance of homeostasis, the Martini Effect and the 18^th Column.

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