Foods you can eat with Sleep Apnea

The Sleep Apnea Exercise Program

Here Is a Tiny Sample of What Youll Get When You Register for the Sleep Apnea Exercises Program: 18 step-by-step videos that show you exactly how to do the sleep apnea exercises. A 52-page manual that includes a description of each exercise; illustrations to show you how to do each exercise; an explanation of what each exercise does for your body. The manual includes these sections: Causes of sleep apnea; Relationship between sleep apnea and snoring. Scientific studies backing up sleep apnea exercises. How to test your sleep apnea at home. Daily tasks to keep your sleep apnea at a low level. Names and website addresses of speech language pathologists in the U.S. and U.K. who specialize in sleep apnea, and have agreed to list their contact details in my manual. Names and contact details for obstructive sleep apnea support groups. MP3 (audio) recordings of the exercises that you can download and listen to on your iPod, iPhone, or MP3 device. (This is especially useful for the exercises that youll want to do in front of the mirror) Access to an online Members Area, where youll be able to download the manual, watch the videos, and get the bonuses! More here...

The Sleep Apnea Exercise Program Overview

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Author: Marc MacDonald
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American Sleep Apnea Association ASAA A

Nonprofit organization founded in 1990 by persons with apnea and concerned health care providers and researchers. The ASAA is dedicated to reducing injury, disability, and death from sleep apnea and enhancing the well-being of patients. The ASAA promotes education and awareness, research, and the A.W.A.K.E. network of voluntary mutual support groups. As part of its endeavors to increase understanding of sleep apnea, the ASAA fulfills thousands of requests for information from the public each year and answers a multitude of questions about diagnosis and treatment options. The ASAA also works with other nonprofit organizations and societies for health care professionals to reach the undiagnosed. In addition, the ASAA serves as an advocate for people with sleep apnea and helps them live with this disorder. The A.W.A.K.E. Network plays a crucial role in the ASAA's educational and advocacy efforts. A.W.A.K.E. is an acronym for Alert, Well, And Keeping Energetic, characteristics that are...

Sleep Apnea Syndromes and neuropsychological disorders

In addition to nocturnal Sleep Apnea Syndrome symptoms there are a lot of daytime symptoms. It is assumed that the reduced sleep quality, arising out of deep sleep or REM- It is also assumed that the OSAS accompanying Insomnia and sleepiness influence cognitive functions (Jennum et al. 1993). As reported by Schwarzenberger et al. (1987) that patients with EDS have complaints and problems in situations of physical rest and during prolonged monotonous concentration tasks. A study by Kales (1985) showed that 76 of OSAS patients have cognitive deficits in the areas of thinking, learning ability, memory, communication and the ability to learn new information. Naegele et al. (1995) were able to establish in Sleep Apnea Syndrome patients that they were reduced at executive functions when these tasks involve the acquisition of information to memory processing. Another study by Cassel et al. (1995) showed that Sleep Apnea Syndrome patients have a reduced non-verbal performance and processing...

Have sleep apnea and use a continuous positive airway pressure CPAP machine Will I use this following surgery

In general, people with sleep apnea will be managed without their C-PAP machine for at least a few days. The concern is that the increase in airway pressure these machines Sleep apnea is a disorder that primarily affects overweight people. The definition of sleep apnea is complete cessation of airflow at the nose and mouth multiple times an hour during sleep. For many people apnea is noted by their bed partners. Some people find out that they have sleep apnea as part of the workup for gastric bypass surgery. In our center sleep studies are performed on most people prior to surgery. We generally want people to be treated with a C-PAP machine for at least two months prior to surgery. A C-PAP machine prevents apnea by increasing airway pressure with each breath a person takes. The C-PAP machine overcomes the tendency of the airway to collapse due to the fatty deposits in the neck or airway tissues. For many people weight loss totally cures their sleep apnea. Consequently, C-PAP may not...

Obesity and Sleep Apnea

Obstructive sleep apnea is defined as an absence of breathing during sleep. Currently, it is recognized that sleep apnea is part of a continuum from health to disease. 649, 650 Apnea is currently defined as cessation of airflow for at least 10 seconds and is characterized as either central (if no respiratory effort occurs), obstructive (if continued effort is noted), or mixed (if both central and obstructive components are present). 651-653 Apnea is associated with either a fall in oxyhe-moglobin desaturation or an arousal from sleep. Hypopneas, which are defined as partial reductions in airflow associated with falls in oxygen saturation or arousals from sleep, are also recorded. The sleep apnea syndrome has been clinically defined as recurrent apnea or hypopnea associated with clinical impairment usually manifested as increased daytime sleepiness or altered car-diopulmonary function. In general, the average number of episodes of apnea and hypopnea per hour are reported as an index...

Sleep Apnea

Obesity, particularly upper body obesity, is a risk factor for sleep apnea and has been shown to be related to its severity. 19,20 The major pathophysi-ologic consequences of severe sleep apnea include arterial hypoxemia, recurrent arousals from sleep, increased sympathetic tone, pulmonary and systemic hypertension, and cardiac arrhythmias. 21 Most people with sleep apnea have a BMI > 30. 96,97 Large neck girth in both men and women who snore is highly predictive of sleep apnea. In general, men whose neck circumference is 17 inches or greater and women whose neck circumference is 16 inches or greater are at higher risk for sleep apnea. 98 Additional information on sleep apnea is included as Appendix IV

Measuring Sleep Disorders

Sleep architecture can be studied using PSG, and MSLT provides measures of alertness. These studies are not routinely required for the assessment of sleep in PD. However, in cases where obstructive sleep apnea or severe PLM is suspected, PSG is essential. In cases of severe RBD or other parasomnias, PSG is useful for confirmation of diagnosis. A pathological MSLT result (sleep latency < 10 minutes) in a PD patient may also suggest a propensity to sudden onset of sleep.

Rapid Eye Movement Behavior Disorder and Restless Legs Syndrome

The treatment of choice for RBD is clonazepam, a benzodiazepine, although the mechanism is unknown and there are no controlled trials (13). Other drugs thought to be helpful for RBD include pramipexole, levodopa, carbamazepine, donepezil, and melatonin (64,89-91). Caution needs to be exercised with the use of clonazepam, as in some cases, RBD may be confused with sleep apnea, which can be worsened by clonazepam. Nighttime dosing with drugs such as selegiline may aggravate RBD. Others have reported a paradoxical worsening of RBD with deep brain stimulation (DBS) of the subthalamic nucleus (STN) (92).

Sleep disorders 41 Insomnia

Interestingly, the reverse relationship does not appear to occur since ADHD symptoms are not commonly found in DSP. Therefore one might assume that SOI per se, as typical of DSP, is not enough to produce daytime feature of ADHD unless accompanied by nighttime hyperactivity sleep fragmentation, as in most ADHD children (Walters et al., 2008). As for sleep maintenance insomnia (SMI), several primary sleep disorders such as obstructive sleep apnea syndrome (OSAS), periodic leg movement disorder (PLMD), and restless legs syndrome (RLS) concur in increasing wakefulness after sleep onset (WASO) with night-time awakenings and lowering sleep efficiency with related detrimental effects on performance (Gruber et al., 2007). 4.3 Sleep apnea (OSAS)

Rationale for Guidelines Development

An estimated 97 million adults in the United States are overweight or obese, 1 a condition that substantially raises their risk of morbidity from hypertension, 2-6 type 2 diabetes, 7-10 stroke, 11-13 gallbladder disease, 14, 15 osteoarthritis, 16-18 sleep apnea and respiratory problems, 19-21 and endometrial, breast, prostate, and colon cancers. 22-24 As a major contributor to preventive death in the United States today, 25 overweight and obesity pose a major public health challenge. Not only is the prevalence of this serious medical condition soaring among adults (between 1960 and 1994, overweight increased from 30.5 to 32 percent among adults ages 20 to 74 and obesity increased from 12.8 percent to 22.5 percent), but it is also affecting ever greater numbers of American youth and exacting a particularly harsh toll from low income women and minorities. The Third National Health and Nutrition Examination Survey (NHANES III) estimated that 13.7 percent of children and 11.5 percent of...

Complications of prematurity

Some babies will benefit from breathing assistance called continuous positive airway pressure (CPAP). A plastic tube that fits in the nostrils provides additional pressure in the air passages to keep the tiny air sacs in the lungs properly inflated. If the intervals of pauses in breathing last longer than 10 to 15 seconds, the baby is said to be having an apneic episode, or an A and B spell. A stands for apnea, a pause in breathing. B stands for bradycardia, the medical term for a slow heartbeat. Sometimes the oxygen level also briefly drops, which is termed a desaturation episode (desat).

How can I rationalize surgically changing my insides and risking significant complications even death just to lose

An article in the Journal of the American Medical Association (January 8, 2003) reported that marked obesity in a man aged twenty to thirty could reduce his life expectancy by up to thirteen years. An extremely obese woman in this same age range might expect to lose up to eight years compared to her normal-weight friends. These are not small numbers. People who are overweight are more likely to develop obesity-related illnesses such as heart disease, pulmonary hypertension, stroke, diabetes, sleep apnea, and arthritis. And obese people are much more likely than lean people to develop blood clots in the legs and lungs, gallstones, pancreatitis, abdominal hernia, fatty liver, polycystic ovary syndrome, high blood pressure, arthritis, gout, lower back pain, infertility, urinary incontinence, and cataracts.

And Make Bread for Yourself

Corn syrup, sugar, hydrogenated fats, and colors sabotage normal bodily function. I have encouraged patients with tremors, digestive disturbances, sleep apnea, and pain syndromes to limit wheat bread and see miraculous results. The protein in wheat bread, called gluten, literally glues the villi in your intestine together diminishing absorption.

Genetics of Prader Willi Syndrome

Fulfillment of diagnostic criteria and genetic testing confirm in individuals suspected with PWS. In 1993, age-stratified diagnostic criteria were published by Holm et al. PWS is very likely in children < 3years of age with 5 points (3 from major criteria) or in those > 3 years of age with 8 points (4 from major criteria). Major diagnostic criteria for PWS (1 point for each) include infantile central hypotonia, feeding difficulties in infancy, accelerated weight gain in early childhood, hypgonadism, developmental delay and typical facial features (narrow bifrontal diameter, almond palpebral fissures, narrow nasal bridge, down-turned mouth). Current minor diagnostic criteria for PWS (1 2 point each) include decreased fetal movement, sleep apnea, short stature, hypopigmenta-tion, small hands feet, narrow hands with straight ulnar border, esotropia myopia, thick saliva, skin picking and speech problems. Other commonly reported features of individuals with PWS include high pain...

Amplitude Market Opportunity

By prevalence, or the total number of cases existing within the population. For example, when continuous positive airway pressure (CPAP) was first introduced, it had the full population of 18 million patients with obstructive sleep apnea to treat. Similarly, new trials have exponentially increased the target population for implantable defibrillators, pushing the curve's peak higher and sliding the technology further back down the curve from stage 3 to 2.The last component that bears mention is pricing. Robust pricing is one of the biggest reasons why devices are such an economically attractive industry. There are a few reasons for this

Self Help Therapies for Insomnia

Insomnia is by far the most prevalent of all sleep disorders. Sleep apnea, characterized by the cessation of airflow through the mouth and nose during the sleep period, affects about 2 of adult women and 4 of adult males (Flemons, 1999 Partinen & Hublin, 2000). Because people with apnea breathe normally during the day, this potentially fatal disorder can go undetected for many years. Restless legs syndrome and periodic limb movement appear with approximately the same frequency as sleep apnea, although the majority of cases are considered mild with little functional impairment (Montplaisir, Nicolas, Godbout, & Walters, 2000). The International Classification of Sleep Disorders Revised (ICSD-R American Sleep Disorders Association, 1997) lists dozens of other sleep disorders, most of which are extremely rare (e.g., narcolepsy) or occur exclusively in children (Partinen & Hublin, 2000). The non-insomnia sleep disorders usually require medical interventions. As such, self-help...

Restless Legs Syndrome RLS

Symptoms include an irresistible urge to move the legs, sensations of creeping, crawling, numbness, itching, tugging, and tingling. These symptoms tend to become worse during prolonged sitting or at night and improve when the legs are moved. Severe RLS can also involve the arms and even the trunk. RLS is thought to be occasionally associated with attention deficit disorder (ADD) and commonly occurs with end-stage renal (kidney) disease dialysis. The diagnosis is based on history and physical exam, and sometimes a sleep study will be ordered to check for other sleep disorders, such as sleep apnea. For those whose RLS disrupts or prevents their sleep, medications used to promote sleep might include anticonvulsants, benzodiazepines, opioids, and dopamine agonists. People who do not respond to treatment with sleep medications also may benefit from iron, B-12, and folic acid supplements. Pregnant and perimenopausal women are at higher risk for RLS due to iron...

Surgery for Weight Loss

Bypass Roux-en Y ) can induce substantial weight loss, and serve to reduce weight-associated risk factors and comorbidities. Compared to other interventions available, surgery has produced the longest period of sustained weight loss. Assessing both perioperative risk and long-term complications is important and requires assessing the risk benefit ratio in each case. Patients whose BMI equals or exceeds 40 kg m2 are potential candidates for surgery if they strongly desire substantial weight loss, because obesity severely impairs the quality of their lives. Less severe obese patients (BMIs between 35 and 39.9 kg m2) also may be considered for surgery. This group primarily includes those patients with high-risk comorbid conditions (cardiovascular, sleep apnea, uncontrolled type 2 diabetes) or weight-induced physical problems interfering with performance of daily life activities.

Diagnosis of parasomnias

All parasomnias more commonly affect persons who have breathing disorders during sleep. Polysomnography is appropriate for any patient with symptoms or signs of obstructive sleep apnea, such as daytime hypersomnolence, nocturnal hypoxia, loud snoring and increased neck circumference. REM behavior disorder often occurs concomitantly with degenerative neurologic illnesses that may require further evaluation. In adults, the onset of arousal disorders such as somnambulism and night terrors may reflect underlying neurologic disease. Thus, neurologic evaluation, including imaging of the central nervous system, may be indicated (Bornemann et al., 2006).

G Consideration of Special Populations and situations

The panel also evaluated population factors and clinical situations that might potentially influence the physiological, medical, behavioral, or sociocultural context for obesity identification and treatment. Evidence on special populations and situations was captured from non-RCT evidence when available, but in many cases such evidence was meager. Population factors selected for special consideration with respect to obesity classification and treatment were age, gender, race ethnicity, socioeconomic status, pregnancy, eating disorders, sleep apnea, extreme obesity, concurrent treatment of other major conditions (such as heart disease or diabetes), and treatment of obesity in conjunction with smoking cessation.

Steep situation 4 How long is too long

HtVNG If you don't feel rested after six to eight hours of sleep, you may have a serious sleep problem known as sleep apnea. Sleep apnea involves a series of episodes in which your breathing stops while you sleep. You awaken momentarily to gasp for air, and then you fall back asleep, only to have your breathing cease yet again. Sleep apnea results in very poor quality sleep and frequently leads to nodding off in the daytime. Snoring can be a sign of sleep apnea, but that's not always the case. If you think you may have sleep apnea, your physician can refer you to a sleep clinic where the condition can be accurately diagnosed.

Respiratory Disorders

Respiratory disorders are common in adults with Down's syndrome, with the underlying pathology often multifactorial. Structural and functional anomalies such as hypotonia and small lower airway volume can, for example, combine with cardiac defects, excessive mucus secretion and collection in the upper airways to confound accurate diagnosis. As with many adults with learning disabilities, especially those living within communal settings, gastro-oesophageal reflux (GORD) caused by the bacterium Helicobacter pylori is very common, causing significant discomfort from gastritis. Sleep disturbance caused by frequent intermittent periods of breathing cessation (sleep apnoea) is common in adults with Down's syndrome and needs investigating to enable an accurate clinical picture of respiratory disturbance from which a diagnostic pathway can be established.

Diagnosis for REM sleep behavior disorder

Eisensehr et al. and Gagnon et al. pointed out the limitations of these criteria because one half of the cases of RBD with PD would have been undetected based clinical interviews alone (Eisensehr et al., 2001 Gagnon et al., 2002). RBD-like features can occur with other sleep conditions such as obstructive sleep apnea syndrome (OSAS), sleepwalking, night terrors, and sleep-related seizures (see below 4). In the second version of the ICSD (ICSD-2), PSG findings were required to establish the diagnosis. The first essential criterion is the presence of REM sleep without atonia. The second criterion is the presence of either sleep-related injurious or disruptive behaviors revealed by history or abnormal REM sleep behaviors documented during PSG recording. Time-synchronized video recording is essential for helping to establish the diagnosis of RBD during PSG. The last two criteria are exclusion criteria, which are the absence of epileptiform activity during sleep and the presence of other...

Taft William Howard 18571930 President 190913 and Chief Justice of the USA 192130

He reduced his size to 250 pounds and lowered his blood pressure, declaring that I can truthfully say I never felt any younger in all my life. Too much flesh is bad for any man. It affects a man both physically and mentally (Anon. 1913). Taft suffered from chronic drowsiness during his presidency but not afterwards the sleepiness may have been what we now call sleep apnea, which is linked to obesity (Brown 2003).

Differential diagnosis of REM sleep behavior disorder

Obstructive sleep apnea syndrome (pseudo RBD) Sleep-related epilepsy Psychiatric diseases Sleep-related dissociative disorder Panic disorder Severe OSAS and nocturnal epilepsy may mimic the symptoms of RBD. Patients with severe OSAS may present with unpleasant dreams and dream-enacting behaviors (Iranzo & Santamaria, 2005). Continuous positive airway pressure (CPAP) therapy can eliminate abnormal nocturnal behaviors. Sleep-related seizures usually present with repetitive stereotypical behaviors.

Sleepdisordered breathing disorders in neurological diseases

Sleep-disordered breathing in patients with Duchenne muscular dystrophy has a characteristic clinical course (Barbe, 1994). In children under 10 years mostly obstructive apneas occur, while in older children, with the development of disease, the apneas of central origin predominate (Smith, 1989 Suresh, 2005). The occurrence of obstructive sleep apnea and snoring at a younger age is associated with frequent enlargement of the tongue (Barbe, 1994 Suresh, 2005) There are no large systematic studies on sleep -disordered breathing in other types of muscular dystrophies. Recently published study analyses SDB in 51 patients with facioscapulohumeral muscular dystrophy (Della Marca, 2009). 22 patients had abnormal breathing during sleep, 13 of them had obstructive breathing disorders (3 of them required the CPAP treatment). In 4 patients during REM sleep hypoxia of central origin were found, 3 patients had mixed type of respiratory disorders. Other parameters such as BMI, daytime sleepiness,...

Think I am a good candidate for gastric bypass surgery What do I need to do to obtain insurance coverage for this

Ship with your primary care doctor, he or she will know about your weight loss attempts and will be treating you for any of your obesity-related illnesses or conditions (elevated cholesterol and triglycerides, gallstones, pancreatitis, abdominal hernia, fatty liver, diabetes or prediabetes, polycystic ovary syndrome, high blood pressure, heart disease, pulmonary hypertension, stroke, blood clots in the legs and lungs, sleep apnea, arthritis, gout, lower back pain, infertility, urinary incontinence, or cataracts). As a way to boost your chances of immediate approval by your insurance company, I advise asking some of your other physicians to also write a letter of support to your insurance company. This might include your pulmonary doctor (if you have any obesity-related lung problems such as sleep apnea) your endocrinologist (if you have diabetes or poly-cystic ovary syndrome) your obstetrician-gynecologist (if you have obesity-related infertility or menstrual problems) your...

Sample Letter from Your Primary Care Doctor or Surgeon

I am writing to request coverage for gastric bypass surgery for my patient Ms. Donna Smith. Ms. Smith is a thirty-three-year-old woman who is 5'3 tall and weighs 295 pounds, giving her a BMI of 52. She already suffers from many obesity-related disorders including diabetes, hypertension, hyperlipidemia, and sleep apnea. She has also been diagnosed with polycystic ovary syndrome and has been unable to become pregnant. I believe all her obesity-related conditions will be markedly improved with gastric bypass surgery. Following polysomnography one year ago, Ms. Smith was diagnosed with sleep apnea. Since her diagnosis she has been treated with C-PAP (continuous positive airway pressure). Ms. Smith has had a great deal of difficulty tolerating C-PAP, but has been reluctant to undergo uvulo-palatopharyngoplasty (a surgical procedure designed to increase the pharyngeal lumen by resecting redundant soft tissue). Gastric bypass with resultant weight loss is likely to dramatically improve Ms....

Head and Neck Manifestations

The most common findings of laryngeal sarcoidosis are diffuse symmetric enlargement of the supraglottic structures and turban-like thickening of the epiglottis. The sites of laryngeal involvement in decreasing order of frequency are the epiglottis, aryepiglottic folds and arytenoids, false vocal cords, true vocal cords, and subglottis. Radiographic studies may demonstrate an enlarged epiglottis (37,38).

Strategies for Weight Loss and Weight Maintenance

Pharmacotherapy In carefully selected patients, appropriate drugs can augment LCDs, physical activity, and behavior therapy in weight loss. Weight loss drugs that have been approved by the FDA for long-term use can be useful adjuncts to dietary therapy and physical activity for some patients with a BMI of > 30 with no concomitant risk factors or diseases, and for patients with a BMI of > 27 with concomitant risk factors or diseases. The risk factors and diseases considered important enough to warrant pharmacotherapy at a BMI of 27 to 29.9 are hypertension, dyslipi-demia, CHD, type 2 diabetes, and sleep apnea. Continual assessment by the physician of drug therapy for efficacy and safety is necessary.

Neurodegenerative diseases of the central nervous system and SDB 41 Alzheimer disease

Searching for links between Alzheimer's disease and sleep-disordered breathing has already started in the eighties. Cognitive deficits observed in individuals with SDB was seen as a preliminary stage in the development of dementia. Cognitive deficits in individuals with impaired respiratory function were found on both verbal, spatial and executive functions as well as short-term memory (Naegele, 1995 Alchanatis, 2005). A number of pathomechanisms may contribute to cognitive impairment in patients with respiratory disorders. The important part play episodes of hypoxia and subsequent oxidative stress resulting in impaired cholinergic transmission in the central nervous system (Gibson, 1981 Shimada, 1981). Another pathomechanism may be associated with changes in cerebral blood flow, observed during sleep -significant hypoperfusion after an episode of apnea. Studies using magnetic resonance spectroscopy showed a decrease in metabolism in the frontal lobes in people with severe respiratory...

Sleepdisordered breathing SDB in patients with ischemic stroke

Similar results for sleep-disordered breathing in patients with ischemic stroke and TIA were obtained in the group of 161 patients (Parra, 2000). The incidence of sleep-disordered breathing in the group with ischemic stroke was 74.5 , while in the TIA group, 61.5 . Another study (Wessendorf, 2001) have shown the incidence of apnea during sleep in 44 of patients with ischemic stroke, obstructive apneas were the most prominent type of SDB -94 , central apneas occurred in 6 of patients. Turkington (2002) observed presence of SDB (AHI> 10) in 61 of patients with ischemic stroke. In other studies (Harbison, 2002), the incidence of sleep-disordered breathing in patients with acute stroke was 94 and decreased during hospitalization to 72 within 6 weeks after stroke. Results presented by Iranzo (2002) show that SDB (AHI> 10) in the first night after the stroke occurred in 62 of patients. Another study (Kaneko, 2003) showed sleep-disordered breathing in 72 of patients with ischemic stroke....

Noninvasive Ventilation

The goals of NIPPV in asthma are to reduce work of breathing and potentially decrease the degree of hyperinflation, with mechanical support conducted long enough for pharmacologic therapies to take effect. The former is accomplished in two ways. Application of continuous positive airway pressure (CPAP) or expiratory positive airway pressure (EPAP) when matched to the raised intrathoracic pressure seen as a consequence of dynamic hyperinflation and assessed by the measurement of intrinsic positive end expiratory pressure (PEEP) allows inspiratory flow to be initiated with lower intrathoracic pressure swings. This reduces the ''inspiratory threshold load'' on breathing in a dynamically inflated state. Adding inspira-tory pressure support assists the exhausted asthmatic in generating adequate tidal volume and further reduces work of breathing and risk of progression to ventilatory failure. Furthermore, the addition of positive pressure may lead to decreased inspiratory time and extension...

Symptoms And Diagnosis

While these criteria originally were developed to ensure that FM patients in research studies were as similar as possible, the classification criteria has migrated into the clinical arena and is considered the current gold standard for diagnosing FM in a clinical setting. The 1990 ACR diagnosis criteria may change in the future when laboratory markers develop that are inexpensive and easy to use in a clinic setting. Examples of markers in other diagnoses include using a sphyg-momanometer for determining high blood pressure and glucose testing to detect diabetes. The current objective laboratory markers in FM are not so easily measured in a health-care clinic setting. They require a combination of functional brain imaging with evoked pain, cerebral spinal fluid analyses taken at rest, blood tests taken during the stress of acute exercise, overnight laboratory-based sleep studies, and resting heart rate variability monitoring. In addition to being burdensome and time consuming for the...

Box 8 Clinician and Patient Devise Goals

Least six months before considering pharma-cotherapy. In addition, pharmacotherapy should be considered as an adjunct to lifestyle therapy in patients with a BMI > 30 with no concomitant obesity-related risk factors or diseases, or for patients with a BMI > 27 with concomitant obesity-related risk factors or diseases. The risk factors or diseases considered important enough to warrant pharmacothera-py at a BMI of 27 to 29.9 are hypertension, dyslipidemia, CHD, type 2 diabetes, and sleep apnea. However, sibutramine, the only FDA approved drug for long-term use, should not be used in patients with a history of hypertension, CHD, congestive heart failure, arrhythmias, or history of stroke. Certain patients may be candidates for weight loss surgery. Each component of weight loss therapy can be introduced briefly. The selection of weight loss methods should be made in the context of patient preferences, analysis of past failed attempts, and consideration of the available resources.

What is an obesityrelated illness

Obesity-related illnesses and conditions include elevated cholesterol and triglycerides, gallstones, pancreatitis, abdominal hernia, fatty liver, diabetes and prediabetes, polycystic ovary syndrome, high blood pressure, heart disease, pulmonary hypertension, stroke, blood clots in the legs and lungs, sleep apnea, arthritis, gout, lower back pain, infertility, urinary incontinence, and cataracts. If you have one of these conditions gastric surgery can be considered when the BMI is 35 or higher. In many cases gastric bypass surgery can dramatically improve obesity-related conditions. I have had many patients who after gastric bypass surgery were able to give up their blood pressure, diabetes, and cholesterol lowering medications. Many young women who have been unable to become pregnant conceive and go on to have healthy babies (more on this later).

The Sleep Medicine Physician

Physicians who have studied in this subspecialty can administer and interpret a sleep study. Sleep studies are critical for patients with signs or symptoms suggestive of sleep apnea (a disorder characterized by pauses and gasps while breathing during sleep) or narcolepsy (a neurological condition characterized by extreme tiredness and or falling asleep during the day at inappropriate times). Symptoms of sleep deprivation may include extreme daytime sleepiness, going to sleep while driving, loud snoring with pauses between breaths, and waking with an occipital headache (pain in the back of the skull and radiating down the neck). Sleep medicine physicians may or may not be interested in treating chronic insomnia. Some are comfortable with providing a long-term prescription of controlled substance sleep agents others will rely instead on sleep hygiene, tricyclic or SSRI medications, and referral for cognitive behavioral therapy.

Sleep and pregnancy

Obstructive sleep apnoea (OSA) is the most common of these sleep disorders and is characterized by the complete or partial collapse of the pharyngeal airway during sleep. To resume ventilation, feedback mechanisms arouse the individual, which leads to sleep disruption. OSA is associated with an increased CVD risk. Although, men are twice as likely to develop OSA as women, the risk is increased in women if they are overweight. Moreover, data from recent studies indicates that snoring and OSA increase during pregnancy. The prevalence of OSA is very low in normotensive women low-risk pregnancies but is increased among normotensive pregnant women with high risk pregnancies and, in those with gestational hypertension (pregnancy-induced hypertension (PIH) pre-eclampsia) during pregnancy, the prevalence is even higher. women younger than 20 or older than 35 or women who are overweight, have a history or hypertension or kidney disease or diabetes. Recent studies indicate that OSA per se is an...

Obstructive Apnea

Symptoms Snoring is the most common symptom other signs include color changes, labored breathing or gasping for air during sleep or sleeping in unusual positions. Because obstructive sleep apnea may disturb sleep patterns, these children may wake up sleepy and continue to complain of fatigue and attention problems throughout the day that may affect school performance. one recent study suggests that some children diagnosed with attention deficit hyperactivity disorder (ADHD) actually have attention problems in school because of disrupted sleep patterns caused by obstructive sleep apnea. Treatment obstructive apnea can be cured by keeping the child's throat open to improve airflow. This may be done by surgically removing the tonsils and adenoids, or by providing continuous positive airway pressure (CPAP). CPAP is provided by having the child wear a nose mask while sleeping.

Sleep architecture

Many authors claim that in the absence of an abnormal apnea hypopnea index (AHI) or periodic leg movements (PLMs) index, sleep variables in ADHD children are not far from age normative values (Sangal et al., 2005). In a recent thorough metanalysis of polysomnographic (PSG) studies, Sadeh et al. (2006) examined other factors of variance, including age and gender. Age, in fact, reflects maturational changes of neurobehavioral and neurotransmitter systems, which may deeply influence sleep patterns. Females with ADHD usually present less disruptive behaviors, which can also differentially influence sleep attitude and propensity.

Morbidity

Above a BMI of 20 kg m2, morbidity for a number of health conditions increases as BMI increases. Higher morbidity in association with overweight and obesity has been observed for hypertension, 2-6 76-80 type 2 diabetes, 7 8, 10 81 82, 84-89 coronary heart disease (CHD), 1142,86,8890 stroke, 11-13 gallbladder disease, 14,15 osteoarthritis, 16-18, 91-95 sleep apnea and respiratory problems 21, 96-98 and some types of cancer (endometrial, breast, prostate, and colon). 107-115 Obesity is also associated with complications of pregnancy, menstrual irregularities, hirsutism, stress incontinence, and psychological disorders (depression). 112, 116-128

Sleep disturbances

Obstructive sleep apnoea Age-related sleep changes include advanced sleep phase syndrome and decreased quality of nocturnal sleep (with increased arousals and awakenings, and daytime naps). The incidence of sleep apnoea and periodic leg movements of sleep (PLMS) is also increased in the elderly.

Summary

Site specific treatment in these patients is required and therefore techniques that offer localisation of these anatomical obstructive segments would prove useful. In the author's opinion the two techniques that appear to do so are sleep nasendoscopy and the Apnea-Graph. This view has also been supported by a recent evidence based review article on assessment of obstruction level and selection of patients for obstructive sleep apnoea surgery.27

Background

UARS was initially used to describe a group of patients who were sleepy but did not meet the polysomnography diagnostic criteria of obstructive sleep apnoea syndrome (OSAS) (Guilleminault 1993). The first mention of the term was used about children by Guilleminault (Guilleminault 1982) in 1982 and years later also in women (Guilleminault 1995). Is UARS really a disease . Twenty-five years after first being described, there is still significant controversy among experts as to whether UARS is a specific syndrome. Some authors consider it to be part of the spectrum of obstructive disorders affecting the upper airway (Douglas 2000 Jhonson 2008 Cracowski 2001), while others believe that OSAS and UARS are separate entities (Gold 2008 Bao & Guilleminault 2004 Lindberg & Gislason 2000). Normally, it is up to the clinician practitioner to screen for this syndrome. Due to its diagnostic difficulty, currently UARS is significantly under diagnosed and no standard management strategy in...

Diagnosis

UARS is defined as daytime sleepiness associated to a sleep disordered breathing and arousals related to respiratory effort (RERA) but without sufficient apneas hypopneas for OSAS. The diagnosis is based on the association of clinical symptoms and polysomnographic findings. Nocturnal polysomnography, which is the gold standard for diagnosing SAHS, sometimes demonstrates the presence of apneic events and non apneic breathing (hypopneas), but does not definitively diagnose UARS. Nevertheless, an increased number of RERA may lead to suspicion of UARS. Simplified polygraphic studies are not useful in this disease because they do not provide arousal information. Some laboratories have used the split-night technique followed by CPAP titration successfully. These situations require an index of over 20 RERA during the first three hours of sleep (Kristo 2009). Indeed, the presence of RERA in the absence of apneas and hypopneas is the key polysomnography finding for diagnosing UARS (Bonnet...

Follow up

Te long time evolution of UARS patients, within the overall spectrum of sleep disordered breathing disorders, is an area of interest. RERA may be intermediate event between snoring and hypopnea. RERA predominate in younger and thinner people than apnea and hypopnea episodes. Hypopneas becoming true apneas with increasing age and weight. Few existing studies on the matter. In a five years follow-up study of untreated UARS patients, Guilleminault report that only 10 developed a OSAS and always in the context of weight gain (Guilleminault 2006b). Jonzak, in a retrospective study,also report that obesity as an aggravating factor of severity in follow up six years (Jonzak 2009).

Physical Health

Several thorough reviews (Dietz, 1998a,b Must and Strauss, 1999 Deckelbaum and Williams, 2001 Styne, 2001 Must and Anderson, 2003) have found childhood obesity to be associated with a wide array of disorders that affect multiple organ systems. These disorders include hypertension, dyslipidemia, glucose intolerance insulin resistance, hepatic steatosis, cholelithiasis, sleep apnea, menstrual abnormalities, impaired balance, and orthopedic problems. Some of these conditions produce clinical symptoms in obese children, while others do not however, the metabolic and physiologic changes associated with childhood obesity, along with the obesity itself, tend to track into adult life and eventually enhance the risks of disease, disability, and death.

Treatment

Treatment options for UARS include lifestyle changes, Continous Positive Airway Pressure (CPAP), oral appliance therapy and surgery. All patients with UARS should be counseled about the potential benefits of therapy and the risks of going without therapy. Obesity is a modifiable risk factor associated with OSAS so weight loss should be recommended to all overweight or obese. However, patients with UARS are often not obese, so this recommendation has less value in them. As in the treatment of OSAS, within conservative measures are recommended sleep hygiene and avoiding the supine position. Just like in OSA is advisable to multidisciplinary treatment. Continous positive airway pressure (CPAP) is the treatment of choice for SAHS patients. CPAP was the gold standard for UARS. Initial studies described a good response to CPAP treatment which was considered to be a diagnostic criteria for the syndrome (Messner & Pelayo 2000 Guerrero 2001 Guilleminault 2006). As in mild to moderate OSAS,...

Fogle Jared 1978

Wiches from the 6 grams of fat or less menu. More specifically, his diet consisted of coffee for breakfast, a 6-inch turkey sub, Baked Lays potato chips, and diet soft drink for lunch followed by a foot-long veggie sub for dinner. As he started losing weight, he began exercising by walking to classes instead of riding the bus. A year later, he had lost 245 pounds, and now his diet has more calories but is still low in fat. He credits a friend who was a pre-med student with helping him realize that his morbid obesity was endangering his health by telling him that he had sleep apnea and that his edema (swelling) was linked to diabetes. At his father's recommendation, he visited an endocrinologist whom he was afraid to see for fear of stepping on the scale. However, the endocrin-ologist's advice did not help Fogle lose weight, so he tried

SDB in epilepsy

Synchronization of brain bioelectrical activity, triggered by physiological stages of sleep (Gigli, 1992). The phases of sleep in which there is greatest risk of seizures include the phases associated with a higher probability of awakening - mainly phase I and II NREM sleep type. Phase of sleep associated with EEG desynchronization - REM is characterized by a lower risk of seizures. The probability of awakening during sleep increases the risk of seizure in the case of idiopathic generalized epilepsies (Bonakis, 2009). A similar mechanism was proposed in focal and secondarily generalized seizures (Manni, 2005). Also in these types of epilepsy light sleep phase (I and II NREM) may initiate abnormal synchronous epileptic discharges. The EEG patterns associated with arousal (K complexes) trigger pathological EEG hypersynchrony in the second phase of NREM sleep. Seizure during sleep is associated with the interruption of the continuity of sleep and disorder of its architecture. Seizure,...

Clinical History

Infants with PWS exhibit decreased fetal movement, weak cry, neonatal hypotonia, genital hypoplasia (cryptorchidism and clitoral hypoplasia), and failure to thrive (due to hypotonia and poor feeding). Toddlers with PWS acquire major motor milestones later than controls (walk at 24 months). Hyperphagia becomes evident between 18 months and 7 years of age. The majority of patients with PWS have growth hormone deficiency with short stature manifest during childhood and lack of a pubertal growth spurt. Individuals with PWS have an elevated pain threshold and vomiting threshold, with reports of delayed diagnoses of fractures, appendicitis, and gastroenteritis with significant morbidity. Obesity-related comorbid-ities, including sleep apnea, diabetes, and cor pulmo-nale, will shorten life expectancy without aggressive interventions. Behavioral problems, including obsessive-compulsive behavior (skin picking and rectal digging), stubbornness, and food foraging (including garbage and frozen...

Consequences

Obesity has significant medical consequences, especially for adults, but also for children and adolescents. Among adults, obesity is a major risk factor for heart disease, myocardial infarction (heart attack), strokes, cancer, and many other diseases. During adolescence and childhood, obesity can contribute to problems of the joints, especially the hips, knees, and spine, and more difficulty with chronic illnesses, such as asthma. Obesity affects the endocrine system, leading to changes in sex hormones, adrenal hormones, and the ability to respond appropriately to insulin. Type II diabetes has become more common during adolescence as the prevalence of obesity has increased. Sleep apnea, due to obstructed breathing during sleep, is more common among obese children and adolescents.

Severe Complications

Pickwickian syndrome Very severe obesity may be associated with hypoventilation and or upper respiratory obstruction with sleep apnoea. (The sleepy fat boy in Charles Dicken's Pickwick Papers is the origin of the syndrome's name.) Underventilation leads to increased circulating carbon dioxide levels, which may precipitate pulmonary hypertension and right-sided heart failure. Rising circulating carbon dioxide levels may result in the respiratory centre of the brain ceasing to respond to carbon dioxide buildup and instead responding to falling oxygen levels as stimulus to breathe. Thus, if affected individuals are given oxygen because of increasing cyanosis, the stimulus to breathe may be removed with potentially disastrous consequences.

Respiratory System

The obesity-hypoventilation syndrome may be associated with, or exacerbated by, obstructive sleep apnea, a syndrome characterized by repeated collapse of the upper airway and cessation of breathing with sleep. Obstructive sleep apnea occurs when the tongue obstructs the glottis and prevents entry of air into the trachea. Up to 50 of massively obese people have sleep apnea. The risk of arrhythmias and sudden death increases during apneic episodes. Weight reduction usually reduces the severity of sleep apnea, and massive weight reduction, such as that after gastric bypass surgery, eliminates the disease in most patients.

Nervous system

Pseudotumor cerebri This syndrome is characterized by increased intracranial pressure, headaches, blurred vision or loss of vision, and papilledema. It is most common in massively obese individuals and may be seen in association with sleep apnea or with the obesity-hypoventilation syndrome. It may be associated with retinal hemorrhage or loss of vision from severe papilledema. Some investigators believe that increased intraabdominal pressure with massive obesity is an etiologic factor for pseudotumor cerebri. Major weight loss, particularly after obesity surgery, results in dramatic improvement.

Obesity Epidemic

The obesity epidemic poses a public-health challenge. Obesity has a more pronounced effect on morbidity than on mortality, and an increase in its prevalence will have an important effect on the global incidence of cardiovascular disease, type 2 diabetes mellitus, cancer, osteoarthritis, work disability, and sleep apnoea. A 1 increase in the prevalence of obesity in such countries as India and China leads to 20 million additional cases. The state of childhood obesity in the U.S.A., Canada, and many other countries worldwide has reached epidemic proportions the Canadian prevalence tripled between 1981 and 1996.

Sleep Disorders

Or maintenance of sleep, or with sleep that is inefficient. These include common sleep timing problems such as frequent night wakings and difficulty falling asleep at night or difficulty waking in the morning. Dyssomnias also include relatively rare problems such as obstructive sleep apnea (associated with enlarged tonsils and adenoids) and narcolepsy (sudden daytime sleep attacks).

Appeal Letter

Although my policy specifically denies coverage for medications to treat obesity, it says nothing about surgical treatment for morbid obesity. Given the fact that I am 5'3 tall and weigh 295 pounds (giving me a BMI of 52) and I already suffer from many obesity-related disorders including diabetes, hypertension, high cholesterol, sleep apnea, One year ago I began to experience sleepiness during the day. Dr. McGowan asked me to have a sleep study called a polysomnograph. The sleep study confirmed the diagnosis of sleep apnea. Since my diagnosis I have been treated with C-PAP (continuous positive airway pressure). I find C-PAP difficult to tolerate, but I am reluctant to undergo uvulo-palatopharyngoplasty (a surgical procedure designed to increase the pharyngeal lumen by resecting redundant soft tissue) because I have been told by my pulmonologist (Dr. William Messanote) that gastric bypass with its attendant weight loss would likely make this procedure unnecessary. I enclose a letter...

Rbdsqj

We developed a Japanese version of the RBDSQ (RBDSQ-J) after obtaining approval from the patent owner and investigated its validity and reliability (Miyamoto et al., 2009). The RBDSQ-J was administered to 52 consecutive patients with iRBD diagnosed according to criteria in the ICSD-2 (mean age 66.4 years 36 males, 16 females), 55 consecutive OSAS patients who had responded well to CPAP therapy (mean age 63.1 years 44 males, 11 females) after a diagnosis of RBD was ruled out by history and PSG and 65 apparently healthy subjects (mean age 64.6 years 37 males, 28 females).

Reference List

Millman RP, Carlisle CC, McGarvey ST, 28 Eveloff SE, Levinson PD. Body fat distribution and sleep apnea severity in women. 96. Chua W, Chediak AD. Obstructive sleep apnea. Treatment improves quality of life and may prevent death. Postgrad Med. 1994 95 123-126, 131, 135-138. 97. Loube DI, Loube AA, Mitler MM. Weight loss for obstructive sleep apnea the optimal therapy for obese patients. J Am Diet Assoc. 1994 94 1291-1295. between neck circumference, radiographic pharyngeal anatomy, and the obstructive sleep apnoea syndrome. Eur Respir J. 1990 3 509-514.

Other parasomnias

Sleep bruxism is the third most common parasomnia and it can be bothersome to the bed partner. Bruxism is not a dangerous disorder. However, it can cause permanent damage to the teeth and uncomfortable jaw pain, headaches, or ear pain. Approximately 8.2 of people experience it at least once a week. Sleep apnea and anxiety disorders are the most prominent risk factors for bruxism. Bruxism could be a reflex to open the airway after an apneic or hypopneic event. Bruxism may improve with treatment of sleep apnea with continuous positive airway pressure. Sleep bruxism does not have a definite cure. The goals of treatment are to reduce pain, prevent permanent damage to the teeth, and reduce clenching as much as possible. Stress reduction, relaxation, biofeedback, hypnosis and improvement of sleep hygiene have been tried with no persistent or significant improvement. To prevent damage to the teeth, mouth guards or appliances (splints) have been used since the 1930s to treat teeth grinding,...

The Parasomnias

Although clinical history may suggest a diagnosis, in some situations such as when there is a high risk of physical injury or loud snoring suggestive of obstructive sleep apnea, confirmation of diagnosis should be obtained by a single night of polysomnography (PSG) with video telemetry. PSG would show an increased electromyographic (EMG) activity during REM sleep. Symptoms of RBD may predate the diagnosis of PD. Schenck et al. (37) reported that in 1l of 29 men (38 ), 50 years or older in whom idiopathic RBD was diagnosed, a parkinsonian disorder was identified after a mean interval of 3.7 years following the diagnosis of RBD and 12.7 years after the onset of RBD. One study (41) suggested an increased risk of developing PD in individuals who have RBD and olfactory disturbance. This concept is consistent with the recent hypothesis of Braak et al. (21) who suggest that the preclinical stages 1 and 2 of PD start at the olfactory and medullary area of the brainstem. Although the...

Symptoms

SAHS is widely associated with cardiovascular risk. Long-term effects can lead to severe cardiovascular and cerebrovascular diseases. However, there is little data regarding the association of cardiovascular disease and UARS. Some studies have found an association between hypertension and UARS, with a good response to CPAP treatment (Guilleminault 1996), but this association has been put into question. Notably, this controversy sheds light on the importance of hypoxia and sympathetic activation (which are not present in UARS) in OSAS as intermediary mechanisms associated with cardiovascular events. The diagnosis of UARS is often delayed becasue of the absence of respiratory events in polysomnography. Sometimes the symptoms of UARS have been confused with other medical conditions, such as asymptomatic habitual snoring, sleep deprivation, chronic fatigue syndrome, idiopathic hypersomnia, psychiatric disorders (Lewin & Pinto 2004) and asthma (Guerrero 2001).

Very LowCalorie Diets

VLC diets have also been proven to be an effective method in jump-starting patients on conventional weight-loss treatments (Quaade and Astrup 1989). In addition, VLC diets have been shown to reduce cravings for unhealthy foods (Harvey et al. 1993 Martin et al. 2006) and improve obesity-related conditions, such as non-insulin-dependent diabetes (Capstick et al. 1997), sleep apnea and hypertension (Kansanen et al. 1998), cardiovascular disease (Ramhamadany et al. 1989), and hormonal and metabolic disorders, such as polycystic ovarian syndrome and related hirsutism (Okajima et al. 1994). Calorie Diet-Induced Weight Loss on the Severity of Obstructive Sleep Apnoea and Autonomic Nervous Function in Obese Patients with Obstructive Sleep Apnoea Syndrome, Clinical Physiology 18 (4) 377-85.

Bariatric Surgery

Bariatric surgery is the practice of bypassing parts of the digestive tract to allow a morbidly obese patient (BMI > 40) to lose weight either through consuming less food or through malabsorption. Malabsorption refers to food passing directly through the digestive tract without the nutrients being absorbed by the body. This practice is only recommended for patients for whom other weight-loss options, including medical diets, have failed, and if the patient has a serious condition assumed to be caused by the weight, such as diabetes or sleep apnea. They are usually at least 100 pounds overweight. These patients must have failed earlier psychological attempts at changing behavior, such as Weight Watchers or Jenny Craig. There can be no uncorrected metabolic diseases that may be responsible for the obesity, such as low thyroid function. Most importantly, the patients are screened (and most eliminated) for any psychological imbalance or unrealistic expectations of surgery and of weight...

Obesity

The adipose fat cell is not only a passive storage site but an endocrinologically active secretor of many substances like leptin, adiponectin, and cyto-kines, which participate in an inflammatory response and may mediate a host of adverse consequences, including insulin resistance and diabetes. Obesity is related to an increased risk of developing type 2 insulin-resistance diabetes mellitus, hyper-lipidemia, heart disease, obstructive sleep apnea, asthma and other respiratory problems, back pain and orthopedic problems, fatty liver (nonalcoholic steato-hepatitis or NASH), gallstones, and depression. The increasing incidence of type 2 diabetes in obese adolescents is already being noticed, with estimates of 200 000 diabetics under age 20 years in the US predicted to rise to a lifetime risk of developing diabetes of 33-39 for those born in the year 2000.

Insomnia

Restless leg syndrome and sleep apnea, a condition in which there is intermittent cessation of breathing during sleep that may be caused by a problem in the central nervous system affecting the diaphragm or a blockage in the upper airway, can benefit by weight loss if overweight and by regular exercise. Caffeine, drugs, and alcohol should be avoided and stress reduced. Food allergies or a deficiency of iron or folic acid may be a factor in restless leg syndrome taking 200 to 800 IU vitamin E can alleviate symptoms of the condition by increasing blood circulation to the legs 80 mg gingko biloba extract three times daily may be beneficial. Rhus toxicodendron or causticum are homeopathic remedies that can be beneficial for restless leg syndrome and for sleep apnea, lach-esis, or homeopathic opium.

Sleep Apnea

Sleep Apnea

Have You Been Told Over And Over Again That You Snore A Lot, But You Choose To Ignore It? Have you been experiencing lack of sleep at night and find yourself waking up in the wee hours of the morning to find yourself gasping for air?

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