CPAP is a machine and a mask you wear at night that forces air through your nose and throat. CPAP can be hard to get used to for some people. If CPAP does not work, the next step may be surgery. However, before resorting to CPAP, or surgery as a last resort, lifestyle changes may help, especially for mild sleep apnea. [1,2]

How Do You Know You Have Sleep Apnea?

The obvious symptoms of sleep apnea happen while you are asleep, so lots of people have it and don’t know it unless a sleep partner tells them. For most people sleep apnea happens when the tissues at the back of your throat collapse inward enough to obstruct breathing. The result is loud, noisy snoring with short, quiet periods of apnea, which is not breathing. [1,2]

In you don’t have a sleep partner to tell you about night time symptoms, you can suspect sleep apnea if you wake up with a dry sore throat, you wake up with a headache and feeling sleepy, or you have daytime sleepiness that causes you to be tired, irritable, and brain fogged. Having restless nights and waking up frequently is another warning sign. [1,2]

You may be at higher risk for sleep apnea as you get older. Tissues in the throat tend to get weaker and with age. You may also be at risk of you have a family history of sleep apnea or if you have a short, thick neck. Men are at higher risk than women. There is not much you can do about these risk factors, but other risk factors for sleep apnea can be changed. That’s where lifestyle changes come in. [1,2]

Lifestyle Changes to Help Sleep Apnea

In most cases, a doctor will recommend lifestyle changes for sleep apnea before CPAP. Even if you do need CPAP, these changes are still an important part of treatment:

1. Lose weight.

Being obese or overweight is the most important risk factor for sleep apnea. Losing weight may be the best treatment.

2. Get exercise.

Thirty minutes of brisk walking or another aerobic exercise can help you lose weight, but even without weight loss, exercise has been shown to improve sleep apnea.

3. Avoid alcohol.

Alcohol causes a deeper sleep and more collapse of your airway. Drink only in moderation, or avoid alcohol. Alcohol is most likely to cause sleep apnea if you drink before bedtime.

4. Don’t take sedative medications to help you sleep.

Sedative medications relax the muscles in your throat and make sleep apnea worse.

5. Don’t smoke.

Smoking triples the effect of sleep apnea. It causes your airway to be inflamed.

6. Don’t sleep on your back.

Sleeping on your back causes your soft palate to drop down into the back of your throat. Sleep on your side. It can also help to sleep with your chest and head elevated. You can prop up the head of your bed or sleep on a wedge. [1-3]

Other changeable risk factors can be treated with medication. Having long-term nasal congestion from allergies or sinusitis can contribute to sleep apnea. You doctor may treat these conditions along with lifestyle changes. [1,2]

Don’t Ignore Sleep Apnea

If you suspect sleep apnea let your doctor know. Your doctor may suspect sleep apnea from your symptoms, but the best way to diagnose this condition and determine severity is to do a sleep study, called nocturnal polysomnography. This test  is done while you sleep to measure your breathing rate, heart rate, blood pressure, and oxygen level. [1,2]

Sleep apnea is a potentially serious problem. It can increase your risk for high blood pressure, heart disease, and type 2 diabetes. The good news is that it doesn’t always mean CPAP or surgery. Lifestyle changes may do the trick and give you and your sleeping partner a better night’s sleep. [1-2]

RECOMMENDED FOR YOU

• 11 Surprising Sleep Apnea Symptoms
• Do You Have Obstructive Sleep Apnea?
• Dreaming of Better Sleep?

SOURCES

1. Mayo Clinic, Sleep apnea – Symptoms and causes – Mayo Clinic
2. NIH,Sleep Apnea | NHLBI, NIH
3. Mayo Clinic, Home Remedies: Stop the snoring – Mayo Clinic News Network

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What Causes Insomnia?

Insomnia can be a short-term or long-term issue. Short-term (or transient) insomnia can be caused by illness, stress, travel, or environmental factors. Long-term (or chronic) insomnia is usually caused by an underlying psychological or physical condition, according to the University of Maryland Medical Center.

Illnesses or medical conditions that can cause short-term insomnia include allergies, gastrointestinal problems, arthritis, asthma, chronic pain, and neurological conditions, according to the National Sleep Foundation.

Neurological diseases that may cause insomnia include Parkinson’s or restless leg syndrome (RLS). People who have RLS, for example, typically experience an increase in symptoms during periods of rest or inactivity; this makes sleeping much more difficult. Studies show that people suffering from RLS are more likely to suffer from depression, stress, and anxiety.

Insomnia not only can have an impact on your nights, but on your days as well. A chronic lack of sleep causes daytime sleepiness and an increase in anxiety and irritability, and also puts you at risk for drowsy driving and falls at home.

Some of these conditions can be mistakenly attributed to aging and related medical problems, so if you believe you aren’t getting enough sleep at night, it’s important to see your healthcare provider. Your physician may prescribe medication to treat your insomnia. Non-benzodiazepine sedative hypnotics such as Ambien, Sonata, Lunesta, and Rozerem are the most popular, according to the University of Maryland Medical Center. As with any prescription drug, it’s important to understand any and all possible side effects.

Beyond Sleep Meds

Prescription medications may not be necessary to treat your insomnia. In certain instances, the solution may lie in lifestyle changes. The following six tips can go a long way in making sure you fall asleep easily and stay asleep throughout the night.

1. Set the same bedtime and wake-up time each and every day. This can help your body to get in a routine for when to sleep. It’s also important to avoid naps if suffering from insomnia, as this may disturb your body’s sleep routine.
2. Avoid electronics and screens before bed. These devices may distract you from falling asleep and can keep your body in an alert state.
3. Exercise during the day. The more physical activity your body goes through during the day, the more likely you are to feel tired when it comes time to sleep.
4. Avoid stimulants before bedtime. Set a cutoff time during the day to have that last cup of coffee. A study by the Journal of Clinical Sleep Medicine examined the effects of caffeine on sleep and recommended not using caffeine within 6 hours of bedtime.
5. Avoid alcohol before bedtime. While consuming alcohol before bed may initially help you to fall asleep quickly, you’re more likely to experience disruptions during your sleep and wake up throughout the night.
6. Avoid staring at the clock. If you’re experiencing trouble falling asleep, staring at a clock as time passes by can only magnify the issue and increase your anxiety related to not falling asleep.

Stick with these changes for some time and don’t get discouraged if you find yourself continuing to experience insomnia at first. Your body may have to go through an adjustment period to practice good sleep hygiene.

If an insomnia problem still persists over time, however, seek help from your physician or consider seeing a sleep specialist.

The post What Keeps You Up at Night? 6 Ways to Beat Insomnia appeared first on University Health News.

Q: I’m sure my wife has sleep apnea—she rouses several times during the night, making choking sounds, and often is tired during the day. She isn’t taking my concerns seriously, so how can I convince her to discuss her symptoms with her doctor? 

A: You are correct that sleep apnea symptoms warrant a consultation with the doctor. The condition occurs when soft tissue at the back of the throat blocks the airway during sleep—the brief awakenings your wife seems to be experiencing are a sign she isn’t getting sufficient oxygen.
    Getting treatment for her symptoms will make a big difference to your wife’s energy levels, as well as help her stay alert during the day. It should benefit her overall health, too, since sleep apnea is linked to high blood pressure, heart attack, stroke, diabetes, depression, and memory problems. A recent study (Journal of Clinical Sleep Medicine, Jan. 15) suggests that seniors whose sleep apnea goes untreated have more doctor’s appointments, emergency room visits, and hospital stays than seniors whose sleep apnea is treated. I hope this will convince your wife to seek medical advice. If she is diagnosed with sleep apnea, she may need to use a continuous positive airway pressure (CPAP) machine at night. These devices deliver a steady flow of air to the lungs via nasal cannula or a face mask. I use one myself, and it has made a world of difference to my sleep.

Rosanne M. Leipzig, MD, PhD
Geriatric Medicine

Q: My brother has been diagnosed with Barrett’s esophagus. Can you tell us more about this condition and how it is treated?

A: Barrett’s esophagus is a condition that can develop if the esophagus suffers long-term exposure to stomach acid—as such, it typically occurs in people with gastroesophageal reflux disease (GERD), in which stomach acid leaks up into the esophagus. The lining of the esophagus is different from the lining of the stomach, and there is a “border” separating the two types of tissue at the area where the organs meet. In Barrett’s esophagus, the cells that line the stomach grow above this border. Over time, these cells can become abnormal, and may turn cancerous. This is rare, but it means that people with Barrett’s esophagus must be closely monitored. If GERD is present, this also should be treated with antacids and lifestyle and dietary changes, such as quitting smoking, losing weight if necessary, avoiding dietary triggers (fatty foods, citrus, tomatoes, garlic, chocolate, peppermint, caffeinated and/or carbonated beverages, and alcohol), and not eating within two to three hours of bedtime.
   If monitoring suggests that your brother’s condition is worsening, his doctor may recommend a biopsy to examine for abnormal cells. If these are found, they can be destroyed using a technique called ablation, in which the cells are heated or frozen.

Brijen J. Shah, MD
Gastroenterology

Q: My husband has developed an inguinal hernia. Can you tell us more about these hernias, and how they are treated?

A: An inguinal hernia occurs when body tissue (usually part of the intestine) bulges through a weak area in the abdominal muscles. Older people are at particular risk of this because the abdominal muscles tend to weaken with age.
    An inguinal hernia can cause pain, and a sense of pressure in the groin. It also is possible for a complication called strangulated hernia to occur if the bulging tissue is trapped in the abdominal wall. This cuts off the blood supply to the trapped tissue and is a medical emergency. Signs include sudden, intense pain, nausea, vomiting, and fever—the hernia bulge also turns a reddish-purple color.
    If your husband’s hernia is not causing problems, his doctor may recommend monitoring, but if it is painful or grows larger, surgical repair may be necessary to push the bulging tissue back into place and reinforce the weakened area with synthetic mesh. If surgery is not advisable for any reason, your husband may gain relief from wearing a truss, which is a supportive undergarment that holds the herniated tissue in place.

Celia M. Divino, MD
Surgery

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Sleep Apnea Symptoms: Not all Are Easy to Identify

Sleep apnea is best known for its hallmark symptom of cessation of breathing during episodes in the night. But there is a long list of sleep apnea symptoms, some of which may surprise you:

• Snoring
• Occasional waking with gasping for air
• Insomnia
• Daytime sleepiness
• Fatigue
• Dry mouth
• Loud breathing or shallow breathing
• Headache
• Irritability
• Mood swings
• Bone loss and osteoporosis
• Depression

Sleep Apnea Screening?

In many cases, people experience symptoms of sleep apnea without knowing that they have it. After all, the most noticeable and obvious symptoms like snoring occur while you are asleep.

But if you’re experiencing any of these symptoms, especially inexplicable mood swings or a depressed mood, getting screened for sleep apnea may help you to identify the root cause of your symptoms.

Can Sleep Apnea Really Cause Depression?

Several studies have shown that people with obstructive sleep apnea are significantly more likely to also have depression than the general population.[1] The results of clinical studies show that the prevalence of depression in sleep apnea patients is between 21% and 39%.[2]

So what can explain such a high overlap between depression and sleep apnea? Researchers can’t know for sure whether this is just a correlation, or whether sleep apnea can cause depression directly. One theory is that the lack of oxygen (hypoxia) that occurs with sleep apnea may cause problems in the body and brain that lead to depression.[1,2] Sleep apnea may also cause inflammation in the body and affect neurotransmitter activity, both of which could contribute to depressive symptoms.[1]

Another possible explanation is that depression develops in response to some of the other sleep apnea symptoms like poor sleep quality. Sleep apnea may cause poor sleep and thus fatigue, sleepiness, and other symptoms making daily life difficult; these could in turn trigger depression.[2]

Several studies support this explanation, showing that sleep apnea accompanied with high levels of daytime sleepiness is even more highly associated with depression than sleep apnea alone.[2,3] In one study, men who had previously undiagnosed sleep apnea and excessive daytime sleepiness were four to five times more likely to have depression than men without either condition.[3]

Treating Sleep Apnea Could Improve Your Depression

Many people have found relief from depression when they address and treat their sleep apnea. In one study, participants with sleep apnea who scored higher than a 10 on a health questionnaire measuring depressive symptoms were considered clinically depressed. After the 228 people in the study started to use CPAP therapy to treat their sleep apnea, the percentage of people who scored higher than a 10 on the depressive symptoms questionnaire decreased from 74.6% to only 3.9%.[4]

Other studies have found conflicting results, suggesting that depression may not be so easily relieved in all cases. But if you are suffering from depression, identifying and treating a possible sleep disorder is certainly worth a try.

Diagnosis and Treatment of Sleep Apnea

If you have depression (or one of the many other sleep apnea symptoms like dry mouth or headache) and can’t quite figure out why, get screened for sleep apnea.

A sleep specialist can run tests to measure your oxygen intake during the night to determine if you have this sleep disorder. If so, there are a variety of options to treat the condition. Many people use a CPAP machine, which is a device that helps you to get plenty of oxygen while you sleep. Read How to Stop Sleep Apnea – 4 Non CPAP Remedies for alternative options.

Share Your Experience

Have you ever had sleep apnea? What symptoms did you experience? What treatment options worked for you? Share your experience in the comments section below.

Originally published in December 2015, this post has been updated.

[1] Sleep Breath. 2015 Jul 9. [Epub ahead of print]
[2] Lung. 2015 Apr;193(2):261-7.
[3] Science Daily News Release. 2015 May 18.
[4] J Clin Sleep Med. 2015 Mar 17. pii: jc-00354-14. [Epub ahead of print]

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What Is Serotonin?

Serotonin, the “happy neurotransmitter,” is a powerful brain chemical intricately linked with mental health and is one of the best supplements for depression. Sufficient serotonin in the brain allows you to feel calm and optimistic and provides a sense of well-being, while serotonin deficiency has the opposite effect. Low serotonin levels (or abnormal serotonin function) is the most recognized underlying cause of depression.

Studies show that serotonin imbalances may not only lead to classic depression symptoms like sadness and pessimism, but other symptoms such as food cravings, sleep disturbances, aggression, panic, obsessiveness, and more. (See also our post “What Does Serotonin Do?“)

Watch for Serotonin Deficiency in the Aging Brain

As the brain ages, deficiencies in neurotransmitters such as serotonin are more likely to occur. Low serotonin is not so much a specific risk factor for mild cognitive impairment and Alzheimer’s as it is a sign that overall brain health and function are compromised. Likewise, boosting serotonin production may not necessarily prevent mild cognitive impairment or Alzheimer’s. Instead, low serotonin and the symptoms it causes should be seen as red flags that brain health is suffering, which increases the risk for mild cognitive impairment and Alzheimer’s.

Serotonin deficiency symptoms include:

• Depression
• Pessimism
• Anxiety
• Insomnia
• Repetitive thoughts and obsessive thinking
• Low self-esteem
• Irritability
• Shyness, fears, phobias or panic attacks
• PMS
• Cravings for sugar or carbohydrates
• Seasonal Affective Disorder (depression that’s worse in the winter)
• Feeling better after taking SSRIs (selective serotonin reuptake inhibitor antidepressant medications)

Many of the dietary and lifestyle pitfalls that increase the risk of mild cognitive impairment and Alzheimer’s can also deplete serotonin levels. These include processed diets based on sweets and starchy foods, lack of exercise, and chronic stress. But, the upside to this equation is the same factors that lower the risk of mild cognitive impairment and Alzheimer’s can also improve serotonin activity.

The aim is to lower inflammation in the body and brain, as inflammation blocks serotonin production. In fact, research increasingly shows depression to be a symptom of inflammation. Therefore, although diminished serotonin activity may be seen in patients with mild cognitive impairment and Alzheimer’s, it is most likely just one of many symptoms of a diet- and lifestyle-induced inflammatory process that has sabotaged and degenerated the brain to the point of memory loss and dementia.

How to Increase Serotonin Levels with Serotonin Supplements

The good news is that a number of serotonin supplements have been shown to increase serotonin and effectively treat symptoms of serotonin deficiency. SAM-e, 5-HTP, and L-tryptophan St. John’s Wort have each been shown in multiple human studies to affect serotonin imbalances and to treat depression. Let’s take a brief look at how to use each of these serotonin boosters to improve mood, treat insomnia, and ease other low serotonin symptoms.

5-HTP.  Your body makes 5-hydroxy tryptophan, or 5-HTP, from tryptophan, and then converts it into serotonin. When taken as a supplement, 5-HTP is well-absorbed and crosses the blood-brain barrier where it gets converted to serotonin. 5-HTP is believed to offer stronger serotonin support than L-tryptophan (see below). Clinical trials have confirmed the efficacy of 5-HTP supplements for depression, sleep disorders, binge eating and panic disorders._[1-3]

L-Tryptophan. L-Tryptophan is an essential amino acid required by the body to synthesize serotonin. As discussed above, the conversion of L-tryptophan to serotonin is a two-step process in which 5-HTP is synthesized as an intermediate step. Taking L-tryptophan as a serotonin supplement enhances the synthesis of serotonin and increases serotonin levels within the body._[4] Nevertheless, integrative practitioners report success with the use of L-tryptophan for insomnia, mild depression, and for people who do not tolerate 5-HTP since, compared to 5-HTP, L-tryptophan is generally considered more gentle. It has even been found to help non-depressed, healthy people process emotions in a more positive way._[5]

SAM-e. S-adenosyl methionine (SAM-e—pronounced Sammy), produced from the amino acid methionine, is present in all the body’s cells and is required for hundreds of reactions, including the synthesis of serotonin. As a supplement, SAM-e has been used extensively for treating depression in Europe for over 30 years, and a review of SAM-e studies published in the American Journal of Clinical Nutrition concluded that SAM-e supplementation was a safe and effective treatment for depression._[6] Drs. Richard Brown, M.D., of Columbia University and George Papakostas, M.D., of Harvard Medical School both advocate the use of SAM-e for clinical depression._[7,8]

Saint John’s Wort. Extracts of the flowering St. John’s wort plant exert their antidepressant actions by inhibiting the reuptake of serotonin as well as norepinephrine and dopamine, making more of these neurotransmitters available to the brain. For people suffering from mild to moderate depression, studies show that St. John’s wort extracts are significantly more effective than placebo._[9] They have been found to be better tolerated but to work just as well as standard antidepressant drugs._[9]

Safety First

Though having too little serotonin is not good for you, too much serotonin can cause harm. Do not take more than one serotonin booster at a time. Natural serotonin pills or other natural supplements for depression may not be appropriate for all types of depression and may not be compatible with certain types of depression medication. If you are taking an anti-depressant, vitamins for depression, or other natural supplements for anxiety and depression, consultation with a healthcare practitioner is strongly advised. A healthcare professional can also provide insight about the best supplements for anxiety treatment, or the best supplements for depression.

Other Natural Supplements for Anxiety and Depression

Depression, anxiety, and other mood disorders have other possible underlying causes in addition to serotonin deficiency. For example, read Could Your Depression Be Caused by a Sleep Disorder? Depression Can Be One of the Many Surprising Sleep Apnea Symptoms.

Other vitamins that help with depression include the neurotransmitter dopamine. Dopamine is also involved in mental-emotional health, and specific dopamine supplements may also be indicated. Learning more about all the potential underlying causes of depression and anxiety can help you target your natural treatment protocol.

For related reading, visit these posts:

• Serotonin: Vital Brain Chemical Affects Both Mood and Cognition
• It’s Difficult to Define Serotonin—This “Brain Chemical” Has Multiple Actions All Over the Body
• Serotonin Deficiency: A New Target for Mild Cognitive Impairment and Alzheimer’s
• Serotonin Deficiency: Is This Really a Cause of Depression?

Originally published in 2013, this post is regularly updated.

[1] Asian J Psychiatr. 2013 Feb;6(1):29-34.</a
[2] Eat Weight Disord. 2012 Mar;17(1):e22-8.
[3] Altern Med Rev. 1998 Aug;3(4):271-80.
[4] Anal Bioanal Chem. 2012 Feb;402(4):1593-600.
[5] Psychopharmacology (Berl). 2006 Jul;187(1):121-30.
[6] Am J Clin Nutr. 2002 Nov;76(5):1158S-61S.
[7] 141st APHA Annual Meeting. Abstract 283939. To be presented Nov 6, 2013.
[8] Can J Psychiatry. 2012 Jul;57(7):406-13.
[9] J Clin Psychiatry. 2009;70 Suppl 5:23-7.

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• Obstructive sleep apnea (OSA) is by far the most common, affecting as many as 18 million men and women in the United States. In OSA, breathing is interrupted when the upper airway is blocked by the collapse of excess soft tissue in the back of the mouth behind the tongue during sleep.
• Central sleep apnea occurs when there is a change in the brain’s signal regulating the muscles that control breathing.

If you have OSA, you may awaken suddenly, gasping for air. Having your airway blocked is like trying to drink through a wet paper straw—you keep sucking on it, but nothing gets through. Although snoring and excessive daytime sleepiness are the most common symptoms of OSA, the condition also can produce choking, snorting, dry mouth, and headaches in the morning. Even if you are snoring, choking, or gasping, you’re probably unaware of it, since these behaviors occur during sleep. Usually, they don’t bring you to a fully awakened state. In most cases, the symptoms are noticed by a person’s bed partner or another member of the household.

In a single night, a person with OSA may have from five to more than 100 episodes of abnormal breathing per hour of sleep. The cutoff of air may lead to low levels of oxygen and high levels of carbon dioxide in the blood, alerting the brain to signal the upper airway muscles to open. When this happens, sleep becomes lighter and is interrupted. These frequent arousals keep you from getting the deep, continuous, restorative sleep you need and cause daytime sleepiness. The frequent blockages in breathing also may elevate nighttime blood pressure and cause heart rhythm disturbances.

For people with OSA who suffer from daytime sleepiness, heart disease is a particular concern (see “Excessive Sleepiness Connected to Heart Disease Risk”). Treatment of OSA is the first-line approach to overcome sleepiness in these patients. However, in some cases, residual excessive sleepiness continues. Fortunately, the U.S. Food & Drug Administration has approved medications to relieve daytime sleepiness from OSA. While the medications may reduce the likelihood of a driving accident or other potential incident caused by falling asleep during the daytime, whether it lowers heart disease risk is yet unknown. These medications include modafinil (Provigil), armodafinil (Nuvigil), and solriamfetol (Sunosi).

Vitamin D deficiency also has been linked to OSA and other sleep disorders, including restless legs syndrome (see Chapter 5). Vitamin D deficiency is common: One study found that 74 percent of participants were deficient in this “sunshine vitamin.” However, more research is needed to determine if there’s a correlation between vitamin D levels and OSA severity, and whether vitamin D supplementation may help alleviate OSA. However, vitamin D plays such an important role in our health that anyone who is vitamin D-deficient should talk to their doctor about taking vitamin D supplements or increasing daily sun exposure in a safe manner.

Sleep Apnea and Your Health

OSA predisposes people to multiple health problems. The most common associations are:

High blood pressure. Up to half of people with OSA have high blood pressure. Mild and moderate OSA have been linked with a more than three times higher risk of developing hypertension. Severe OSA may affect the ability to control blood pressure, even if a patient is taking three or more blood pressure medications (see “Blood Pressure Control Affected by OSA”).

Diabetes. OSA is associated with a higher incidence of insulin resistance and glucose intolerance, two conditions that contribute to an increased risk of type 2 diabetes. OSA also has been linked with diabetes onset at a younger age and diabetes that is more difficult to control.

Poor quality of life. OSA can lead to irritability, sexual dysfunction, depressed mood, and accidents caused by dozing off while driving or working. If OSA symptoms, such as loud, frequent snoring, interrupt your bed partner’s sleep, it may have a negative effect on your relationship.

Liver damage. OSA may be a risk factor for liver damage caused by reduced oxygen supply to the liver during sleep.

Obesity. Severe OSA may predispose individuals to weight gain. Anyone with a higher number of apneas and hypopneas (a milder sleep-associated respiratory event characterized by shallow breathing) per hour of sleep is at particularly high risk and may gain weight steadily over time.

Parkinson’s disease. OSA appears to increase the risk of Parkinson’s disease, but only in women.

Low bone density. OSA nearly triples the risk of osteoporosis in women, and severe OSA has been connected with low bone density in men.

Cancer. Multiple research studies have linked OSA with cancer incidence, resistance to cancer treatments, and cancer mortality. The connection is particularly strong in women (see “OSA May Increase Cancer Risk in Women”).

Stroke. Research suggests that OSA doubles or triples the risk of stroke in middle-aged and older men. The risk appears in men with mild sleep apnea and rises with the severity of OSA. Studies have linked a higher stroke risk in women  only with severe OSA. Conversely, up to two-thirds of patients who suffer a stroke develop OSA later, even if they do not fit the typical OSA patient type (see “OSA Common After Stroke”).

Heart attack. OSA increases the risk of having a heart attack or dying from one by 30 percent over a period of four to five years. OSA may disturb the balance between “bad” LDL cholesterol and “good” HDL cholesterol and increase the likelihood of developing aggressive atherosclerotic plaques that narrow or block coronary arteries. If these plaques rupture or completely block blood flow to the heart, they can cause a heart attack. Studies also have shown that patients with OSA have multiple blood vessels narrowed by atherosclerosis, as well as extensive vessel involvement.

Arrhythmias/sudden cardiac death. OSA doubles the risk of sudden cardiac death. In studies, the most common predictors for arrhythmias (irregular heartbeat) were an age of 60 or older, 20 or more apnea-hypopnea episodes per hour of sleep, and an oxygen saturation level below 78 percent during sleep. Fortunately, treating OSA with continuous positive airway pressure after ablation (a procedure that restores normal heartbeat) has been shown to lower the likelihood the arrhythmia will recur.

Memory loss. In a study linking OSA to brain damage and memory loss, MRI scans revealed that structures in a region of the brain that deals with memory were almost 20 percent smaller in people with OSA than in those without the sleep disorder. It is thought that the repeated drops in oxygen that occur throughout the night may be causing these brain cells to lose function and die.

Alzheimer’s disease. A good night’s sleep seems to be important for the brain to clear the beta-amyloids that form the plaques associated with Alz­heimer’s disease (AD).

OSA that develops after age 65 doubles the risk of developing AD, the most common form of dementia; the more severe the OSA, the higher the risk. In one study, AD symptoms appeared an average of 60.8 months after OSA was diagnosed—13 to 18 months sooner than in study participants without OSA. OSA severity also made a difference. Mild OSA (five to 15 apneas per hour of sleep) increased AD risk 1.67 times, moderate OSA (15 to 30 apneas per hour) increased risk 1.81 times, and with severe OSA (30 or more events per hour), the risk was 2.63 times above normal. Women with OSA were at higher risk of developing AD than men with OSA. Education level was also an important risk factor: Adults with a high school education or less had twice the risk of adults who attended graduate school.

Scientists have linked poor sleep quality along with poor diet to the early accumulation of the plaques associated with AD. Part of the mechanism may involve cortisol, a hormone manufactured by the body that plays a role in regulating many core functions, including sleep. Cortisol levels naturally rise and fall with day and night. However, diets characterized by high intake of refined sugars, salt, animal fats, and animal proteins, and by low intake of fruits and vegetables, can boost the cortisol level at night so that it interferes with the natural circadian system, resulting in poor sleep quality. Scientists suggest that dietary changes that influence the body’s cortisol levels—and in turn promote good sleep—might be a safe and novel way to help protect the brain.

Post-surgery delirium. OSA has been linked with a more than two-fold risk of delirium, a sudden state of severe confusion and diminished brain function, after surgery.

Poor blood flow. Researchers have pinpointed a possible reason for the toll OSA takes on the brain: MRI images have revealed weaker blood flow in the brains ofindividuals with the sleep disorder.

Sleep Apnea and Women

Like severe snoring, sleep apnea once was thought to occur mostly in men, but it affects women, too, particularly after menopause. OSA may be underdiagnosed in women, and there may be some clinical differences in the presentation between the sexes as well. A Canadian study found that women with OSA were more likely than men to suffer from depression, an underactive thyroid (hypothyroidism), or insomnia.

Other research suggests that OSA may pose hidden dangers for women. Autonomic responses—the controls that impact such functions as blood pressure, heart rate, and sweating—are weaker in people with OSA, but even more so in women than in men. While women with OSA may appear to be healthy, their OSA symptoms tend to be subtler, which often means their sleep problems are missed, and an OSA diagnosis is delayed.

Diagnosing OSA

Often, the first person to spot OSA is your bedmate, who complains that you snore loudly or that you repeatedly gasp for breath during the night. If you have symptoms of OSA, report them to your physician.

Unfortunately, OSA often goes undiagnosed in older adults. Researchers found that 56 percent of American adults ages 65 and older are considered at high risk for OSA, yet only 8 percent have been treated for the sleep disorder. In the small percentage of adults who were given a sleep study, OSA was confirmed in 94 percent, and 82 percent were subsequently treated with CPAP. According to sleep experts, some older patients do not realize that snoring, daytime sleepiness, and fatigue are not normal symptoms of aging, but rather are symptoms of OSA that can contribute to a number of serious ­medical conditions.

The American Academy of Sleep Medicine recommends that physicians ask their patients if they have any symptoms of OSA during routine examinations. The American College of Physicians recommends that physicians consider offering a sleep study to patients who experience unexplained daytime sleepiness.

Lab-Based Sleep Study

Sleep specialists diagnose OSA with a sleep study. For an in-depth, comprehensive study, you will likely spend the night in a sleep lab. A test called polysomnography will record a variety of bodily functions, including brain waves, to detect the various stages of sleep, muscle activity, eye movements, heart rate, breathing, airflow, and blood ­oxygen levels.

Electrical sensors will be attached to your scalp, eye area, face, and legs to measure movement. Bands will be placed around your chest and abdomen to help gauge your breathing patterns, and a clip to measure blood oxygen through the skin will be attached to one finger. Airflow through your nose and mouth will be monitored with several devices to assess the frequency and severity of breathing problems. The study is not painful, and most people sleep well enough in the lab to yield useful findings.

The test shows if and how frequently breathing events related to apnea or hypopnea occur, and if there are periods of low blood oxygen and reduced airflow. All of this data is analyzed to determine if a diagnosis of OSA is warranted, and, if so, the level of severity. Sleep studies also can help identify other sleep disorders, such as narcolepsy, periodic limb movements, and abnormalities in sleep stage distribution.

Home Sleep Study

The most recent guidelines from the American Academy of Sleep Medicine suggest that people who don’t have other complicating medical problems, such as severe cardiopulmonary disease, take a home sleep test for OSA. Adults between the ages of 18 and 65 who have a high probability of moderate-to-severe OSA and no other medical conditions are most likely to benefit from a home test.

Home testing involves the use of a portable system that is worn while you sleep in your own bed. The system monitors and records respiration, heart rate, air flow, blood oxygen level, and time spent snoring during the night.

Future Diagnostic Tests

In the future, it may be easier to diagnose OSA using technology currently in development and testing. These approaches will require a review by the FDA to determine validity and safety for home use.

Emerging research also shows that analyzing a person’s breathing sounds while awake may accurately detect OSA. Larger studies are needed to confirm these findings.

Treating OSA

There are no FDA-approved medications to treat OSA itself, only daytime sleepiness caused by OSA. Although medical marijuana is being increasingly used to treat many medical conditions, the American Academy of Sleep Medicine does not recommend it for OSA. In pilot clinical trials of dronabinol, a synthetic form of tetrahydroconnabinol, many patients experienced intense daytime sleepiness as a side effect. In addition, its effects and safety over time have not been studied.

If you have OSA, an important part of the treatment involves making lifestyle changes, such as losing weight, if applicable. You also may be urged to quit smoking and avoid the use of alcohol, sleeping pills, and muscle relaxants, all of which make the airway more likely to collapse during sleep.

In many cases, sleeping position influences the severity of OSA. Up to 75 percent of people with OSA experience more frequent and longer pauses in breathing when they sleep on their backs. Special pillows that help keep you on your side rather than on your back while sleeping, and a device that vibrates when you roll onto your back, have been shown to reduce back sleeping by 84 percent, which reduced the severity of OSA. Elevating the head of your bed about six inches also may help. However, often, it is insufficient to overcome OSA.

If your OSA has caused high blood pressure or other problems, these conditions will need separate treatments. Some people with OSA also may suffer from hypothyroidism (an underactive thyroid), and thyroid hormone replacement may need to be considered.

Losing Weight

Losing weight is an effective way to reduce OSA symptoms and associated disorders. A large body of evidence has shown that people who lose weight can cut their number of apneas by half or more. Often, the most severe cases of OSA are associated with obesity.

The most effective and healthiest diets are those that go beyond calorie and portion control and supply your body with optimal nutrition. Adopting healthy eating behaviors that become part of your daily routine will help you maintain a healthy weight and better overall health on a long-term basis. Fad diets, on the other hand, may result in rapid weight loss, but generally, they are very difficult to stick with, and they may not meet all of your nutrition needs.

Calorie control can be an effective method of weight loss and weight management. Knowing how many calories foods contain can help you to incorporate “checks and balances” into day-to-day eating (for example, making up for any high-calorie treats with lower-calorie options at other times of the day). However, some people find calorie counting difficult, or they simply don’t want to keep track of numbers all day every day. For these people, a more structured eating plan may be easier to follow.

Weight-Loss Programs. Many people who are trying to lose weight get good results from following commercial weight-loss diets, such as WW (the new name for Weight Watchers), Jenny Craig, and Nutrisystem. In its annual report on the best diets in America, U.S. News & World Report has ranked WW the No. 1 dietary plan for weight loss for the past several years.

WW allocates foods a certain number of points based on their fat, calorie, and fiber content. You are given a specific number of daily points, depending on your present weight and activity level; if you stick to the number of points, you lose weight. (Many healthy foods have zero points.) WW has different programs, including ones that offer workshops and personal coaching, so you can choose the level that’s best for you. And if you have a smartphone, you can use the WW app to keep track of all of your information.

Another option is the national nonprofit Take Off Pounds Sensibly (TOPS), which provides tools, information, and support. TOPS members choose one of three eating plans to follow. Support is a key element of TOPS; you can attend weekly meetings in person or online and exchange tips and strategies with other members.

Healthy Eating Patterns. A Mediterranean-style diet has been linked with many health benefits, and researchers have found that following this diet and exercising regularly may help reduce sleep apnea symptoms. Researchers examined 40 obese patients with OSA. Half were given a low-fat diet, while the other half followed a Mediterranean diet, which emphasizes fruits, vegetables, legumes, whole grains, and healthy fats and is low in sweets, red meat, and processed foods. Both groups were encouraged to increase their physical activity, and both groups received continuous positive airway pressure (CPAP) therapy. Six months later, an overnight sleep study revealed that those who followed the Mediterranean diet had fewer apnea episodes during REM sleep, as well as a greater decrease in abdominal fat, than those who followed a low-fat diet.

Other strategies that may help with weight loss include intermittent fasting, eating more plant-sourced foods and fewer animal-sourced foods, and following a vegetarian or vegan diet. If you don’t want to follow a regimented diet plan, you can try old-fashioned sensible eating, making small changes every day—perhaps eating less sugar and fewer processed foods, eating more fiber-rich foods, using portion control, and making overall healthier food choices.

The bottom line: Different people will find success with different diets, and you may have to try several before you find the one that works for you. You also can get professional help: Ask your doctor for a referral to a registered dietitian nutritionist, who can evaluate your nutrition needs and consider your lifestyle and food preferences to devise an eating plan that will help you lose weight safely.

Using an Oral Appliance

The American Academy of Sleep Medicine recommends oral appliances for the treatment of chronic snoring and mild cases of OSA in individuals who don’t improve with lifestyle changes. These devices help keep the throat open by repositioning the tongue and lower jaw. A dentist specializing in sleep medicine fits the oral appliance, monitoring closely for comfort to avoid dental movement or joint discomfort. A repeat sleep study while wearing the device is recommended to determine whether it improves the patient’s breathing. About half of patients are helped to some extent by the device.

Using a Sleep Mask

For moderate and severe OSA, a continuous positive airway pressure (CPAP) device, which forces air through the nasal passages at a pressure that prevents the tissues of the throat from collapsing during sleep, is generally prescribed. The device delivers air through a small mask that fits over the nose, and, if needed, also over the mouth. Some newer masks deliver air through nasal pillows, which are placed at the opening of the nostrils. The correct air pressure is calibrated after a night in the sleep lab. Some devices can vary the flow of air to match an individual’s specific breathing pattern, while others start out the night with a lower air pressure and slowly increase it, so the wearer can fall asleep before the full pressure kicks in.

CPAP is not a cure but a treatment for OSA. Apneas will recur if you use the device improperly or stop using it. However, treating OSA with CPAP has been shown to provide many health benefits. It improves blood pressure control and cardiovascular function. It also reduces daytime fatigue and sleepiness and restores memory consolidation, improving quality of life. In a 2015 study of middle-aged overweight and obese adults, wearing a CPAP device for eight hours a night for two weeks improved blood sugar control and the ability of insulin to regulate blood sugar.

CPAP also has been shown to lower hospital readmission rates and emergency room visits among people with heart disease and to reduce the risk of death in people with OSA who also have chronic obstructive pulmonary disease (COPD) or obesity (see “CPAP Is a “Must” for Obese Patients with OSA”).

CPAP machines also may provide automatic self-adjusting pressure based on need, called APAP (A is for auto). This technology may be a better option for patients who have OSA predominantly during specific stages of sleep (e.g., REM sleep) or while sleeping on their backs. Some of the newer machines are able to function in either CPAP or APAP mode, and are preset and adjusted based on each person’s need as prescribed by their doctor.

Alternatives to CPAP

A different treatment for mild OSA and snoring uses a self-adhesive, one-way resistor valve that is applied to the opening of each nostril nightly. The disposable device produces positive airway pressure that may effectively treat snoring and mild OSA. Unfortunately, it’s not possible to predict who will respond best to this therapy.

Hypoglossal Nerve Stimulation. The most recent OSA therapy approved by the U.S. Food & Drug Administration (FDA) utilizes a pacemaker-like nerve-stimulating device. The device is surgically implanted in the chest, with an electrode that monitors breathing patterns and a second probe placed under the skin and connected to the hypoglossal nerve under the jaw on one side. During inhalation, the device stimulates the nerve, which controls muscles in the upper airway and tongue and opens the airway. (Another name for this treatment is “upper airway stimulation,” or UAS.) This treatment has been found to produce a significant drop in the number of apneas per night, resulting in meaningful improvements in snoring, daytime alertness, and sleep-related quality of life. (How does UAS compare with CPAP? See “Which OSA Treatment Is Best?”)

The device is approved as a second-line therapy, meaning that only patients who failed, or are not candidates for, CPAP are eligible for this treatment.

Surgery

For severe snoring associated with OSA, surgery may be used to reduce excess tissue in the upper airway to make breathing easier. Surgery is not without risks, however. It may not be completely successful, and it may even lead to the development of scar tissue; therefore, careful evaluation by an ear, nose, and throat physician or oral surgeon is recommended. The success rate for surgical treatment of OSA is about 40 percent, depending on the type of surgery and the criteria for success.

UPPP.  For many years, uvulopalatopharyngoplasty (UPPP) was the primary surgical treatment for OSA. In UPPP, part of the uvula, soft palate, tonsils, and excess tissue in the throat are removed. UPPP requires general anesthesia and an overnight hospital stay. In laser-assisted uvulopalatoplasty (LAUP), an outpatient procedure, a laser is used instead of a scalpel. UPPP and LAUP may reduce or eliminate OSA. However, their effectiveness is difficult to predict, and the benefits may not be lasting. Today, a growing number of patients who would have been treated with UPPP or LAUP are treated with hypoglossal nerve stimulation.

Ablation. High-frequency radio-wave ablation uses radiofrequency energy from a probe to generate heat that shrinks the structures in the upper airway, including the uvula and the base of the tongue. The heat is delivered to the tissues beneath the mucous membrane, so patients experience less post-operative discomfort than with UPPP or LAUP. However, this procedure is not yet approved as a treatment for sleep apnea; it’s used primarily for snoring.

Turbinectomy. In cases of enlarged tissue in the nose, a surgical reduction of the inferior turbinates (tissue located inside the nose) may reduce snoring. This approach should be personalized based on an individual’s anatomy and underlying health issues, as well as the severity of OSA.

Central Sleep Apnea (CSA)

In OSA, breathing stops because the airway becomes blocked by tissue. In CSA, patients stop breathing because their brains stop sending the signal to breathe. CSA is associated with other health conditions and an increased risk of mortality. CSA is most often associated with heart failure, but it is also common in patients who take medications that suppress breathing, such as opioids for pain management. CSA may even occur upon starting treatment with a CPAP for OSA.

A treatment similar to CPAP called adaptive servo-ventilation (ASV) is often effective in treating CSA. ASV has been very successful in treating central changes in breathing during sleep. An ASV machine looks very similar to CPAP or APAP machines; however, it has a more advanced system for adjusting the pressure settings during inhalation and exhalation. However, ASV is not recommended in cases in which patients have some other health conditions. For example, sleep experts often advise against using ASV in patients with severe, symptomatic heart failure. Typically, ASV is also not recommended in cases of extreme obesity that lead to shallow breathing at night.

An entirely different approach that is similar to the nerve stimulator for OSA is now available for treating CSA. This approach uses an implanted pacemaker-type device to stimulate the phrenic nerve, which runs from the neck to the diaphragm, to control the breathing muscles. The first such device, the “Remede- System,” was approved by the FDA in 2017. In the clinical trial leading to its approval, CSA patients who received the implant experienced a 50 percent drop in the severity and frequency of their apnea episodes (compared to 11 percent of the placebo group), hypoxia (low oxygen in the blood), and arousals, and they also reported improved sleep quality and quality of life. The system was found to be safe as well as effective. This treatment is now available in many hospitals in the United States.

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Older adults are at particular risk for poor sleep. Harrison Bloom, MD, associate clinical professor of geriatrics and palliative medicine at Mount Sinai, says that health issues such as arthritis often cause pain and discomfort that disturbs sleep as we age. “Wakefulness also may result from medications that are used to treat health issues,” he adds. “It’s common for older adults to feel sleepy during the day, due to poor slumber the night before, but to have difficulty getting to sleep once they’re in bed. Early waking also is a tendency.”

Unfortunately, previous research into the self-help methods seniors use to try to sleep better suggests that they frequently choose treatments that can potentially worsen their symptoms. There also is evidence that many older adults don’t consult their healthcare provider about their treatment choices. How can you ensure you sleep better while staying safe and healthy?

Poor Sleep and Disability The study we reference included 3,620 people aged up to 75, and analyzed survey data from 1995-1996 and 2004-2006. At both time points, 11 percent of the participants reported sleep problems. Those reporting sleep problems during the first survey were 55 percent more likely to experience limitations in their ability to complete activities of daily living (ADL), such as bathing, dressing, and walking one block, 10 years later. They were 28 percent more likely to have problems when it came to what are called “instrumental” activities of daily living (IADL)—for example, vacuuming, climbing stairs, and carrying groceries. Among participants who reported no disabilities during the first survey, those who had sleep problems were twice as likely to have problems with ADL 10 years later, and 70 percent more likely to have problems with IADL.

Dr. Bloom notes that lack of physical activity is associated with a greater risk for disability, and says it is possible that the chronic fatigue that can result from poor sleep may deter people from taking sufficient exercise. “The association between poor sleep and obesity also may be a factor, since obesity is linked with disability,” he adds. “Other conditions linked to poor sleep—such as cardiovascular disease, painful joints, and depression—also may play a role in the study findings.”

Self-Help Measures Aren’t Always Helpful In previous studies, seniors have reported engaging in a variety of approaches to try to improve their sleep. Commonly used interventions include reading, watching television, and listening to the radio. But Dr. Bloom says that in order to fall asleep quickly you need to condition yourself to “switch off” once you’re in bed. “If you use the bed for other pursuits, such as reading, you may not develop this conditioned response,” he points out.

Many older adults also use alcohol to help them drift off, but it’s a myth that alcohol helps you achieve restful sleep. While alcohol has a natural sedative effect that might help you go to sleep initially, it can exacerbate sleeplessness because it disturbs the balance between REM sleep (lighter sleep that includes dreaming) and non-REM sleep (deep sleep), preventing the brain from performing the normal restorative job it does overnight. “Alcohol also interacts with many medications older adults take,” Dr. Bloom says. “Alcohol and drugs can be a risky combination that affects balance, putting you at risk for falls.”

Sleep Medications Should be a Short-Term Solution While sleep medications can be useful to break a pattern of poor sleeping when all else fails, they come with their own potential problems. “In older adults, sleeping pills can cause daytime drowsiness and impair memory, and they’re also associated with falls,” Dr. Bloom confirms.

A 2015 study suggested that older adults are prone to using over-the-counter sleep medications for 15 days or more per month, which is considered to be indicative of inappropriate use. “Sleep medications can be a useful short-term measure, with the emphasis on short-term,” says Dr. Bloom. “However, they are not intended for chronic use, and their safety and efficacy has not been well studied in older adults.” Dr. Bloom points to simple sleep hygiene as a solution that could make a difference to your sleep quality without you having to rely on drugs—see What You Can Do for more.

Seek Medical Advice if You Have Sleep Apnea Symptoms Snoring or gasping during sleep, or feeling excessively tired despite apparently sleeping well, can be signs of a condition called sleep apnea. You’re more at risk for this if you’re overweight. If you’re suffering these symptoms your doctor may recommend you attend a sleep disorders clinic for follow-up.

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Stress as a Cause of Fatigue

Chronic or severe stress is a very common cause of fatigue. Stress is a real or interpreted threat that results in physical and be-havioral responses that are designed to help the body adapt. Situations that are new, unpredictable, or that appear threatening or uncontrollable activate the body’s stress response systems, which are controlled by the brain, the nervous system, and the ad-renal glands. The purpose of these responses is to mobilize the energy necessary for your body to adapt to the demands of a stressful situation.

In the short term, stress can be positive, because it can help you to grow, to learn, and to adapt. In the long term, however, when stress becomes chronic, uncontrollable, unpredictable, and difficult to cope with, it begins to take a toll on your health.

Stressors may be physical, chemical, and emotional. They may be real or exist only in your mind. Sources of acute stress are usually fairly obvious, but it is vital for you to identify and address your unique sources of chronic stress to overcome your fatigue.

There are many forms of chronic stress. Mental and emotional stress are the most obvious, but sleep disorders, blood sugar dysregulation, oxidative stress, and chronic inflammation are all forms of chronic stress.

Your overall stress load is made up of multiple factors, including your genetic predispositions; recent and distant history (especially trauma, abuse, or major life events); coping behaviors; habits and lifestyle; and exposure to environmental toxins.

When your body is bombarded by repeated stress triggers and prolonged stress, your overall well-being pays the price. Your stress response systems can become sluggish, ineffective, or prolonged, or they may not start or stop correctly. This, in turn, taxes your body’s nervous, hormonal, immune, metabolic, and cardiovascular systems, causing fatigue among a variety of other physical and psychological problems.

Fatigue is one of the primary symptoms that can result from chronic stress and a dysfunctional stress-response system. If you perceive yourself to be highly stressed, studies show that you are much more likely to suffer from not only greater fatigue, but from daytime sleepiness, poor sleep quality, and decreased sleep duration. You are also at higher risk for sleep apnea. Which of these apply to you?

• Work-related stress
• Stress caused by over-commitment
• Lack of social support
• High demands
• Lack of control
• Lack of rewards

All of these have been shown in studies to drain energy resources and cause fatigue.

Stress, Adrenal Fatigue, and HPA Axis Dysfunction

In order to understand how stress causes fatigue, it’s helpful to understand a little about what’s known as the the hypothalamic pituitary adrenal (HPA) axis.

The HPA axis makes up your body’s hormonal system for responding to stress. “HPA” refers to three hormone-secreting glands:

• The portion of the brain known as the hypothalamus
• The pituitary gland in the brain
• The adrenal glands, which sit on top of the kidneys

The HPA axis can be activated by an array of mental and physical stressors. Activation occurs when the brain interprets a threat, causing nerve cells in the hypothalamus to secrete a hormone called “corticotropin-releasing hormone” (CRH).

The CRH travels to the pituitary gland, which responds to its presence by secreting a pulse of another hormone called “adre-nocorticotropin hormone” (ACTH).

ACTH is then carried to the adrenal glands, where it stimulates the secretion of cortisol. In a properly functioning HPA axis, chemicals in the hypothalamus are sent to the pituitary gland, which triggers the production of a hormone that is sent to the the adrenal cortex, triggering the production of cortisol.

Cortisol

Of all the hormones involved in the HPA axis, the adrenal stress hormone cortisol receives the most attention. This is because of the direct relationship cortisol has with energy levels and fatigue. Cortisol regulation is intricately related to both physical and psychological well-being and aids in the healthy functioning of a wide variety of systems throughout the body.

• In the nervous system, cortisol is involved in learning, memory, and emotion.
• In the metabolic system, cortisol helps regulate blood sugar.
• In the immune system, cortisol regulates inflammation and the development of immune cells.

Cortisol measurements can be used to determine whether your HPA axis is functioning properly (i.e., whether your body and your mind have the energy they need to adequately adapt to challenges and stressful situations).

HPA axis activity may be assessed by measuring levels of cortisol in samples of saliva taken at different times of the day. When an HPA axis is functioning properly, cortisol levels are highest approximately 30 to 40 minutes after waking and decline over the course of the day, when levels reach a trough, prior to sleep onset. Many labs now offer salivary cortisol testing in a take-home kit.

Healthy HPA axis functioning requires HPA resilience, which refers to the ability of the HPA system to react appropriately to stressful conditions. Either one big stressful event or chronic stress over time can cause the HPA axis to lose resilience and function incorrectly.

It is thought that high levels of stress experienced early on in life can interfere with the successful development of a child’s HPA axis.

Childhood stress may negatively affect the way a child develops his or her ability to deal with subsequent stresses that occur later on in life. Studies have confirmed that childhood trauma is a direct risk factor for HPA axis dysfunction as measured via cor-tisol levels, for fatigue in adulthood, and for chronic fatigue syndrome.

Once it has lost resilience, the HPA axis may either overreact or “under-react” to stressful events. In other words, stress can both increase and decrease HPA axis activity, depending on the individual and on the nature of the stress.

Both overactivity and underactivity of the HPA axis can result in fatigue, although it is underactivity of the HPA axis with which fatigue is most frequently associated. When the HPA axis is under-
reactive and cortisol levels become chronically reduced, fatigue and other symptoms worsen.

The main symptoms of low cortisol levels are:

• Fatigue
• Pain
• Increased sensitivity to stress

As the body’s main stress hormone, cortisol is the first thing you may want to check off your list of potential fatigue factors. In patients with chronic fatigue syndrome, dysfunction of the HPA axis characterized by low cortisol levels is one of the hallmark features.

Studies have shown that the lower the cortisol levels in those with CFS, the more severely one may experience fatigue and other symptoms.

A number of other fatigue-related conditions, in addition to CFS, also are associated with stress, hypoactivity of the HPA axis, and low cortisol. These conditions include fibromyalgia (a disease that causes chronic and widespread pain and fatigue), post-traumatic stress disorder (PTSD), and certain types of depression.

Even those considered healthy by conventional standards can suffer from low cortisol. In one study, healthy adults who felt significantly sleepier during the day, were more likely to feel anxious or exhausted, and were more likely to experience poor health when they had low cortisol levels upon awakening

In some people—fibromyalgia patients, for example—studies have found that, while cortisol levels appear normal, the cells’ receptors for cortisol (glucocorticoid receptors) do not function properly. This renders the cortisol ineffective and results in a situation that mimics low cortisol.

On the opposite end of the spectrum of HPA axis dysfunction, cortisol levels are chronically elevated rather than low. This also can cause fatigue. A “burnt out” feeling and certain types of depression are often associated with high cortisol levels during the day.

DHEA

In addition to cortisol, the adrenal glands are responsible for secreting the steroid hormones dehydroepiandrosterone (DHEA) and DHEA-sulfate (DHEAS). DHEA is converted into testosterone and estrogen in body tissues.

DHEA and DHEAS also are made and used directly by the brain.

In fact, DHEA and DHEAS are the most abundant steroid hormones in the human body. Surprisingly, in spite of this, their part in the human body is not well understood by scientists.

It is known that DHEA secretion declines steadily with age and in conjunction with chronic stress, inflammation, and illness. DHEA plays an important role in:

• Maintaining overall health
• Protecting the nervous system
• Proper immune function
• Helping prevent diabetes
• Preventing blood sugar imbalance
• Preventing obesity and cancer
  Preventing memory loss
• Slowing the effects of aging

Research into the role of DHEA in fatigue is conflicting. Some studies have found that high DHEA levels predict the length of life in men, while other studies have found that low DHEA levels were associated with fatigue, anxiety, depression, and overall low mood. However, there is a lack of solid evidence that DHEA supplementation reduces fatigue or stress. Small studies show potential benefits in fatigue associated with depression and Addison’s disease (a rare adrenal disorder).

Testing for DHEA is not common and the results can be difficult to interpret, but tests can be useful in investigating HPA axis dysfunction.

Depression and Anxiety as Causes of Fatigue

Depression is a treatable medical illness characterized by prolonged intense feelings of sadness. Fatigue is the symptom of depression that is most commonly reported to family practitioners and the symptom that correlates most strongly with a lack of so-cial functioning, days of lost work, and low work productivity.

The severity of fatigue in those suffering from depression depends on the severity of the depression itself. Depression also may be accompanied by anxiety and insomnia, which may increase the amount of fatigue.

While fatigue is often a symptom of depression, the reverse is also true: Depression is often a symptom of fatigue.In addition, if you’re fatigued but not currently depressed, you’re at a higher risk for developing depression later on in life.

The insomnia, chronic sleep loss, poor sleep quality, and reduced amounts of rapid eye movement (REM) sleep that are typically associated with depression may be partly responsible for the fatigue and excessive daytime sleepiness frequently experienced by those with depression.

On the opposite end of the spectrum, people with depression also may tend to oversleep—and too much sleep is also a major cause of fatigue and excessive daytime sleepiness.

In some cases, sleep disturbances are a side effect of anti-depressant medications, rather than the depression itself.

Anxiety, Depression, and Fatigue

Anxiety disorders are characterized by excessive worrying. Fatigue is one of the many symptoms that often accompany anxiety, along with restlessness, feeling “keyed up” or on edge, difficulty concentrating, forgetfulness, irritability, muscle tension, and sleep disturbances (including difficulty falling or staying asleep, restlessness, or unsatisfying sleep). Headaches, muscle aches, and digestive symptoms are also common.

Anxiety disorders, such as generalized anxiety disorder, panic disorder, post-traumatic stress disorder (PTSD), and obsessive-compulsive disorder, are the most common mental health problems in the U.S.

Over your lifetime, you have a 16.6 percent chance of experiencing an anxiety disorder. General anxiety that does not quite meet the criteria of an anxiety disorder is even more common.

When anxiety is treated conventionally, drugs are often the sole method, but clinical trials have shown that drugs alone are not effective on a long-term scale. Moreover, anxiety medications have side effects that are often as equally disruptive as the disor-der itself. Some of the most common side effects of traditional anxiety medications are:

• Drowsiness
• Dependency
• Impaired cognition
• Memory loss
• Sexual dysfunction

If you have anxiety or depression, you are suffering from a real illness. Healing is possible, but it takes time, commitment, and practice. In addition to therapy (and, in some cases, medication), lifestyle changes, nutritional support, and natural therapies can be immensely helpful in overcoming fatigue, depression, and anxiety. These natural treatments are covered later.

Thyroid Imbalance as a Cause of Fatigue

The thyroid gland and the hormones it produces play a critical role in your metabolism and your ability to achieve and maintain normal physical and mental energy.

A low-functioning thyroid can lead to a long list of chronic symptoms, often subtle and ignored, with fatigue usually near the top of that list. “Hypothyroidism” is the technical name for an underactive thyroid. It’s an extremely common hormone disorder, especially in women.

The thyroid gland is located in your neck and it produces two key hormones: T4 (thyroxine/thyroid hormone) and T3 (triiodo-thyronine hormone), which are crucial for metabolism and keeping your energy levels up.

Here are a few important definitions to refer back to in this section:

• Thyroid—The hormone-releasing gland located in your neck that acts as the metabolic accelerator in your body
• Hypothyroidism—The condition that results when your body is not producing enough thyroid hormone
• Autoimmune thyroid disease—A disorder in the body that causes the immune system to mistakenly attack the body’s thyroid gland and the most common cause of hypothyroidism
• T4—The “reserve” form of the thyroid hormone that must be converted by the body to the metabolically active thyroid hormone T3
• T3—The hormone that goes into body cells and performs the marvelous energy-producing metabolic work

Hypothyroidism is most commonly caused by autoimmune thyroid disease, a disorder in the body that causes the immune system to mistakenly attack the body’s thyroid gland.

The attack renders the thyroid incapable of producing enough thyroid hormone to keep your metabolism working at a normal pace, leading, ultimately, to fatigue and other symptoms.

Almost 5 percent of the United States population has been diagnosed with hypothyroidism, while 4 to 20 percent of people have what doctors call “subclinical hypothyroidism,” which, most experts agree, is the equivalent of the early stages of mild thyroid failure.

Symptoms of Hypothyroidism

Hypothyroidism causes your brain and body to slow down. Those affected feel tired, “heavy,” and slow, both physically and men-tally. It is important to determine whether you carry many of the symptoms of hypothyroidism.

Typical symptoms of hypothyroidism include:

• Fatigue
• Weight gain or obesity
• Depression
• Sensitivity to cold
• Thin and friable (easily crumbled) nails
• Muscle aches
• Headaches
• Decreased libido
• Low basal body temperature (consistently below 98.6°F)
• Weakness
• Cold intolerance
• Water retention
• Dry skin
• Thinning of the lateral 1/3 of the eyebrows
• Menstrual irregularities
• Memory loss and cognitive impairment
• High cholesterol levels
• Decreased tolerance for exercise

What Causes Fatigue in People with Hypothyroidism?

The general fatigue associated with hypothyroidism is caused by a number of different mechanisms but is primarily the result of an overall decrease in metabolism.

Cells throughout the entire body rely on thyroid hormone to perform their basic metabolic functions. A lack of thyroid hormone results in a slower basal metabolic rate. When metabolism is low, activity of the mitochondria within cells is impaired, which leads to low levels of ATP (adenosine triphosphate—an energizer in the cells) and, ultimately, to generalized fatigue. In addition to general fatigue, low ATP levels also contribute to muscle symptoms such as increased muscle tension, pain, and weakness.

Furthermore, patients with hypothyroidism are known to produce more lactic acid, which also contributes to muscle pain, muscle cramps, and fatigue.

Many individuals with hypothyroidism may notice fatigue especially with physical exertion. This is caused in part by the direct effects of thyroid hormone on heart tissue. Without enough thyroid hormone, the heart slows down and decreases the amount of blood pumped, reducing the flow of oxygenated blood to the tissues.

Because thyroid hormone also influences blood sugar metabolism and blood flow to the brain, thyroid hormone deficiency also can cause fatigue by decreasing the amount of glucose and oxygen available to the brain. This leads to the lethargy, forgetfulness, and depression common to those with hypothyroidism.

Diagnosis of Hypothyroidism

TSH, or thyroid stimulating hormone, is a hormone released by the pituitary gland in the brain. Its function is to stimulate thyroid hormone production by the thyroid gland. TSH can be measured in a simple blood test. This test is the most important factor for diagnosing hypothyroidism.

TSH levels within the normal range indicate a healthy thyroid. However, when the TSH level is high, your clinican will request a blood test for T4 levels. Many conventional clinicians will diagnose hypothyroidism when TSH is abnormally high and T4 is abnormally low. This combination indicates that the brain is trying very hard to stimulate the thyroid gland to make T4 thyroid hormone, but the thyroid gland is not able to do it.

Anyone who feels constantly tired, “in a fog,” cold, and unable to lose weight or keep weight off despite dieting should be checked for hypothyroidism.

If your thyroid gland is not producing enough thyroid hormone, you will continue to feel debilitating fatigue, despite whatever positive steps you might take in response to the suggestions highlighted in this book.

Subclinical and Sublaboratory Hypothyroidism

If you have an elevated TSH but your thyroid hormones (T4 and T3) are in the normal range, you have what is referred to as sub-clinical hypothyroidism.

The term subclinical hypothyroidism often gets misused and is, indeed, confusing, given that the signs and symptoms (fatigue, depression, weight gain, and high cholesterol) are very often clinically significant and can reduce your quality of life.

Furthermore, even though subclinical hypothyroidism is considered a mild form of hypothyroidism, studies show that if left untreated, it poses serious risks, including:

• Increased risk of other serious diseases, such as heart disease and insulin resistance
• Increased risk of dying from any cause

On the other hand, studies have proven that treatment for subclinical hypothyroidism can:

• Significantly reduce fatigue
• Decrease risk factors for cardiovascular disease, including high cholesterol, waist-to-hip ratio, and endothelial dysfunction, an early marker of atherosclerosis (hardening of the arteries)

Sublaboratory hypothyroidism, which is very similar to subclinical hypothyroidism, refers to the condition in which the signs and symptoms of hypothyroidism are present, even though standard TSH, free T4, and free T3 tests produced normal results.

Why Does Sublaboratory Hypothyroidism Occur?

There are various reasons hypothyroidism may not be recognizable.

There’s currently a wide range for normal TSH and other thyroid hormone values, and these ranges are controversial. A threshold of 4 to 5 has been conventionally used to diagnose an elevated TSH, but data from large population studies have suggested a much lower TSH cut-off, with an upper limit of 2 to 2.5. If you have had your TSH measured and it fell somewhere be-tween 2 and 5, your doctor likely assumed your TSH was normal and, therefore, that you did not have hypothyroidism.

The time of day, the season, and your genetics all cause considerable variations in thyroid hormone levels. Levels fluctuate throughout the day, so it is possible you were tested at a time when your levels were within the normal range, missing the fact that more often they are abnormal.

Tissue levels of thyroid hormone may be low. Emerging evidence shows that, although standard blood test results might be normal, levels of thyroid hormones, specifically T3 (the more metabolically active thyroid hormone), in body tissue might still be low.

T3 functions inside the cells of your tissues, rather than in your blood. It is in the tissues that T3 stimulates energy production via its ability to act as a “key” on cellular receptor sites and increase the production of ATP from the cell. In medical terms, this phenomenon is sometimes referred to as “cellular resistance to thyroid hormone.”

Normally, once the thyroid gland produces and releases T4, the T4 travels to various tissues in the body, via the blood, where it is converted to the more metabolically active T3. However, in a number of conditions ranging from depression to obesity, the enzyme that is responsible for the conversion of T4 to T3 may be suppressed.

This suppression occurs everywhere in the body except the pituitary, where the enzyme doesn’t function in the same way. The pituitary is still able to perceive normal T3 levels, even though T3 is low throughout the rest of the body’s tissues, and continues to produce a normal amount of TSH, resulting in a normal TSH blood test.

T4 may be converting into a molecule called reverse T3 (rT3) instead of active T3. Reverse T3 acts as a metabolic “brake” during periods when a system requires less energy. Reverse T3 is called the “anti-thyroid” hormone because, during times of signifi-cant bodily stress or illness, it blocks T3 from having an effect. Increased levels of rT3 reduces metabolism, suppresses T4 to T3 conversion, and reduces T3 levels inside of cells. Reverse T3 can be measured in the serum. An abnormally high serum level of reverse T3 indicates low T3 activity inside of cells, even if serum TSH and T3 are normal.

With significant stress, chronic illness, inflammation, and aging, TSH tends to decrease, as does conversion of T4 to T3 inside the cell. In these conditions, instead of converting to T3, T4 is converted to reverse T3 and TSH production becomes suppressed, though it still appears to be within the “normal” range.

There is no easy way to measure tissue level of hormones directly. Health-care providers must rely on serum testing, despite the fact that it reflects only the levels of thyroid hormones in the blood. However, studies indicate that measuring the ratio of two subsets of T3 (rT3 and free T3) can be a useful indicator of tissue thyroid levels. Free T3 and rT3 tests can be ordered at most major clinical laboratories. Even though this method is still just a measure of the amount of T3 in the serum and not of what is in-side cells, it is a more accurate reflection of the amount of T3 that is “available” for the body to use.

Kent Holtorf, MD, who specializes in alternative treatments for hypothyroidism, chronic fatigue syndrome, and complex hor-mone disorders, states that a free T3/rT3 ratio of less than 1.8 picoggram/nanogram (pg/ng) is consistent with low tissue thyroid activity. Dr. Holtorf notes that patients with a free T3/rT3 ratio of less than 1.8 and symptoms of hypothyroidism who test normal for TSH and T4 levels often notice significant improvement with their symptoms when treated with T3 replacement.

Because the normal process of converting T4 to T3 can be diminished, it’s not surprising that T4 supplementation has little ef-fect on some people who find treatment with T3 or T4 and T3 combinations significantly more effective.

Central Hypothyroidism

Another culprit of deceptively normal thyroid testing is central hypothyroidism. This condition develops when the thyroid gland produces too little thyroid hormone, which results because of the malfunction of one or both of the structures in the brain that regulate the thyroid gland (the hypothalamus and the pituitary gland).

The deficiency results in insufficient production of thyroid stimulating hormone (TSH) despite an otherwise normally functioning thyroid gland, which renders it unable to produce sufficient thyroid hormone.

Central hypothyroidism is much less common than primary hypothyroidism and is usually caused by brain cancer (pituitary ad-enomas) or traumatic brain injury. The main symptom of central hypothyroidism, as with all types of hypothyroidism, is fatigue.

Lab tests typically reveal normal to low-normal TSH levels, along with low-normal T3 and T4 levels. Diagnosis is confirmed by the TRH stimulation test.

Conventional therapy is usually levothyroxine (T4). The dose is typically slowly increased until fatigue and other symptoms im-prove. Health-care practitioners also may utilize some form of T3 replacement, as we’ll discuss later.

Thyroid Hormone Deficiency? How to Find Out

How do you know if you do have a thyroid hormone deficiency? And how can someone suffering from debilitating fatigue deter-mine whether a dysfunctional thyroid is an underlying cause?

First, look at your symptoms and compare them to the typical symptoms listed earlier in this chapter and repeated, for quick reference, in the sidebar on this page. The more symptoms you have from this list, the more likely it is that you have a thyroid imbalance.

If your symptoms appear to match those of a typical thyroid patient, ask your doctor to run blood tests that include the meas-urement of free T3 and rT3.

Remember, this test can be ordered from most clinical laboratories. If the ratio of free T3/rT3 is low (less than 1.8 pg/ng, de-pending on the laboratory’s methods) your condition is consistent with low tissue thyroid activity regardless of whether your TSH levels are in the standard lab range or not.

The good news is that patients with low tissue thyroid levels and normal TSH levels often experience significantly reduced symptoms of fatigue, depression, weight gain, and other problems when treated with thyroid hormone replacement that includes T3.

If you do in fact have a thyroid problem, correcting it will produce remarkable improvements: You’ll have a new spring in your step and a new zeal for life.

Fatigue and Sex Hormone Decline or Imbalance

As we hit middle age, there’s a slow but gradual decline in all physiological functions. Energy loss, loss of muscle mass, and in-creased fat mass are tied to declining hormone levels. This age-related drop in hormone levels is referred to as menopause in women and andropause in men.

Hormone loss is the result of deteriorating hormone-secreting glands like the thyroid, pancreas, adrenals, testes, ovaries, and pituitary glands. Testosterone in men and estrogen and progesterone in women are the primary sex hormones covered in this chapter, but a lack of thyroid hormone, DHEA, growth hormone, melatonin, and other pituitary hormones are important to consider.

Andropause

Testosterone deficiency affects at least 20 percent of men in the United States over the age of 50 and at least 25 percent of men over 70. Fatigue is a key symptom.

Men with low testosterone levels report lower energy and vitality compared to men of the same age with normal testosterone. Low testosterone levels also have been associated with poor general health, poor cognitive function, and poor sexual health.

The following symptoms are associated with low testosterone levels:

• Fatigue
• Inability to perform vigorous activity
• Depression
• Reduced sex drive
• Erectile dysfunction
• Memory loss
• Weight gain (especially around the waist)
• Anemia
• Decreased muscle mass and strength
• Decreased bone mineral density

As you can see, testosterone is about more than just sexual health or muscle strength. If you have fatigue accompanied by a decreased desire for sex or problems with erections, low testosterone levels may be to blame.

The most common way to measure testosterone is with a blood test. A total measurement of testosterone in the serum of less than 200 to 250 nanograms per decilite is considered low in most laboratories; values between 250 and 350 ng/dL are usually considered borderline low, although standards may vary.

Just as with thyroid blood tests, the total testosterone level doesn’t give the full picture: It’s possible to have a normal total testosterone level but, at the same time, have low levels of testosterone available to the body’s tissues.

“Free testosterone” is the portion of the total testosterone that’s not bound to proteins and, therefore, is available for the body to utilize. Free testosterone makes up about 2 percent of the body’s total testosterone and is considered the “active” version of the hormone.

Menopause and Perimenopause

In women, the drop in hormones (progesterone and estrogen in women) occurs much more suddenly than in men, which is why menopause can lead to more extreme and obvious symptoms.

Menopause is the process that marks the end of menstruation in women and usually occurs in women between 45 and 55 years old. Hot flashes and fatigue are two of the most common complaints associated with menopause. Perimenopause refers to the interval just before menopause, during which ovarian function begins a steadier decline.

Menopause and perimenopause symptoms include the following:

• Fatigue
• Hot flashes
• Thinning of the vaginal mucosa (which can cause burning, itching, bleeding, and painful intercourse)
• Thinning of the urinary mucosa (which can lead to frequent
  urinary tract infections or painful urination)
• Incontinence
• Thinning and loss of elasticity of the skin
• Insomnia
  Difficulty concentrating
• Anxiety
• Headaches

Estrogen deficiency associated with menopause can contribute to a decrease in bone density and an increased risk of osteo-porosis and bone fractures.

A deterioration of cholesterol levels also occurs, characterized by decreased levels of “good” cholesterol (HDL) and increased levels of “bad” cholesterol (LDL) and triglycerides—and, as a result an increased incidence of cardiovascular disease.

Sleep Disturbances and Fatigue

Sleep disturbances in menopausal and perimenopausal women are mainly attributed to hot flashes during the night, or “night sweats.” Frequent menopausal sleep disturbances have been found in other studies to be related to the following negative side effects:

• Psychological symptoms
• A diminished self-perceived health status
• A prevalence of unhealthy behaviors
• Arthritis

Research shows that fatigue in older women also can be related to stress, depression, and excessive weight gain.

Even genetic differences that determine the way women process and metabolize estrogens have been found to make a difference in menopausal symptoms. As with all genetic factors, however, keep in mind that your genes are not your destiny. Just because you may have a genetic predisposition toward menopause-related fatigue doesn’t mean you have to continue to experience it, or that you will.

Your actions and your environment play a large role in determining which genes are expressed. Smokers, for instance, are known to have more serious problems with menopausal symptoms because of interactions between genes that metabolize estrogens and toxins from cigarettes.

The decisions you make now have very real consequences over your general health—even the genetic aspects of it that can seem outside of your control.

Poor Sleep and Fatigue

Sleep is the most important restorative process for your body and your mind. The regeneration that occurs during deep sleep renews your energy and helps to determine your long-term health. Not surprisingly, sleep issues can lead to fatigue and excessive daytime sleepiness. Three of the most common sleep-related causes of fatigue are:

• Not being able to fall sleep or stay asleep (insomnia)
• Not allowing yourself enough sleep time (sleep deprivation)
• Having a sleep disorder related to breathing (sleep apnea)

Each of these conditions produces sleep disturbances and results not just in fatigue, but other symptoms such as depression, tension, mood disturbances, and reduced attention, motivation, vigilance, and concentration.

Adequate quantity and quality of sleep are necessary not just to keep you energized during the day, but to regulate the proper functioning of your immune, inflammatory, nervous, and hormonal systems. For this reason, sleep disorders and sleep deficiency either directly cause or aggravate many health problems, and yet they’re often overlooked causes of adverse health effects and increased mortality rates. The poorer you sleep, studies show, the more health issues you tend to experience.

Part of the reason that these negative effects of sleep deprivation occur is because growth hormone, the “anti-aging” hormone, is secreted during sleep. Growth hormone helps support you in terms of:

• Regenerating tissue
• Cleansing the liver
• Building muscle
• Breaking down fat stores
• Normalizing blood sugar

The fatigue and health issues that arise from poor sleep also are related to free radicals and inflammation. Many physiological and pathological processes, such as infections and environmental toxins, increase the body’s concentrations of oxidizing sub-stances, known as free radicals. During sleep, free radicals are removed from the brain, reducing oxidative stress and minimizing cell aging.

Sleep loss also is known to result in a state of low-level systemic inflammation, which can further exacerbate fatigue. This is why focusing on decreasing inflammation is one of the natural strategies for treating fatigue, as we will see later.

In the next three sections of this chapter, we’ll look more closely at three prevalent sleep-related causes of fatigue.

Sleep Apnea

Obstructive sleep apnea (OSA) is the most common sleep-related breathing disorder, affecting 3 to 7 percent of the population.

In obstructive sleep apnea, the airway narrows or collapses, causing sufferers to stop breathing for brief, repeated periods throughout the night, and reductions in the body’s oxygen levels. People with sleep apnea usually snore loudly and may experi-ence apnea “episodes,” or lapses of breathing that interrupt snoring and end with snorts. (See sidebar for a list of other common sleep apnea symptoms.)

An overnight sleep study, called a polysomnograph, is required to diagnose obstructive sleep apnea. It is a recording of sleep breathing patterns that usually involves in-laboratory measurement of brain waves and arousals, eye movement, chin movements, airflow, respiratory effort, oxygen levels, electrocardiographic (ECG) tracings, body position, snoring, and leg movements.

If you think you might have sleep apnea, it’s imperative that you get diagnosed and treated, given the severe health risks associated with this disorder. (Sleep apnea may increase your risk of atrial fibrillation, cancers, chronic kidney disease, stroke, ather-oschlerosis, high blood pressure, glaucoma, metabolic disorders, according to the National Institutes of Health.)

Sleep Deprivation

Sleep deprivation is the most common cause of excessive daytime sleepiness. The medical term for sleep deprivation is “insufficient sleep syndrome.” It is considered a disorder that occurs in individuals who persistently fail to obtain the sufficient amount of sleep required to achieve normal, alert wakefulness.

Most people require around seven hours of sleep during their main sleep episode to feel refreshed and alert during the day-time. Yet many people experience shorter amounts of sleep to meet work, family, social, and educational demands. This habit comes at a high price. People who suffer from insufficient sleep syndrome struggle with impaired functioning associated with excessive daytime sleepiness and fatigue and put their overall health at risk.

Restricting sleep time to six hours a night for 14 consecutive nights has been shown in studies to significantly impair functioning.

In fact, symptoms of sleep deprivation can occur after only one night of sleep loss. Often, those who are sleep-deprived are not even aware of their impaired functioning. Studies have found that people who are chronically sleep deprived are often una-ware that they are demonstrating increased deficits in performance and brain function.

Sleep is a process the body uses to help maintain balance and regulation of the immune system. Sleep deprivation or disturbance of sleep cycles also have been found to suppress immune function, in part by increasing release of inflammation-producing chemicals, known as cytokines.

Having a good night’s sleep is now understood to be crucially important for weight control.

Lack of sleep can lead to weight gain, increased belly fat, and obesity. The increased fatigue and tiredness associated with sleeping too little makes the maintenance of a healthy lifestyle more difficult, weakening your resolve to take care of yourself by eating healthy foods and exercising.

Studies have shown that sleep restriction also leads to a set of hormonal changes related to appetite control. Not getting enough sleep decreases your body’s ability to regulate blood sugar, elevates cortisol concentrations, disrupts the stress and HPA axis, decreases the “satiety hormone” leptin, increases the appetite-stimulating hormone ghrelin, and increases hunger and appetite.

Insomnia

Almost all of us have experienced the occasional night of sleeplessness, had difficulties falling or staying asleep, or had non-restful sleep.

But, insomnia is chronic sleeplessness that is defined as difficulty initiating or maintaining sleep or experiencing non-restorative sleep for at least one month, causing significant daytime impairment. An estimated 10 to 30 percent of the population experiences insomnia.

Fatigue is the most consistent daytime symptom associated with insomnia. Studies suggest, however, that poor sleep may not be the only reason for fatigue in individuals with insomnia.
Sleep studies on people with chronic insomnia have shown that the severity of sleep disturbance is not the only factor in determining the severity of fatigue. Other factors, such as depression and the subjective feeling of poor sleep quality, are more related to fatigue in insomniacs than actual sleep loss.

However, most people with chronic insomnia actually do not have daytime sleepiness. In fact, most insomniacs are unable to sleep during the day when provided with opportunities to do so, despite feeling excessively tired or fatigued.

Chronic insomnia decreases your quality of life and productivity, and increases your chances of becoming ill. Insomnia can cause mood disturbances (such as anxiety and depression) that can lead to employment and relationship problems. Poor stress-coping strategies have been linked with an increased risk of developing insomnia.

If you’re suffering from insomnia, getting this sleep disorder under control is imperative for overcoming your fatigue. Curing insomnia takes more than a just a pill; it requires a comprehensive approach that almost always involves lifestyle changes. Thou-sands of individuals have overcome insomnia by making these kinds of changes to their lifestyle, and so can you.

Fatigue Causes: Poor Nutrition, Poor Digestion

The relationship between your energy levels and the quality of your diet cannot be understated. In fact, making dietary changes can be profoundly effective, and even curative, in many cases of fatigue.

There isn’t a single diet that’s best for treating fatigue or fatigue-related medical conditions, but there are some general nutritional practices that do stand out. Research shows that standard American (or Western) diet lacks the nutrients necessary for the energy that people need to function healthily everyday. This diet leads to many fatigue-inducing problems, such as inflammation, blood sugar dysregulation, and insulin resistance, food allergies, and poor digestive health.

The Role of the Western Diet on Fatigue

The all-too-typical U.S. eating patterns of the Western diet include almost 40 percent refined grains and sugars and almost 20 percent refined vegetable oils.

Numerous studies show that Western diets rich in fried foods, processed meats, and commercial baked goods are associated with fatigue and fatigue-related illnesses, whereas diets rich in fruits, vegetables, whole grains, lean proteins, and healthy fats are associated with higher energy levels. Why does the Western diet cause more instances of fatigue?

• Western diets provide plenty of calories but insufficient nutrients, phytochemicals (chemical compounds that occur naturally in plants), and antioxidants, all of which are necessary for proper functioning of the thousands of biochemical and physiological processes that keep you balanced and energized.
• Western diets wreak havoc on your blood sugar metabolism, causing blood sugar highs and lows and insulin resistance, which result in fatigue.
• Western diets promote inflammation, another major cause of fatigue.

We’ll explore each of these topics now in greater depth.

Nutritional Deficiencies and Imbalances

Fatigue is an early symptom of vitamin and mineral deficiencies. Cells rely on vitamins and minerals to generate energy. Deficiency in one’s diet is a surprisingly common malady in today’s over-fed and under-nourished population.

A high percentage of adults in the U.S. consume less than the minimum daily allowance of many essential vitamins and minerals. Adequate amounts and the proper balance of the essential vitamins and minerals, along with the right phytonutrients and essential fats, are important for disease prevention and optimal health.

Let’s take a closer look at some of the most important vitamins and minerals related to fatigue.

Vitamin C

Vitamin C (ascorbic acid) regulates many genes, some of which are responsible for energy metabolism. The recommended daily allowance for vitamin C is between 60 to 75 milligrams (mg) per day for women and 90 mg per day for men. However, 20 to 30 percent of American adults consume less than 60 mg of vitamin C daily.

According to the National Institutes of Health, “Vitamin C deficiency is much more common than is generally recognized, especially because the first symptom of deficiency is fatigue, a nonspecific and common complaint.”

Studies have tested the ability of vitamin C (taken orally with other vitamins, minerals, and/or antioxidants) to combat fatigue. In one randomized, placebo-controlled, double-blind study, the effects of a daily effervescent tablet containing 500 mg vitamin C, B vitamins, calcium, magnesium, and zinc was tested in 215 healthy males ages 30 to 55 years. After 33 days, when compared to those who were given a placebo, participants taking these daily vitamins reported:

• Increased energy and “vigor”
• Less mental tiredness
• Improved general mental health
• Lower subjective stress
• Significantly higher scores on a series of mental tests designed to detect sluggishness

Healthy individuals should be able to get enough vitamin C from a diet rich in fruits and vegetables. However, people who smoke, are exposed to second-hand smoke, and have a restricted diet, cancer, kidney disease, or malabsorption may struggle to get adequate vitamin C from diet alone and may benefit from supplements.

Traditionally, supplements have been taken orally, but today there’s an increasing trend to give vitamin C and other vitamins and nutrients intravenously. Early research into the effectiveness and safety of this method is promising in treatment for fatigue in both healthy adults and those with a history of cancer.

Investigators in one study evaluated the effect of intravenous vitamin C on fatigue in 141 healthy office workers ages 20 to 49 in a randomized, double-blind, controlled clinical trial. Volunteers received either 10 grams of vitamin C with saline or saline only intravenously. Fatigue scores were measured before intervention, two hours after intervention, and one day after intervention. The fatigue scores measured after one day varied significantly different between the two groups: Fatigue scores decreased in the vitamin C group after two hours and remained lower the following day.

Vitamin E

Vitamin E is actually a group of eight antioxidants:

• Four tocopherols (alpha, beta, gamma, and delta)
• Four tocotrienols (alpha, beta, gamma, and delta)

Alpha-tocopherol is the form of vitamin E found in the largest quantities in the blood and tissues and appears to have the greatest nutritional value.

The main function of alpha-tocopherol is its role as an antioxidant (a molecule that inhibits the oxidation of other molecules). Fats, which are an integral part of all cell membranes, are especially vulnerable to destruction through oxidation by free radicals.

Because alpha-tocopherol is a fat-soluble vitamin, it is uniquely suited to intercept free radicals and prevent a chain reaction of lipid destruction that would destroy cell membranes throughout the body.

Another function of alpha-tocopherol not related to its antioxidant capacity include its role in controlling molecules and enzymes in immune cells and inflammatory cells. The generation of excessive free radicals, otherwise known as reactive oxygen species, contributes to exercise-induced skeletal muscle damage, which results in muscle fatigue and soreness.

Antioxidants like vitamin E have been shown in some (but not all) studies to reduce the oxidative damage that occurs as the result of skeletal muscles contracting. Although some studies have shown that lower levels of vitamin E were associated with in-creased severity of fatigue and muscle pain in CFS, there is limited, inconclusive evidence of the benefits of taking vitamin E supplements for the treatment of fatigue.

Probably the best way to improve your vitamin E levels is to eat more vitamin E–rich foods, including: green leafy vegetables, whole grains, fortified cereals, vegetable oils, and nuts.

B Vitamins
The B vitamins include:

• B1 (thiamine)
• B2 (riboflavin)
• B3 (niacin)
• B5 (pantothenic acid)
• B6 (pyridoxine)
• B7 (biotin)
• B9 (folic acid)
• B12 (cobalamins)
• Biotin

These vitamins help facilitate the body’s ability to receive or create energy from food. Vitamin B deficiency, due to increased needs or a poor diet, compromises the ability of mitochondria in the cells to generate energy.

A lack of even just one of the B vitamins can compromise the entire sequence of biochemical reactions necessary for trans-forming food into energy. Vitamin B12 deficiency, in particular, is associated with fatigue. Ten to 15 percent of aging adults have a B12 deficiency.

Patients with CFS have been found to have low levels of B vitamins in some but not all cases. One group of researchers found a 50 percent prevalence of folate deficiency in CFS patients, while another group found high homocysteine levels in cerebrospinal fluid (which they attributed to lack of B12). Both the low B12 and high homocysteine levels were found to correlate to the severity of the patients’ fatigue.
Researchers from King’s College in London found what they called “functional deficiencies” of three other B vitamins: B6 (pyr-idoxine), B2 (riboflavin), and B1 (thiamine). The term “functional deficiency” refers to how nutrients actually function inside the body’s cells. Instead of measuring the actual amount of the vitamins found in the blood, these researchers used a specialized la-boratory that measures how vitamins function inside cells—specifically white blood cells.

Some patients with fatigue report greatly improved energy with the introduction of B vitamin supplements, whether they have a deficiency or not. However, as with many natural therapies, there are few studies testing whether B vitamin supplementation can actually help reduce fatigue.

Of the studies that have been conducted, results are mixed and often difficult to interpret, since so many different forms and methods of using B vitamins are available. Injections seem to work better than oral supplements for some, while other studies show that, at least with vitamin B12, tablets that dissolve under the tongue increase levels just as effectively as injections.

Only you can determine whether B vitamin supplementation will reduce your fatigue. It may be helpful to undergo at least a six-week trial with a high-potency B complex supplement, along with an additional 2,000 micrograms of sublingual (under the tongue) B12, if you believe you may be suffering from a deficiency.

Magnesium

Magnesium is an essential mineral. It is involved in more than 300 metabolic reactions, including energy production. In addition to being needed to produce ATP (the energy on which the body runs), magnesium is important for:

• Bone health
• Protein
• Fatty acid formation
• Making new cells
• Activating B vitamins
• Relaxing the muscles

Magnesium deficiency impairs the energy production pathway required by mitochondria to generate ATP and reduces the mitochondria’s ability to resist free-radical damage. It can result in excessive production of oxygen-derived free radicals and low-grade inflammation. Chronic inflammation and oxidative stress have both been identified as causative factors in several fatigue-related conditions, such as depression and CFS.

Twenty-three percent of adults in the U.S. fail to meet the recommended dietary intake of magnesium. Low magnesium levels have been linked to an increased risk of chronic fatigue as well as numerous other health-related conditions, including:

• High blood pressure
• Stroke
• Heart disease
• Glucose intolerance
• Insulin resistance
• Type 2 diabetes
• Obesity
• Metabolic syndrome
• Inflammation
• Oxidative stress
• Asthma
• Osteoporosis
• Migraines
• Colon cancer
• Depression

Magnesium deficiency is best determined by looking at the level of magnesium present in red blood cells, rather than in se-rum. In some studies, patients with chronic fatigue syndrome were found to have significantly lower red blood cell magnesium levels than the general population.

Even in CFS patients without apparent magnesium deficiency, supplementation with magnesium has been found to significantly improve oxidative stress. Foods that are rich in magnesium include spinach, black beans, nuts, and seeds.

Iron Deficiency and Anemia

Anemia, a common cause of fatigue, is characterized by a reduced number of red blood cells and a reduced concentration of hemoglobin (the iron-containing protein in red blood cells that transports oxygen). There are many causes of anemia, including nutrient deficiencies. Iron deficiency is a common cause of anemia, but deficiencies of folate or vitamin B12 are also causes.

Here are a few key facts about anemia:

• Even mild anemia is linked to fatigue and a lesser quality of life.
• Your chance of being mildly anemic increases with age.
• Mild anemia affects more than one in 10 elderly individuals.
• In older women, anemia is associated with depressive mood, which may further exacerbate feelings of fatigue.

Anyone with unexplained fatigue should be tested for anemia. Anemia is diagnosed with a simple and inexpensive blood test known as a complete blood count, or CBC. To determine the cause of anemia, further testing may be needed. Anemia occurs when the concentration of hemoglobin in the blood is lower than 12 g/dL in women and 13 g/dL in men. Mild anemia is typically defined as a hemoglobin concentration between 10.0 and 11.9 g/dL in women and between 10.0 and 12.9 g/dL in men.

Anemia can occur at any age. In people over 65 years of age, the underlying cause of mild anemia remains unexplained in about a quarter of cases.

It is possible, especially in menstruating women, to become deficient in iron without becoming fully anemic. Like anemia, iron deficiency has been shown to cause fatigue and is associated with less vitality and poor mental health. It has also been shown to negatively affect physical work performance and cognitive functioning and to decrease immune function.

Besides heavy menstruation, other common causes of low iron levels include:

• Regular blood donation
• Pregnancy
• A diet low in bioavailable sources of iron

The best way to determine whether you have an iron deficiency is by measuring your ferritin levels rather than your actual iron levels. 
Ferritin is a protein found inside cells that stores iron so your body can use it later. If your ferritin level is low but still within the “normal” range, it is likely that you do not have enough iron.

A recent study in France found that iron supplementation for 12 weeks decreased fatigue by almost 50 percent from base-line—a significant difference compared with a placebo—in menstruating, iron-deficient, non-anemic women with unexplained fatigue and low ferritin levels.

Iron Excess

You may be surprised to know that high iron levels (a condition referred to as “iron overload”) are relatively common and may also induce fatigue. In fact, fatigue is the most commonly reported symptom of excess iron. In one European study, researchers found iron overload in 1.8 percent of the population (whereas they found iron deficiency and anemia in 0.5 percent of males and 6 percent of females).

In the U.S., one out of every 200 to 300 people has hereditary hemochromatosis, the most common cause of excess iron. White men over 40 are most at risk.

Besides fatigue, other common symptoms of iron overload include:

• Joint pain
• Low libido
• Erectile difficulties

Liver disease and diabetes also may occur in the later stages of the disease because the excess iron accumulates in these organs.

The treatment for excess iron is relatively simple and typically consists of regular blood removal (“therapeutic phleboto-my”—like a blood donation, only your blood is discarded). Ingesting less iron and watching your alcohol intake to protect your liver is also typically recommended.

Vitamin D

Vitamin D is a hormone now known to control more than 200 genes and to be important for much more than just bone health. Research on the wide-reaching affects of vitamin D has exploded over the past decade. It has been established that vitamin D deficiency—a global epidemic estimated to affect more than a billion people—is highly prevalent in people with fatigue and CFS.

In studies, low vitamin D levels have been linked to numerous other symptoms and chronic diseases, including:

• Muscle weakness
• Chronic pain
• Lower-back pain
• Metabolic syndrome
• Type 2 diabetes
• High blood pressure
• Breast cancer
• Colon cancer
• Prostate cancer
• Poor stress resilience
• Depression
• Hypothyroidism
• Cognitive decline
• Reduced work productivity
• Lung disorders such as COPD (chronic obstructive pulmonary disease) and asthma
• Increased risk for falls and disability among the elderly
• Death from all causes

Vitamin D deficiency and borderline deficiency (or “insufficiency”) is surprisingly common, even among those who live in areas with year-round sunshine. Therefore, it’s worth having a blood test to determine whether you’re deficient. Some studies have shown significant improvement in patients’ energy levels with vitamin D supplementation.

L-Carnitine

L-carnitine is a naturally occurring nutrient made in the body from the amino acids lysine and methionine. L-carnitine is required for energy production in the powerhouses of the cells (the mitochondria) through the release of energy from fats. It transports fatty acids into the mitochondria and is especially important for energy generation in heart and skeletal muscle tissue.

In situations of high-energy needs, the body can run out of this important nutrient. Therefore, L-carnitine is considered a “conditionally essential” nutrient.

Acetyl-L-carnitine is similar in form to L-carnitine and has some like functions, including its involvement in metabolizing food into energy. The acetyl group that is part of acetyl-L-carnitine contributes to the production of the neurotransmitter acetylcho-line, which is required for normal mental functioning.

L-carnitine deficiencies have been found in some CFS sufferers, as have abnormalities in the way acetyl-L-carnitine is used by the brain. Elderly people also are more likely to have low L-carnitine levels and to benefit, in terms of energy levels, when taking L-carnitine as a supplement.

Coenzyme Q10

Coenzyme Q10 (CoQ10) is present in the membrane of every cell in the body. CoQ10 has two crucial functions in cells:

• It plays a critical role in the production of energy as ATP within the mitochondria of cells.
• It is a powerful free radical scavenger (or antioxidant) that can mitigate damage caused by oxidative stress.

Though CoQ10 is produced naturally in the body, aging and various diseases or pathological mechanisms can disrupt its synthe-sis, leading to CoQ10 deficiency. CoQ10 deficiency is associated with decreased energy (due to lower ATP levels) and increased oxidative stress. Low levels of CoQ10 in the blood have been detected in chronic fatigue syndrome, fibromyalgia, and depression.

Blood Sugar Dysregulation

The Western diet, high in simple sugars and processed foods, is notorious for causing issues with blood sugar regulation. If you eat a meal loaded with sugar and refined carbohydrates, you can experience wild swings in blood sugar that make you feel tired, anxious, irritable, and hungry for more quickly absorbed sugars. This type of eating pattern is also known as a high-glycemic-load diet, meaning it contains high amounts of the kind of carbohydrates that release glucose into the blood very quickly.

High-glycemic-load diets have been shown in studies to cause:

• Sleepiness
• Nighttime sleep disruptions
• Slow reaction times in tests of cognitive performance

When you repeat the process, day in and day out, of eating a diet full of empty calories, refined and simple carbohydrates (bread, pasta, rice, potatoes), sugars, and sweetened beverages (sodas, juices, sports drinks), your cells start to become resistant, or unresponsive, to insulin. As a result, your pancreas ends up secreting more and more insulin in an attempt to lower your blood sugar. Insulin resistance is a pre-diabetic condition that has reached epidemic levels.

Experiencing fatigue and other low blood sugar symptoms two to four hours after a high-carb meal may be a warning sign that you have insulin resistance or are in the early stages of diabetes. Despite how common it is to feel sleepy following a high-glycemic-load meal, it’s not normal, nor is it healthy. This type of sleepiness is the classic sign of what is known as reactive hypoglycemia—and an early symptom of prediabetes or insulin resistance.

Reactive hypoglycemia is characterized by low blood sugar symptoms after eating large amounts of sugar or refined carbohydrates. Common symptoms:

• Fatigue
• Weakness
• Tiredness
• Dizziness
• Sweating
• Shakiness
• Palpitations
• Anxiety
• Nausea
• Hunger
• Difficulty concentrating

Take a typical breakfast these days: Swigging a large, sweetened coffee drink and grabbing something from the pastry case will give you a big energy surge by causing your sugar and insulin levels spike. What follows, however, is the inevitable “crash,” when your blood sugar level plummets. With this crash comes low blood sugar symptoms, like fatigue.

A high insulin level in your blood, which can easily be measured by your doctor, is the classic sign of insulin resistance. High insulin causes your body to lose muscle and create belly fat while also causing inflammation and oxidative stress. The downstream effects of insulin resistance, in addition to an expanding waistline and fatigue, are worth considering.

• High insulin levels and insulin resistance are linked to:
• High blood pressure
• High cholesterol
• High triglycerides
• Low HDL (high density lipoprotein, or “good cholesterol”)
• Low sex drive
• Infertility
• Depression
• Heart disease
• Stroke
• Dementia
• Cancer

A person crosses the line from insulin resistance and prediabetes to diabetes when the cells become so resistant to insulin that the insulin can’t do its job (i.e., it can no longer get the sugar out of the bloodstream and into the cells). This causes blood sugar levels to remain elevated and the pancreas to go into overdrive to produce enough insulin to fight against high blood sugar and resistant cells. At some point, the pancreas becomes unable to produce enough insulin.

If you do cross the line and become diabetic, studies show that you’re even more likely to have general, physical, and mental fatigue, as well as excessive daytime sleepiness.

Should You Eat Meat?

In terms of fatigue, there is no single right answer to the question of whether one should consider adopting a meat-free lifestyle. Studies have shown that both meat-including diets and vegetarian (or vegan) diets can work against fatigue. The key, of course, is the quality of the diet and the inclusion of plenty of vegetables and fruit.

A diet that consists largely of fruits and vegetables is associated with significantly less fatigue as measured by the SF-36, a commonly used, standardized, health-related quality-of-life questionnaire that measures fatigue.

A study of college-age women found that fatigue was associated with not eating enough fruits and vegetables, eating meals at irregular intervals, missing breakfast, eating more “instant” foods, and eating candy. Compared to meat eaters, vegetarians and vegans report significantly less fatigue. Studies show that switching to a vegan diet can improve fatigue and increase feelings of vitality.

In one study at George Washington University, overweight and/or type 2 diabetics received either weekly group instruction on a low-fat, vegan diet or received no diet instruction for 22 weeks. Results determined that the vegan group reported significant improvements in vitality (a measure of fatigue), as well as in general health, physical functioning, and mental health. They also reported that their productivity at work and in regular daily activities was significantly improved.

If you do choose to eat meat, studies show that the quality of the meat matters. A diet that includes high-quality (naturally raised, grass-fed) lean meat, as well as fruit, vegetables, and whole grains, may decrease the fatigue associated with depression and anxiety.

A large study conducted by researchers at the University of Melbourne in Australia found that women who regularly consume a whole-foods-based diet (a diet consisting of foods that are unprocessed and unrefined or processed and refined as little as pos-sible) and high-quality meat were more than 30 percent less likely to experience depression and anxiety compared to those with a Western diet.

In addition, those eating a Western diet (again, heavily processed foods, fried foods, refined grains, sugary products, and beer) tended to be approximately 50 percent more likely to experience depression.

Dr. Felice Jacka, the study’s primary researcher, explained in an interview that high-quality meat is more difficult to come by in the United States, where most cattle are raised in feed lots and given a corn-based diet. This increases their saturated fat and omega-6 fatty acids and decreases very important anti-inflammatory omega-3 fatty acids.

Grass-fed cattle, on the other hand, have healthier levels of omega-3 fatty acids and their meat is generally healthier and less inflammatory.

Digestive Problems and Leaky Gut

The link between digestive problems and fatigue has been noted for years, but it wasn’t until recently that researchers began to really put together the pieces of the puzzle to determine how abnormalities in the digestive system are related to fatigue and what can be done to resolve these issues. It is likely that you have a “leaky gut,” an overgrowth of “bad” microbial flora, and not enough healthy flora if you feel chronically tired and experience digestive symptoms like:

• Abdominal pain
• Bloating
• Loose stools
• Diarrhea
• Alternating diarrhea and constipation
• Gas
• Reflux

Leaky gut is a term for increased intestinal permeability and is known to be at least partly to blame for fatigue and symptoms similar to irritable bowel syndrome (IBS). Leaky gut is caused by a loosening of the tight junctions in the gut lining that form a barrier between the inside and outside of the digestive tract.

Leaky gut can be caused by:

• Any type of inflammatory process, including yeast infections, viruses, and bacteria
• Long-term or very frequent use of antibiotics
• Repeated use of pain-killers, NSAIDs (nonsteroidal anti-inflammatory drugs), or alcohol
• Long-standing psychological stress
• Extended exercise (athletes)
• Food allergies or sensitivities (such as gluten sensitivity)
• Insufficient intake of antioxidants

When any of these factors increase the permeability of the intestinal wall, unwanted bacteria, proteins, and other compounds can leak through. To deal with these foreign compounds, the body mounts an immune response, which leads to inflammation.

Researchers have found that if you have chronic fatigue syndrome, your body likely produces high levels of immune cells in order to battle the toxins given off by unhealthy stomach bacteria. This high level of immune cells is a sign of leaky gut and a cause of inflammation.

In fact, the severity of both chronic fatigue symptoms and digestive symptoms was found to directly correlate with the number of these immune cells that are directed against toxin-generating stomach and intestinal bacteria.

Food Allergies and Intolerances

Like millions of Americans, you may be suffering from the symptoms of food allergy or intolerance and not know it. Consuming foods to which you have an allergy or intolerance can result in a variety of physical and mental symptoms including headaches, heartburn, and fatigue. Other reactions can occur suddenly, are generally more serious, and can produce symptoms as severe as:

• Difficulty breathing
• Hives, itching, or rash
• Shock, with a drop in blood pressure

People who react in this way to certain foods usually know that they have a food allergy. More often, unsuspected food intol-erances, sensitivities, or allergies produce a variety of milder, annoying symptoms, which may not occur until hours or days after the food is ingested. These symptoms typically linger and recur.

The concept of food intolerances, sensitivities, and “delayed food allergies” is still deemed controversial by many conventional physicians. However, studies have shown significant improvements in a variety of symptoms and conditions when these types of food reactions are identified via blood testing and the reactive foods are eliminated from the diet.

Celiac Disease/Gluten Sensitivity

Fatigue is a symptom of two conditions related to the ingestion of gluten-containing foods: celiac disease and gluten sensitivity.

Celiac disease is an autoimmune disorder affecting nearly one out of every 133 Americans. In people with celiac disease, gluten sets off an autoimmune reaction that causes the flattening of the villi (a finger-like projection of the lining) in the small intes-tine. People with celiac disease produce antibodies that attack the intestine, causing damage and illness throughout the body.

People with untreated celiac disease typically experience major fatigue that disrupts their quality of life. The fatigue experienced in those with celiac disease can come and go, as can gastrointestinal symptoms. In fact, some patients with celiac disease suffer from debilitating fatigue but do not have any gastrointestinal symptoms at all.

If you have hypothyroidism due to autoimmune destruction of your thyroid gland (also known as Hashimoto’s thyroiditis, the most common cause of hypothyroidism), your chances of developing celiac disease and some other autoimmune diseases are significantly increased.

The reverse is also true: If you have celiac disease, you are more likely to develop autoimmune thyroid disease. A gluten-free diet has been shown in some studies to prevent people with celiac disease from developing autoimmune thyroid disease. This link between celiac disease, hypothyroidism, and fatigue means it’s important to get tested for celiac disease if you’ve been found to have Hashimoto’s thyroiditis.

Diagnosis of celiac disease is based primarily on blood tests that detect and measure two specific antibodies:

• Immunoglobulin A (IgA) anti-tissue transglutaminase (tTG) antibody
• Immunoglobulin A (IgA) antiendomysial antibody (EMA)

The tests are complex, and sometimes other blood tests are used in conjunction with them. If your test results are positive, your doctor may perform a biopsy of the small intestine to confirm the diagnosis.

As for gluten sensitivity, it’s just what it sounds like: a less severe negative reaction to ingesting gluten. It is sometimes also referred to as gluten intolerance or “non-celiac gluten sensitivity.”

Research at the University of Maryland Center for Celiac Research shows that gluten sensitivity is different from celiac disease in that it typically does not result in the intestinal inflammation that leads to a flattening of the villi of the small intestine (a characteristic of celiac disease).

In addition, auto-antibodies called tissue transglutaminase (tTG), used to diagnose celiac disease, are not present in subjects with gluten sensitivity.

The immune system is activated in gluten sensitivity, and symptoms can arise throughout the body, ranging from fatigue and foggy mind to diarrhea, depression, and joint pain.

The best way to determine whether you have gluten sensitivity is to do a three-month trial on a strict gluten-free diet, monitoring your symptoms as you go along. If your fatigue and other symptoms improve, you likely have gluten sensitivity.

At the end of the three months, you can perform a “challenge” by eating a few normal-sized servings of a gluten-containing food during the day.

Monitor your symptoms on the day of the challenge and for another day or two after. If you notice your symptoms returning, you have confirmation that you’re gluten-sensitive.

Obesity

Individuals who are overweight, obese, or simply have too much belly fat experience more fatigue and excessive daytime sleepiness, according to studies.

It was long believed that one of the primary reasons obese individuals experience higher rates of excessive daytime sleepiness is the increased rate of sleep apnea and sleep disruption in people who are overweight. It is, after all, well known that obesity is the number one risk factor for obstructive sleep apnea.

However, recent research shows that increased daytime sleepiness occurs in obesity regardless of sleep loss or sleep apnea. The new hypothesis is that obesity-related daytime sleepiness and fatigue are associated primarily with metabolic disturbances like insulin resistance and psychological factors.

The interaction of inflammation (characterized by increased cytokines) and cortisol also may play a role in obesity-related fatigue.

Dehydration

Water is the most essential component of your body and the most essential nutrient in your diet. Water comprises about 60 per-cent of your body weight. Without it, you can survive for two to four days. Water is necessary for circulation, biochemical reactions, metabolism, transportation of substances into and out of cells, temperature regulation, and numerous other bodily processes.

Inadequate water intake leads to dehydration, a well-known cause of decreased physical and mental function and mood. The decrements in physical and mental performance typically become apparent when 1 to 2 percent of total body weight is lost.

How do you know if you’re dehydrated? Common signs of dehydration include:

• Reduced skin elasticity
• Dry lips and mouth
• Headache
• Constipation
• Dark urine (straw-colored urine indicates adequate hydration)
• Infrequent urination

Studies indicate that even mild dehydration can cause the following symptoms:

• Increased fatigue
• Decreased physical endurance
• Reduced motivation
• Increased perceived effort
• Disruptions in mood (including confusion and anger)
• Disruptions in cognitive function (including concentration, alertness, and short-term memory)

As you age, the likelihood of becoming dehydrated increases. In aging individuals, the body’s regulation of thirst and fluid in-take undergoes small changes. Older people tend to feel less thirsty and hence drink less than younger individuals.

Studies also show that older individuals, when dehydrated, tend to drink insufficient water to replenish the body’s water defi-cit. Because of this, researchers now believe it may be best for older adults to practice drinking water regularly, even though they
may not feel thirsty.

Caffeine

The most popular stimulant drug in the world is caffeine. The worldwide popularity of tea, coffee, soft drinks, and—now more than ever before—energy drinks is due at least in part to caffeine’s ability to make us feel alert.

Coffee has been proven to enhance alertness and performance in studies of non-tolerant (non-habitual) users. In habitual users, however, caffeine has downsides.

Daily caffeine drinkers who abstain from caffeine experience fatigue and drowsiness as side effects of caffeine withdrawal. And there’s a lesser-known but even more important downside to regularly ingesting caffeine: Although habitual caffeine drink-ers feel like caffeine makes them more alert, evidence suggests that overall there is no total increase in alertness.

The feeling of becoming more alert by drinking caffeinated beverages is merely the reversal of the fatigue that’s caused by acute caffeine withdrawal. In other words, with frequent consumption of caffeine, we don’t experience a net benefit.

When we abstain from consuming caffeine, we’re less alert; consumption of caffeine at this point merely returns your alertness to baseline.

According to some studies, additional negative effects of caffeine include:

• Increased anxiety
• Increased cortisol levels
• Impaired blood sugar management
• Increased cholesterol

Caffeine has been shown in functional MRI studies to activate the part of the brain that perceives threats and that correlates with anxiety levels. Certain individuals are more genetically susceptible to the anxiety-inducing effects of caffeine.

But with modest, regular intake, even those who are more susceptible can develop a tolerance to the anxiety-provoking effects.

Symptoms of caffeine withdrawal begin 12 to 24 hours after the last dose of caffeine. In addition to fatigue and sleepiness, caffeine withdrawal symptoms include:

• Headache (experienced by about 50 percent of users)
• Depressed mood
• Difficulty concentrating/decreased cognitive performance
• Irritability
• Nausea/vomiting
• Muscle aches/stiffness

It is also important to note that caffeine withdrawal symptoms may intensify with the use of energy drinks and shots. This is be-cause energy drinks vary widely in caffeine content, ranging from 50 mg to a dangerous 505 mg per can or bottle. (For compari-son, the caffeine content of a large cup—16 ounces—of brewed coffee is about 188 mg.)

Energy drinks also contain other substances such as B vitamins and amino acids (like taurine and tyrosine). But caffeine typically is the main active ingredient in energy drinks. Plus, they may contain various herbal extracts—some that also contain caffeine,usually in “proprietary” amounts that are not disclosed on the label. Thus, despite their popularity, energy drinks and shots should be avoided.

Lack of Exercise as a Cause of Fatigue

Physical inactivity is consistently associated with fatigue. In U.S. adults ages 20 to 59, those who report feeling tired are almost twice as likely to get insufficient physical activity. Those who report feeling exhausted are almost four times more likely to get insufficient physical activity. In teens, an average of nine hours per day using electronic media doubles the risk of persistent fatigue.

In people who have been exercising regularly (at least 30 minutes three times a week), fatigue begins to appear about one week after they abandon exercise.

Studies show that, in people who do not exercise, even relatively small amounts of routine physical activity within a normal lifestyle are associated with more energy and less fatigue.

Being sedentary may increase fatigue for a number of reasons, including the following.

• Prolonged periods of inactivity cause decreased muscle mass. As muscle is reduced, the number of mitochondria inside muscle tissue also decreases. Within every cell, mitochondria generate the energy used to power all metabolic activities. As muscles lose mito-chondria, they become less efficient (they experience a reduction of strength, tone, and size). This leads to the feeling of a lack of power or energy, stiffness, heaviness (because of blood pooling in the lower limbs), weakness, and pain after normal exercise and activity.
• Prolonged inactivity causes fatigue by deconditioning the cardiovascular system. This causes reduced blood volume, lowered oxygen levels, and less aerobic fitness as measured by VO2 max (the maximum capacity of an individual’s body to transport and use oxygen during incremental exercise). Deconditioning of the cardiovascular system reduces heart and lung function and is associated with dizziness and breathlessness.
• Being sedentary dulls the brain and alters your biological clock (circadian rhythms). It also changes your perception of temperature, noise, and light. These changes lead to impairments in:
• Coordination
• Concentration
• Memory
• Sleep
• Appetite
• Immune function
• Hormone production
• Lack of exercise decreases levels of dopamine, norepinephrine, and serotonin—energy-promoting and mood-enhancing neurotrans-mitters in the brain.

To stay healthy and energetic, you need to be physically active on a regular basis. There is no way around it. The type and duration of physical activity doesn’t matter nearly
as much as the mere act of doing something. Research shows
that any amount or kind of movement is better than none
for improving self-reported energy levels, raising energy-inducing neurotransmitter lev-els, and increasing the number of energy-producing mitochondria inside your cells.

Inflammation, Oxidative Stress, and Mitochondrial Dysfunction

Medical researchers are mapping out the network of connections among inflammation, oxidative stress (caused by free radical damage), and mitochondrial dysfunction. These three processes have been found to either be linked to or lead to fatigue and fatigue-associated chronic conditions, such as:

• Chronic fatigue syndrome
• Depression
• Fibromyalgia
• Insulin resistance/metabolic syndrome

Mitochondrial Dysfunction

Mitochondria are the organelles inside cells that are responsible for supplying upwards of 95 percent of the body’s energy needs. They are often called “the cell’s power plants,” since they convert the energy from food into a form that the body can use.

When the total number, structure, or functioning of the mitochondria decreases or becomes impaired, fatigue is the result. Researchers have found that in people with chronic fatigue syndrome, the structure and function of the mitochondria is dam-aged, and their ability to produce energy is diminished.

How and why does this happen? One way the function of mitochondria becomes compromised is through the generation of reactive oxygen species, known as free radicals.

Free radicals are atoms or groups of atoms with an odd (unpaired) number of electrons that can be formed when oxygen in-teracts with certain molecules. When too many free radicals are generated for the body to handle efficiently, a situation called “oxidative stress” develops.

Oxidative Stress

The process of oxidation—removing electrons from an atom or molecule—can be destructive (think of rusting iron). Oxidation occurs during normal mitochondrial function producing harmful free radicals as a byproduct.

Free radicals are unstable. In order to gain stability, they rob electrons from any other molecules they meet. This creates a domino effect wherein other molecules are left unstable in their wake. A free radical chain can cause extensive cellular damage and even kill cells altogether before eventually fizzling out.

Oxidizing activity from the environment—like radiation, toxins, “bad” foods, and tobacco smoke—further damages cells. Oxida-tive stress is the total burden of this oxidizing activity.

Luckily, your body has developed a number of strategies for containing and minimizing the damage. One such strategy is anti-oxidants, which neutralize free radicals by donating electrons to them.

You consume antioxidants, such as vitamins C and E, in your diet.Your body also has complex mechanisms that repair damage that has already occurred. You even have a system of oxidative stress responses that include a programmed cell au-to-self-destruct, for when the damage becomes too great.

The mitochondria especially depend on these defenses. If free radical production is too great or if antioxidant defenses be-come depleted, oxidative damage occurs and accumulates, resulting in oxidative stress.

The energy-generating mitochondria are some of the first parts of the body to suffer the effects of oxidative stress. Reactive oxygen species focus their attack on the DNA of mitochondria. The resulting damage leads to mitochondrial dysfunction, which is characterized by deficiencies in the mitochondria’s ability to produce energy. Furthermore, oxidative stress can result in inflammation.

Inflammation

You just learned how oxidative stress reduces the ability of the mitochondria within cells to function, resulting in fatigue.

Mitochondrial dysfunction and oxidative stress also lead to fatigue by causing low-grade activation of the immune system in a manner that provokes inflammation. With mitochondrial dysfunction and oxidative stress, the body produces excessive amounts of inflammatory compounds called cytokines.

Cytokines are substances secreted by cells of the immune system that carry signals locally between cells. Some cytokines are pro-inflammatory, meaning they promote inflammation, while others are anti-inflammatory. Over time, the chronic production of pro-inflammatory cytokines leads to a state of chronic, low-grade, body-wide inflammation that causes fatigue.

Two specific pro-inflammatory cytokines—tumor necrosis factor alpha (TNF‑) and interleukin-6 (IL‑6)—are known to cause sleepiness and fatigue. Related illnesses, including depression, obesity, metabolic syndrome, and sleep apnea, have been shown in studies to result in higher levels of IL‑6 and TNF‑, which indicates abnormally high levels of inflammation.

Exactly how the inflammatory cytokines cause fatigue is still under investigation. Researchers believe there are probably nu-merous direct and indirect mechanisms by which chronic inflammation triggers fatigue.

Some of the fatigue is due to the effects of inflammation on the nervous system. And in people with chronic fatigue syndrome, inflammation may be the cause of decreased activation of “the brain’s reward center,” a group of nuclei known as the basal ganglia.

The basal ganglia help to control motion and motivation and are exceptionally vulnerable to the effects of certain pro-inflammatory cytokines. A reduced response in this part of the brain is seen in patients with CFS.

Levels of pro-inflammatory cytokines like TNF-alpha and IL-6 can be measured in the blood and often are used for research purposes. However, they are rarely measured by the average physician.

A much simpler, more widely available, and less expensive way to measure chronic, systemic inflammation is through a blood test called C-reactive protein (CRP). CRP is a non-specific protein, the levels of which increase in the blood in response to inflammation or tissue injury.

Blood levels of CRP are typically higher in those who have CFS or experience chronic fatigue than in people who don’t feel fatigued.

In a sample of 70-year-old women, CRP levels were 40 percent higher in those with fatigue, compared to those without it. A host of fatigue-related conditions besides CFS also are associated with higher CRP levels. Among them:

• Fibromyalgia
• Type 2 diabetes
• Cancer and post cancer
• Infections
• Heart disease
• Arthritis
• Autoimmune diseases
• Inadequate sleep (less than six hours)

The foundational treatment for fatigue must include the reduction of inflammation and oxidative stress and the repair and production of new mitochondria. The good news is that these crucial processes are possible with natural therapies involving nu-trition, exercise, lifestyle changes, and supplements.

Understanding is only the first step. Later in this report, you’ll learn simple, effective strategies for decreasing inflammation, preventing oxidative damage from free radicals, and improving the healthy processes of the mitochondria.

Other Causes of Fatigue

In addition to the causes of fatigue discussed in this chapter, there are others worth mentioning. Among them:

• Cancer treatments
• Chronic pain
• Medications
• Poor detoxification mechanisms
• Toxic exposures

Still another possible cause of fatigue: infections, which we’ll examine below.

Infections

Infections can result indirectly from fatigue and vice versa. In some cases, in fact, patients end up in a vicious cycle of fatigue and infection.

Viruses, bacteria, fungi, and parasites can all cause infections and fatigue. Invasion of body tissues by disease-causing microor-ganisms, like the viruses listed below, are especially notorious for causing fatigue among other symptoms.

• Cytomegalovirus (CMV)
• Enteroviruses
• Epstein-Barr virus (EBV)
• Hepatitis C
• Human herpesvirus-6 (HHV-6)
• Human immunodeficiency virus (HIV)

In most cases, the body is eventually able to contain infection, and the fatigue and other symptoms are resolved. In other cases, such as with hepatitis C or HIV, the infection is not curable, although antiviral treatments can slow the course of the disease and may lead to a near-normal life expectancy.

Many times, chronic fatigue syndrome (CFS) follows a period of viral infection. If fatigue is not cured quickly enough, it may af-fect the body’s ability to fight off infection, providing viruses the chance to remount an attack.

CFS is sometimes considered a “post-viral fatigue.” Indeed, the syndrome sometimes does tend to follow a viral infection, such as a gut infection, or one of the others we’ve listed. Some patients with CFS clearly recall symptoms of an infectious illness before their fatigue took hold—fever, chills, body aches, sore throat, rash, or swollen glands—while other CFS patients recall no such symptoms.

In any case, once chronic fatigue sets in, there is usually no laboratory evidence of an active infection, although disturbances in immune function may be apparent. Some researchers believe these immune disturbances are triggered by chronic viral infections.

Inflammation is another part of the infection–fatigue connection. Specific types and ratios of inflammatory cytokines found in the blood of CFS patients (IL‑10 and TNF‑) may indicate the presence of persistent bacterial, fungal, or viral infections. The underlying presence of a viral infection may be the cause of the fatigue and excessive inflammation.

The Vicious “Infection–Stress–Fatigue” Cycle

Are you caught in a vicious cycle of stress, fatigue, and infection? While it’s easy to see how fatigue can result from chronic stress or infection, you may not be aware of how fatigue also may cause stress.

You also may be unaware of the fact that both fatigue and chronic stress can compromise the immune system, making you more susceptible to infections. A frustrating cycle of fatigue and illness can occur, with one contributing constantly to the other.

Researchers hypothesize that fatigue itself is a significant body stressor that makes you more susceptible not only to new infec-tions but to reactivation of latent viral infections to which you were exposed years ago.

Studies in fatigued and sleep-deprived medical patients show that under stressful conditions, the herpesviruses Epstein-Barr (“mono” or herpesvirus 4) and the common cold sore (herpes simplex I) are reactivated, and the amount of the virus measured in the patients’ bloodstream significantly increases.

The infections that play a role in many cases of chronic fatigue are part of an even wider interconnected web of fatigue, stress, inflammation, and nervous system dysfunction.

The key is to break the cycle and treat the underlying infection while using natural medicines and treatments to support the underlying immune, inflammatory, and stress-response systems.

Health-care practitioners all over the world understand these connections and are helping patients with chronic fatigue to break the cycle and regain their energy. Energy systems are being restored and rebalanced using:

• Natural therapies (the use of nutritional medicine, vitamins, vitamins, minerals, and other nutrients)
• Botanical medicine (the use of medicinal plants such as herbal extracts)
• Lifestyle changes (such as diet, exercise, and stress reduction)

Treatment of an underlying infection begins with diagnosis. Lab tests can help confirm current, recent, and past infections by checking for various antibodies (which indicate exposure to a virus) and various viral titers, or traces of the virus (which can con-firm current viral activity).

However, in the end—even with the most sophisticated lab testing—it may not be entirely possible to determine whether an infection is to blame for your fatigue.

If the presence of an infection cannot be determined, most fatigued individuals still find help via the recommendations provided in this book: improving diets, fixing nutrient deficiencies, decreasing stress, treating oxidative stress and inflammation, and improving the overall functioning of the immune system.

Putting It to Practice

We have gone over so many causes of fatigue by now that you may be feeling overwhelmed trying to determine which specific cause or causes apply to you. But don’t give up!

The next step is to use laboratory testing to find your cause of fatigue, and then employ one or more of the natural healing techniques to boost your energy levels and feel alive again.

The post 2. What Causes Fatigue? appeared first on University Health News.

The Sleep Cycle: Breaking Down Sleep Stages

As we sleep, our brain and body enter a remarkably complex and healing biological state. According to experts at the National Sleep Foundation, there are “two types of sleep: rapid eye movement (REM) sleep and non-REM (NREM) sleep.”

Within NREM sleep there are four distinct stages. These have been studied extensively using electroencephalogram (EEG), which shows that brain activity is quite different in each of the stages.

Stage 1 NREM Sleep

Stage 1 is the stage between being sleep and being awake. Sleep is light and easily interrupted. It occurs as you fall asleep and during brief periods of arousal during sleep. There is a slow-down in brain and muscle activity.

Some people experience a falling sensation accompanied by sudden muscle jerks during stage 1. (See also our post “Is Twitching While Sleeping a Problem? Here’s How to Treat Sleep Myoclonus.”)

Stage 2 NREM Sleep

Stage 2 is the first stage of true sleep but it is still light. Your heart rate and breathing slow down, and you start to become unaware of your surroundings. Brain wave activity slows further, with accompanying sudden rapid bursts of activity called “sleep spindles,” during which muscles become relaxed.

(Photo: Vaeenma | Dreamstime.com)

Stages 3 and 4 of NREM Sleep

Stages 3 and 4 of NREM Sleep—slow wave sleep—are characterized by the presence of slow brain waves called delta waves interspersed with smaller, faster waves.

Breathing and heart rate slow down, eyes are still, blood pressure drops, and muscles relax. If someone were to try to rouse you now, you’d have a hard time awakening and would feel groggy and disoriented. This stage has been associated with tissue regeneration and the release of essential hormones (such as growth hormones).

During slow-wave sleep, some children experience bedwetting, night terrors, or sleepwalking.

REM Sleep

Dreaming occurs in REM (Rapid Eye Movement) sleep, when your limbs are paralyzed but your eyes dart back and forth behind closed eyelids. Your blood pressure increases, and your heart rate and breathing speed up to daytime levels. There is intense brain activity, with brain waves that are fast and irregular (desynchronized).

REM sleep is the most important stage of sleep for memory. Besides dreaming during REM sleep, you also process and consolidate new information you’ve learned.

Sleep Architecture: How Much Sleep Do We Need?

The pattern of sleep that we each get—including how much time we spend in each stage—is called “sleep architecture.” Most adults thrive on seven to nine hours of sleep per night, while teenagers with developing brains need about 9.5 hours. Not surprisingly, infants, with the fastest-developing brains of all, need up to 16 hours of sleep per day.

So what is the ideal pattern of sleep? Each sleep cycle lasts on average of 90 to 110 minutes and is repeated four to six times per night. Early in the night, the cycle is shorter.

For a healthy adult:

• Stage 1: 2 to 5 percent of total sleep time
• Stage 2: 45 to 55 percent of total sleep time
• Stages 3 and 4: 5 to 25 percent of total sleep
• REM sleep: 20 to 25 percent of total sleep time

Sleep architecture varies over a lifespan. Newborns spend about 50 percent of their sleep in REM, while in young children, deep NREM (stages 3 and 4) sleep is longer. In elderly people, deep sleep reduces, while stages 1 and 2 increase. Sleep is more easily disturbed in the elderly but for most people, contrary to popular belief, the need for sleep does not decline.

Cleaning Your Brain

In a 2014 Ted Talk program, neuroscience researcher Jeff Illiff presented mind-blowing research on how the brain deals with its “waste.” He explained that researchers were astonished to find that when we sleep, channels open up around the blood vessels in the brain. These channels flush the brain with cerebrospinal fluid (CSF), which effectively cleans the brain, taking away the waste products from normal metabolism.

When Sleep Goes Wrong

When you’re not getting enough sleep, or if your quality of sleep is poor, all of the positive things that happen in sleep—as described above—decrease. Your body is unable to repair effectively, biological processes are disturbed, and there are significant effects on brain function and cognition.

Lack of quality sleep can impact:

• Heart health. While you sleep your heart takes a rest. It doesn’t need to pump large amounts of blood to your muscles or digestive system. Of course it continues to pump blood to your brain and all around the body, just less vigorously. Lack of sleep puts an increased strain on your heart.
• Hormonal systems. Your hormonal or endocrine system produces chemicals essential to every cell, system and organ in your body. Lack of sleep interferes with hormone release and cellular repair, growth, blood pressure, blood sugar, and sexual health. In teenagers, lack of sleep can interfere with puberty.
• Memory. Lack of sleep limits consolidation of memory, making it difficult to lay down long-term memories.
• Cognitive performance. Lack of sleep will reduce focus, slow processing, and cause errors and may also contribute to poor decision-making and impulsivity.
• Motor skills. Lack of sleep can make you more likely to make mistakes and have an accident.
• Mood. Lack of sleep increases the risk of negativity, depression, anxiety and may worsen serious psychiatric conditions such as bipolar disorder.
• Immune health. Lack of sleep weakens the immune system making you more prone to infection.

This article was originally published in 2018. It is regularly updated. 

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A person with OSA can have from five to 100 apneas per hour, totaling hundreds in a single night. The cutoff of air may lead to low levels of oxygen and increased levels of carbon dioxide in the blood, alerting the brain to signal the upper airway muscles to open. When this happens, sleep becomes lighter and is interrupted. These frequent arousals keep you from getting the deep, continuous, restorative sleep you need, leading to excessive daytime sleepiness. The frequent blockages in breathing lower blood oxygen levels, elevate nighttime blood pressure, and cause heart rhythm disturbances.

A sedentary lifestyle has been correlated with OSA severity. Even when a sedentary lifestyle does not lead to obesity, it may still lead to OSA and its concomitant health risks. Overnight fluid displacement from the legs related to prolonged sitting may be a cause. This finding may help explain why 40 percent of patients with OSA are not obese and why a reduction in OSA has been described when people begin exercise programs, even when they don’t lose weight.

Vitamin D deficiency has been linked to OSA and other sleep disorders, including restless legs syndrome (see Chapter 3). A study of 181 patients found that 74 percent were deficient in this “sunshine vitamin.” The same study did not find any correlation between vitamin D levels and OSA severity. However, a different study did. In this study of 81 patients with OSA and excessive daytime sleepiness, those with more severe OSA had lower vitamin D levels than those with less severe OSA and less daytime sleepiness. Whether vitamin D supplementation alleviates OSA is unknown.

However, vitamin D plays such an important role in our health that anyone who is vitamin D-deficient should talk to their doctor about strategies for replacing it, such as taking vitamin D supplements or increasing daily sun exposure in a safe manner.

Sleep Apnea and Your Health

OSA predisposes people to multiple health problems. The most common associations are:

High blood pressure: Up to half of people with sleep apnea have high blood pressure. Mild OSA more than quadruples the risk of developing hypertension; moderate OSA increases the risk more than 3.5 times. Severe OSA affects the ability to control blood pressure, even if you are taking three or more blood pressure medications.

Diabetes: Severe OSA is associated with insulin resistance, glucose intolerance, and increased risk of type 2 diabetes. But less-than-severe OSA also can trigger the development of diabetes. One study found that mild OSA nearly tripled the risk of diabetes, even when the sleep disorder produced no symptoms. Another study found that moderate, but not mild, OSA increased the risk. The take-home message is that OSA impairs glucose regulation, putting an individual on the path to diabetes, whether the disease develops or not.

Poor quality of life: OSA can lead to irritability, sexual dysfunction, and accidents caused by dozing off while driving.

Liver damage: OSA may be a risk factor for liver damage caused by reduced oxygen supply to the liver during sleep and OSA-induced insulin resistance.

Obesity: Severe OSA may predispose to weight gain. Individuals with a high number of apneas and hypopneas (a milder sleep-associated respiratory event characterized by shallow breathing) per hour of sleep may steadily gain weight over time.

Food cravings: People with diabetes who also have OSA are at increased risk for carbohydrate cravings.

Parkinson’s disease: In 2015, Taiwanese researchers found that OSA appears to increase the risk of Parkinson’s disease, but only in women.

Low bone density: In 2013, OSA was found to nearly triple the risk of osteoporosis in women. In 2016, Japanese researchers found a connection between severe OSA and low bone density in men.

Cancer: Multiple research studies have connected OSA with cancer incidence, resistance to cancer treatments, and cancer mortality.

Stroke: OSA doubles or triples the risk of stroke in middle-aged and older men. The risk appears in men with mild sleep apnea and rises with the severity of OSA. Stroke risk in women only increases with severe OSA.

Heart attack: OSA increases the risk of having a heart attack or dying by 30 percent over a period of four to five years. One study found that people with OSA are prone to developing aggressive atherosclerosis, particularly in the form of soft plaques (deposits of cholesterol, fat, calcium, and other substances that can narrow arteries). Such plaques are predisposed to rupture, causing a heart attack. Studies also have shown patients with OSA to have multiple vessels narrowed by atherosclerosis, as well as extensive vessel involvement.

Arrhythmias/sudden cardiac death: OSA doubles the risk of sudden cardiac death. In studies, the most common predictors were an age of 60 or older, 20 or more apnea episodes per hour of sleep, and an oxygen saturation level below 78 percent during sleep.

Memory loss: One study linked OSA to brain damage and memory loss. In the study, MRI scans revealed that structures in a region of the brain that deals with memory were almost 20 percent smaller in people with OSA than in those without. The repeated drops in oxygen that characterize OSA may cause these cells to die.

Alzheimer’s disease: OSA appearing after age 65 doubles the risk of developing Alzheimer’s disease. The more severe the OSA, the higher the risk. In one study, Alzheimer’s appeared an average of 60.8 months after OSA was diagnosed. This was 13 to 18 months sooner than in study participants without OSA. OSA severity made a difference. Mild OSA (defined as five to 14 apneas per hour of sleep) increased Alzheimer’s risk 1.67 percent. Moderate OSA (15 to 29 apneas per hour) increased risk 1.81 percent. In severe OSA (30 or more events per hour), the risk was 2.63 times normal. Women with OSA were at higher risk of developing Alzheimer’s than men with OSA. Education also was important. Adults with a high school education or less had twice the risk of adults who attended graduate school.

Scientists have linked poor sleep quality along with diet to the early accumulation of the plaques associated with Alzheimer’s disease. Part of the reason may involve cortisol, a hormone manufactured by the body that plays a role in regulating many core functions, including sleep. Cortisol levels naturally rise and fall with day and night. However, diets characterized by high intakes of refined sugars, salt, animal fats, and animal proteins, and by low intakes of fruits and vegetables, can perturb the circadian levels of cortisol, leading to poor sleep quality.

Dietary changes that influence the body’s cortisol levels—and in turn promote good sleep—might be a safe and novel way to help protect the brain, scientists suggest. The review also notes that, indepenent of diet, sleep disorders and poor sleep qualty are associated with a higher risk of Alzheimer’s disease. A good night’s sleep seems to be important for the brain to clear the beta-amyloids that form the plaques associated with Alzheimer’s disease.

Post-surgery delirium: OSA more than doubles the risk of delirium after surgery.

Asthma: People with asthma often have sleep-related breathing problems, including OSA.

Poor blood flow: Researchers have pinpointed a possible reason for the toll sleep apnea takes on the brain—MRI images have revealed weaker blood flow in individuals with the sleep disorder.

Sleep Apnea and Women

Like severe snoring, sleep apnea once was thought to occur mostly in men, but it affects women, too, particularly after menopause. OSA may be underdiagnosed in women, and there may be some clinical differences in the presentation between the sexes as well. A Canadian study indicates that women with OSA are more likely than men to suffer from depression, an underactive thyroid (hypothyroidism), or insomnia.

Other research suggests that OSA may hold “hidden dangers” for women. Autonomic responses—the controls that impact such functions as blood pressure, heart rate, and sweating—are weaker in people with OSA, but even more so in women than in men. While women with sleep apnea may appear to be healthy, their symptoms of OSA tend to be subtler, which often means their sleep problem is missed and they get diagnosed with another condition.

Diagnosing OSA

Often the first person to spot OSA is your bedmate, who complains that you snore loudly or wakes you from sleep when you repeatedly gasp for breath during the night. Anyone with symptoms of OSA should see their physician. However, the U.S. Preventive Services Task Force has recommended against non-symptomatic, routine screening for OSA.

Their decision was based on the fact that no studies have evaluated the direct benefits of OSA screening on mortality, quality of life, or its impact on heart attack or stroke rates. In addition, they found studies evaluating the accuracy of screening tools, such as sleep questionnaires, were lacking. This conclusion does not mean adults should not be screened for OSA. It does mean, however, that screening should be done when patients have symptoms.

The American Academy of Sleep Medicine recommends physicians ask whether patients have the symptoms of OSA during routine examinations. The American College of Physicians recommends physicians should consider offering a sleep study to patients who experience unexplained daytime sleepiness, according to the Journal of the American Medical Association.

Lab-Based Sleep Study

Sleep specialists diagnose OSA with a sleep study. You will likely spend the night in a sleep lab to assess the number and severity of apneas. A test called polysomnography records a variety of bodily functions, including brain waves, to detect the various stages of sleep, muscle activity, eye movements, heart rate, breathing, airflow, and blood-oxygen levels. The number of breathing events per hour of sleep related to apnea or hypopnea, and the degree of low blood oxygen and reduced airflow determine the diagnosis and severity of OSA.

Home Sleep Study

The most recent guidelines from the American Academy of Sleep Medicine suggest a home sleep test for OSA. Adults between the ages of 18 and 65 who have a high probability of moderate-to-severe OSA and no other medical conditions are most likely to benefit from a home test.

Home testing involves the use of a portable monitoring system that is worn while you sleep in your own bed. A newer method under investigation uses a disposable skin patch that is worn overnight.

The SomnaPatch Sleep Monitor weighs less than one ounce, yet records nasal pressure, blood oxygen saturation, pulse rate, respiratory effort, sleep time, and body position. In one study of 179 patients, patch results were equivalent to those obtained by polysomnography, the test performed in a sleep lab. The patch also effectively distinguished OSA from central sleep apnea. The SomnaPatch is not yet FDA-approved.

Future Diagnostic Tests

In the future, it may be easier to diagnose OSA. Emerging research shows that analyzing a person’s breathing sounds while awake may quickly and accurately detect OSA. In one study, 35 subjects were instructed to breathe through their nose at their normal breathing level for at least five breaths and then breathe at their maximum flow level for another five breaths. Then the process was repeated as they breathed through their mouth with a nose clip in place. A microphone placed over the neck picked up the breathing sounds. Several sound features of breathing varied significantly between participants with OSA and those without. The test predicted the presence or absence of OSA with more than 84 percent accuracy, as well as its severity.

Treating OSA

If you have OSA, you’ll be encouraged to make lifestyle changes, such as losing weight. You also may be urged to quit smoking and avoid the use of alcohol, sleeping pills, and muscle relaxants, which make the airway more likely to collapse during sleep.

Sleeping position influences the severity of OSA, with up to 75 percent of people with the sleep disorder experiencing more frequent and longer pauses in breathing when they sleep on their back. Special pillows that help you sleep on your side, rather than on your back, or a device that vibrates when you roll onto your back has been shown to reduce back sleeping by 84 percent, cutting the severity of OSA in half. Elevating the head of your bed six inches also may help.

Although some physicians suggest patients sew a tennis ball on the back of their pajama top to prevent them from rolling over onto their back, the Journal of Clinical Sleep Medicine’s June 2017 issue included information on devices worn on the chest or neck that gently vibrate in response to body pressure. In a review of seven clinical trials, these devices reduced back sleeping by 84 percent, cutting the severity of OSA in half. Devices include NightBalance and Night Shift.

If your apnea has caused high blood pressure or other problems, these conditions will need separate treatments. Some people with hypothyroidism (an underactive thyroid) develop sleep apnea, and thyroid hormone replacement may help solve the problem.

Losing Weight

Losing weight is an effective way to reduce OSA symptoms and associated disorders. A large body of evidence has shown that people who lose weight can cut their number of apneas by half or more. A 10 percent weight loss can help.

Many people who are trying to lose weight get good results from following commercial weight-loss diets. The most effective diets also are weight-management diets that educate people in calorie and portion control and encourage healthy diet behaviors that may help you maintain a healthy weight on a long-term basis.

The glycemic index (GI) is the basis for the South Beach diet. The GI is a measure of a food’s ability to raise blood sugar levels. High GI foods—assigned a GI score of 70 and above—cause blood sugar to spike, which may contribute to poor eating behaviors. However, low GI foods—those with a score below 55—cause blood sugar to rise more slowly, which appears to regulate the appetite.

The South Beach plan promotes unprocessed foods, such as fruits, vegetables, and whole grains that are low in calories and fiber-rich. Fiber takes longer to digest, so you should feel fuller for longer after eating it—this means you may be less likely to overeat inappropriate snacks between meals.

Calorie control is another effective method of weight loss and management, since being more aware of how many calories a food contains can help you to incorporate “checks and balances” into day-to-day eating (for example, making up for any high-calorie treats with lower-calorie options later in the day). In a 2014 study, Weight Watchers dieters lost an average 7.7 to 13.2 pounds after one year compared to 1.8 to 11.9 pounds lost by dieters following traditional weight-loss methods such as low-fat diets, behavioral weight-loss intervention, nutritional counseling, or self-help materials.

Weight Watchers allocates foods a certain number of points based on their fat, calorie, and fiber content. You are allowed a specific number of daily points depending on your present weight and activity level, and you can pick and choose from the foods on the plan to make up the points. You can have the occasional treat, if you use fewer points at your next meal. The system gives the healthiest foods the lowest number of points—for example, fresh fruits and most vegetables are zero points, which gives you an incentive to make healthier selections and be more mindful of what you consume at each meal. Physical activity also is given points, and you’re encouraged to get up to four points (the equivalent of 90 minutes of exercise) a day. It all comes together to provide ongoing weight management alongside a healthy lifestyle.

Another option is the national nonprofit alternative Take Off Pounds Sensibly (TOPS). The basic theory behind TOPS is that the calories you consume should be offset by those you expend. It divides foods into six groups—starch, fruit, vegetables, milk, meat/meat substitutes, and fats. Depending on your calorie needs, you eat a specific number of servings daily from each food group. According to one study, people who followed TOPS for three years lost 5 to 7 percent of their body weight and kept it off. Like Weight Watchers, TOPS stresses healthy food choices and portion sizes and encourages you to attend weekly meetings.

If you don’t want to follow a regimented diet plan, you can try old-fashioned sensible eating, making small changes every day—perhaps eating less sugar and saturated fat, decreasing your usual portion size by a quarter or a third, eating smaller more frequent meals, and making overall healthier food choices.

Changing Your Diet

Another study found that following a Mediterranean diet and exercising regularly may help reduce sleep apnea symptoms. Researchers examined 40 obese patients with OSA. Half were given a prudent (low-fat) diet, while the other half followed a Mediterranean diet, which emphasizes fruits, vegetables, legumes, and healthy fats. Both groups were encouraged to increase their physical activity (mainly by walking for at least 30 minutes each day), and both groups also received continuous positive airway pressure (CPAP) therapy.

Six months later, a sleep study found that those who followed the Mediterranean diet had fewer apnea episodes during REM sleep. The Mediterranean diet group also showed a greater adherence to calorie restriction, an increase in physical activity, and a greater decrease in abdominal fat.

Using an Oral Appliance

The American Academy of Sleep Medicine recommends oral appliances as a first-line treatment for chronic snoring and mild cases of OSA when individuals don’t improve with lifestyle changes. These devices help keep the throat open by repositioning the tongue and lower jaw. A dentist fits the oral appliance, then the individual undergoes a sleep study while wearing the device to determine whether it improves their breathing. About half of patients are helped to some extent by the device.

Continuous Positive Airway Pressure (CPAP)

For moderate-to-severe OSA, a nasal CPAP device, which forces air through the nasal passages at a level that prevents the tissues of the throat from collapsing during sleep, is generally prescribed. The device delivers air through a small mask that fits over the nose, or through plastic nasal prongs. The correct air pressure is calibrated after a night in the sleep lab. Some devices can vary the flow of air to match an individual’s specific breathing pattern, while others start out the night with a lower air pressure and slowly increase it, so a patient can fall asleep before the full pressure kicks in.

CPAP is not a cure for OSA: Apneas will recur if you use the device improperly or stop using it. However, treating OSA with CPAP has many benefits. A 2015 study of middle-aged overweight and obese adults demonstrated that wearing a CPAP device for eight hours a night for two weeks improved blood sugar control and the ability of insulin to regulate blood sugar. Studies also have shown that CPAP reduces blood pressure in people with OSA after two weeks.

CPAP therapy helps restore memory consolidation and reduces the daytime sleepiness and depressive symptoms that impact quality of life in many people with OSA. CPAP also has been shown to lower hospital readmission and emergency room visits in people with heart disease and to reduce the risk of death in people with both OSA and chronic obstructive pulmonary disease (COPD).

CPAP may not be effective in people with type 2 diabetes who have OSA during REM sleep, as opposed to NREM sleep. That’s because CPAP treatment is often limited to the first half of the night, when NREM sleep predominates.

Alternatives to CPAP

A different treatment for OSA uses a self-adhesive, one-way resistor device that is applied to each nostril nightly. The disposable device, which produces an expiratory-only positive airway pressure (EPAP), has been shown to effectively treat mild-to-moderate OSA in about half of people with the disorder. However, it’s not possible to predict who will respond best to EPAP.

Another recently approved OSA therapy is a pacemaker-like device that monitors breathing patterns and is activated during sleep to stimulate the hypoglossal nerve, which controls muscles in the upper airway and tongue during inhalation. In one study, hypoglossal nerve stimulation therapy was found to produce clinically meaningful improvements in snoring, daytime alertness, and sleep-related quality of life in patients with moderate-to-severe OSA who had difficulty adhering to CPAP therapy. The implantable device is approved as a second-line therapy, meaning that only patients with moderate-to-severe OSA who cannot use or fail CPAP can try the new device.

Surgery

For severe snoring associated with OSA, surgery may be used to reduce excess tissue in the upper airway to make breathing easier and reduce snoring. Surgery is not without risks, however. It may not be completely successful, and it may even leave you worse than before. The success rate for surgical treatment of OSA is about 40 percent, depending on the type of surgery and the criteria for success. Moreover, insurance or Medicare may not cover these surgeries.

UPPP. One of the most common procedures is uvulopalatopharyngoplasty (UPPP), which involves cutting away part of the uvula, soft palate, tonsils, and excess tissue in the throat. UPPP requires general anesthesia and an overnight hospital stay. In laser-assisted uvulopalatoplasty (LAUP), an outpatient procedure, a laser is used instead of a scalpel. UPPP and LAUP may reduce or eliminate OSA. However, its effectiveness is difficult to predict, and the long-term side effects and benefits are unknown. In addition, more than one LAUP procedure may be required to sufficiently address the breathing problem. Concerns about scar tissue formation limit the use of this technique.

Ablation. High-frequency radio-wave ablation uses radiofrequency energy from a probe to generate heat that shrinks the structures in the upper airway, including the uvula and the base of the tongue. The heat is delivered to the tissues beneath the mucous membrane, so patients experience less post-operative discomfort than with UPPP or LAUP. High-frequency radio-wave ablation is not yet approved as a treatment for sleep apnea; it’s used primarily for snoring.

Thyroid surgery. Someone with an enlarged thyroid gland (goiter) may find relief from OSA by undergoing thyroidectomy, which removes all or part of an enlarged thyroid gland. The procedure can dramatically improve snoring.

Central Sleep Apnea (CSA)

Whereas in OSA breathing stops because the airway becomes blocked by tissue, patients with CSA stop breathing because their brain stops sending the signal to breathe. CSA is associated with poor outcomes and an increased risk of mortality.CSA is most often associated with heart failure but is common in patients taking opioids for pain management and may even occur when they are on CPAP for obstructive sleep apnea.

A study in Journal of Clinical Sleep Medicine reported a case of a patient who underwent polysomnography testing while on opioids, off opioids, and with various positive airway pressure devices. While on opioids, the patient had severe CSA that persisted during CPAP and bilevel titration (a type of sleep study), but disappeared with adaptive servo ventilation (ASV) therapy, which is similar to CPAP therapy. When opioid use was discontinued, both OSA and CSA disappeared. Later, when the patient gained weight, polysomnography revealed the return of OSA, but not CSA. This time, she was able to tolerate CPAP without having CSA, indicating that opioids were responsible for causing her CSA.

A treatment similar to CPAP, called adaptive servo-ventilation (ASV), is often used to force oxygen into the lungs. However, in 2016 sleep experts issued a warning against using ASV for CSA when the patient has symptomatic heart failure, as it may increase the risk of death.

The good news is that an entirely different approach involves using a pacemaker-type device to stimulate the phrenic nerve to control the breathing muscles. The first such device, known as the “remed¯e System,” was approved by the FDA in late 2017. In the clinical trial leading to its approval, patients who received the implant experienced a 50 percent drop in the severity and frequency of their apneic episodes (compared to 11 percent of the placebo group), hypoxia, and arousals, and improved sleep quality and quality of life in patients with moderate-to-severe CSA.The system proved safe, as well as effective.

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