Sleep Apnea Why CPAP Isn’t Fixing The Real Problem (This Does!) - Transcript

Dr. Mark Hyman
You go to bed at ten, you wake up at six, eight hours of sleep, and yet you wake up exhausted. Your brain feels foggy, you need a coffee to get going, maybe you have headaches in the morning, your blood pressure's creeping up and you think, oh, how can I still be tired if I slept all night? Well, what if you didn't? What if, without even realizing it, your breathing was being interrupted over and over again throughout the night? That's what happens with something called sleep apnea.

Your breathing can slow or can stop, your oxygen can fall, Your brain senses a problem and briefly pulls you out of deeper sleep so you can breathe again. And then you fall back asleep and it happens again and again and again. And sometimes dozens of times in an hour. You may not remember any of it this morning when you wake up, but your body does. And that's why sleep apnea is about so much more than snoring.

These repeated disruptions are associated with high blood pressure, with cardiovascular disease, metabolic problems like insulin resistance, diabetes, problems with the tension, memory, and increase of serious health complications. So today, we're gonna answer a few really important questions. How do you know if you have a CPAP? Why does it happen in the first place? Do you have to use a CPAP machine, which is a breathing machine, to help with it forever?

And from a functional medicine perspective, can we treat the apnea while also addressing the factors that may be driving it? Well, yes. Because when it comes to sleep apnea, don't just wanna ask how do we keep your airway open, I also wanna ask why is your airway collapsing in the first place?

Dr. Mark Hyman
This episode is brought to you by Function Health, empowering you to live a hundred healthy years with over a 160 lab tests for just $365 a year. And use the code Mark twenty twenty six to get $50 off your membership. There are different forms

Dr. Mark Hyman
of sleep apnea, but the most common is something called obstructive sleep apnea or OSA. When you're awake, your muscles keep your upper airway open. When you fall asleep, those muscles naturally relax. Now in someone with obstructive sleep apnea, the airway becomes too narrow or it can close completely and the airway flow is just reduced or it stops. Your tongue can fall backward, the soft tissues collapse, your anatomy may simply leave less room for the air to move.

Dr. Mark Hyman
Your brain then senses the disruption. It briefly wakes you enough to

Dr. Mark Hyman
reopen the airway and you take a breath, and then you fall back asleep and the cycle begins again. Now there are two terms you're gonna hear on a sleep study. Apnea means breathing stops and hypopnea means airflow becomes significantly reduced. And doctors often measure these events using something called your AHI, the apnea hypopnea index, which tells you how many of these breathing events are occurring per hour of sleep. There's also central sleep apnea, which is kind of different.

Instead of the airway physically collapsing, the brain isn't consistently sending the signals needed to breathe properly. So those are different problems, and they require different approaches. But today we're going to focus primarily on obstructive sleep apnea, is the most common, super common, incredibly under recognized, under diagnosed. I've diagnosed it so many times when it's been missed since it's contributing to obesity, diabetes, hypertension, obviously fatigue, depression, cognitive function, you name it. So when most people picture someone with sleep apnea, they picture an overweight middle aged guy snoring incredibly loud, which can't be the case.

And yes, and male sex are important risk factors, but that stereotype can cause us to miss a lot of people. You can be thin and have sleep apnea. You can be physically fit and have sleep apnea. And you don't necessarily have to wake up every morning thinking you slept terribly. So here's a quick checklist.

Do you snore loudly? Has your partner ever noticed that you stopped breathing or that you gasped during the night? Do you wake up with a dry mouth or headache? Do you get eight hours sleep, but still wake up exhausted? Are you sleepy during the day?

Do you have brain fog? Do you have difficulty concentrating? Do you wake up repeatedly and urinate? Is your blood pressure difficult to control? Now these are all clues worth paying attention to, and women are especially important here too because women present with symptoms like fatigue, headaches, and insomnia rather than the stereotypical presentation people associate with sleep apnea.

So don't dismiss chronic exhaustion simply because I sleep eight hours. The question isn't only how long are you sleeping, it is what's happening to your body during those eight hours. Now here's where sleep apnea gets really interesting because every time your airway closes, several things can happen. Your oxygen can fall, your sleep gets interrupted, your nervous system responds to that stress. Then imagine repeating that cycle all night, every night.

You're trying to enter deep restorative sleep while your body is repeatedly being pulled into a physiological stress response. And the American Heart Association describes these episodes as creating both acute and chronic physiological stress. And sleep apnea is associated with hypertension or high blood pressure, atrial fibrillation, heart failure, coronary artery disease, stroke, metabolic syndrome, type two diabetes, obesity, it's sort of a vicious cycle. I had a guy once who had sleep apnea, as soon as he got on his treatment, he lost 50 pounds without even trying. So this is actually something that can be really therapeutic when you figure out what's going on.

Now think about what happens when your oxygen falls and your sympathetic nervous system gets activated. Your heart rate changes, your blood pressure changes, your blood vessels experience repeated stress. That's one reason I want people with resistant high blood pressure and cardiovascular disease to think about sleep apnea. I always think about sleep apnea when someone has high blood pressure. Sometimes we're treating the blood pressure during the day without asking what's happening to this person's cardiovascular system at night.

Then there's metabolism. Obesity is one of the strongest modifiable risk factors for obstructive sleep apnea, but this can become a vicious cycle. Poor metabolic health and excess weight can contribute to airway obstruction, and then fragmented sleep makes it harder to feel energetic, to exercise, to regulate your appetite, because you're craving carbs because you're tired, and to maintain your metabolic health. So you're not looking at two completely different problems. Sleep and metabolic health can feed into each other.

And then there's your brain. If you're repeatedly interrupting restorative sleep and you're experiencing intermittent drops in oxygen, well, it's not surprising that people can struggle with that tension, with memory, concentration, and daytime functioning. The National Heart, Lung, and Blood Institute specifically lists problems with learning, focus, reacting, decision making, and memory among the consequences associated with poor sleep from apnea. Which is why somebody might come to me saying, Mark, my brain isn't working like it used to. And one of those questions I wanna ask is, how are you sleeping?

And how are you breathing while you're asleep? Now we get to the question I think is really important, why you? Two people can go to sleep in the same room, one breathes normally all night, the other stops breathing 30 times an hour. What's different? Well, there isn't just one answer.

So I think about it in several buckets. The first place to look is body composition and metabolic health. Excess weight is one of the strongest risk factors for obstructive sleep apnea. Fat deposits around the neck and the upper airway, they can reduce the space available for the air to move. That makes it more likely to collapse while you sleep.

So when excess weight is contributing to someone's sleep apnea, improving metabolic health and body composition isn't simply about the number on the scale, it can be part of treating an underlying problem. And this can be a vicious cycle. Poor metabolic health can increase risk of sleep apnea as I said, and then sleep apnea disrupts restorative sleep, that allows you to tie your stress, often making it hard to exercise, regulate your appetite, and maintain good metabolic health. So it's just a vicious cycle. We have to think about both sides of the equation.

How can we protect your breathing while you're sleeping and also improve your metabolic health that's contributing to the problem. Now for some people, improving body composition can significantly improve sleep apnea. But remember, you don't have to be overweight to have sleep apnea. Someone can be lean, they can be active, they can be metabolically healthy and they can still have significant airway obstruction. Which brings us to our next major factor.

Your anatomy, your jaw, your tongue, your tonsils, your neck, the shape of your face and skull, the amount of space in your upper airway. All these can influence whether your airway stays open while you sleep or not. So someone can be lean, metabolically healthy, exercise every day and still have significant sleep apnea. That's why telling every patient, well just lose weight isn't good enough. Do you have chronic allergies?

A chronically stuffy nose, sinus problems, structural obstruction, are you mouth breathing all night? If someone can't breathe comfortably through their nose, that's something I want to know about and I want to evaluate it. It doesn't mean fixing nasal congestion will automatically cure significant sleep apnea, but airway health matters. And the fourth thing I want to consider is whether another medical condition may be contributing to the sleep apnea. This is where I look at the whole patient, and it becomes really important to do that.

So certain hormonal and medical conditions, they affect your airway, they affect your breathing, or the way your body regulates respiration during sleep. Hypothyroidism, for example, has been associated with obstructive sleep apnea.

Dr. Mark Hyman
If your glucose came back normal, I have one more question. What's your insulin? Because insulin can start rising before your glucose moves out of range. Insulin helps move your glucose from your blood into your cells for energy. But when your cells become less responsive,

Dr. Mark Hyman
your body makes more insulin.

Dr. Mark Hyman
And that's why metabolic health is so much more interesting than a one normal number. I wanna know how your body's handling the food you eat, how efficiently it uses energy, and how those patterns are changing over time. Your metabolism isn't fixed. It responds to how you move, how you sleep, even how you manage stress. And that is where function comes in.

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Low thyroid function can contribute to weight gain and the changes in tissues and muscles surrounding the upper airway, factors that may make obstruction more likely. There are always hormonal conditions like polycystic ovarian syndrome, or PCOS, now known as polyendocrine metabolic ovarian syndrome, metabolic reproductive syndrome, all these different names, that are associated with an increased risk of sleep apnea, especially when insulin resistance and obesity are also present. So there are conditions like heart failure, heart and kidney disease. Those can also lead to change in fluid balance. So when you lie down at night, fluid can shift from the legs toward the neck and upper body potentially contributing to the narrowing of the airway.

So also certain neurological conditions and cardiovascular conditions also can be associated with central sleep apnea which is a different form where the problem isn't simply the way the airway's collapsing but the brain's control of breathing and how that's being disrupted. So if someone comes to me with sleep apnea, I don't necessarily wanna stop at, well your sleep study is abnormal, here's your treatment. I wanna ask what else is going on with this person? Are there signs of a thyroid problem? Metabolic dysfunction?

Hormone changes? Heart or kidney disease? Are there medications that could be affecting breathing? The sleep apnea can sometimes be one piece of a larger health picture. That doesn't mean treating another condition will automatically make the apnea disappear.

We still need to treat the apnea itself. But understanding what may be contributing to it can help us build a much more complete treatment plan. Alcohol matters, smoking matters, and certain medications matter. Alcohol can affect the muscles involved in breathing, and opioids are particularly important because they interfere with the brain's control of breathing, and they can also contribute to sleep disordered breathing. So if your apnea gets dramatically worse after drinking, or you started a medication and suddenly your sleep has changed, that's information your doctor needs to know.

Dr. Mark Hyman
Now let's

Dr. Mark Hyman
say

Dr. Mark Hyman
you're listening to this and thinking, oh no, this sounds like me. Don't diagnose yourself from a podcast and don't diagnose yourself from your smartwatch either. Your wearable may give you clues, maybe it shows changes in auction, maybe your partner records you while you're storing,

Dr. Mark Hyman
maybe your sleep looks incredibly fragmented.

Dr. Mark Hyman
Those can be reasons to investigate. But if we actually want to know whether you have sleep apnea, you need proper testing. And that may mean a home sleep apnea test or depending on symptoms and medical history, it may mean spending the night in a sleep lab where they can monitor your breathing, oxygen, your heart activity, your sleep stages and other measurements. Now a sleep study is part of how clinicians diagnose sleep apnea. And here's something else I want you to remember.

How you feel isn't always a reliable measure of severity. Some people with significant apnea don't realize how impaired their sleep has become. So if the warning signs are there, test, don't guess. Okay, so now we get to the question everybody asks, if I have sleep apnea, do I really need to sleep with that machine? CPAP stands for continuous positive airway pressure, that's the machine.

A CPAP machine. The CPAP machine essentially creates enough air pressure to keep your airway open while you sleep. And for people with obstructive sleep apnea, CPAP therapy can be incredibly helpful. The American Academy of Sleep Medicine recommends positive airway pressure or PAP therapy for adults with obstructive sleep apnea and excessive sleepiness, and it supports CPAP or auto adjusting PAP for ongoing treatment. But people often just

Dr. Mark Hyman
say, isn't CPAP just

Dr. Mark Hyman
a band aid? Shouldn't I fix the root cause? Well, here's how I think about that. Imagine your house is on fire. You don't tell the firefighters, well, don't use a fire extinguisher until we figure out what caused the fire.

You put up the fire. Then you investigate why it started. And CPAP can protect your breathing tonight and your health. And at the same time, we can ask why do you have apnea? Is it excess weight?

If that's contributing, is it anatomy that your throat is maybe shaped a certain way? Are you drinking alcohol before bed? Do you have significant nasal obstruction? Is there another medical issue we need to address? Those aren't competing approaches.

Dr. Mark Hyman
You can

Dr. Mark Hyman
keep your airway open and work on the factors contributing to the problem at the same time. Now let's be honest, some people love CPAP because they finally understand what good sleep feels like. Other people can't stand it, the mask leaks, their mouth gets dry, their nose gets stuffy, they feel claustrophobic, they rip it off halfway through the night. If that's you, don't just decide, CPAP doesn't work for me, so I guess I'm not treating my sleep apnea. First, troubleshoot it.

Different masks fit differently. If a full face mask feel claustrophobic, a nasal mask or nasal pillows may be more comfortable for some people. If you're waking up with a dry mouth or a nose or throat, heated humidification can make a big difference. Many CPAP machines have a built in humidifier that adds moisture to the air you're breathing. A heated tube can also help moisture from condensing in the mask and tubing.

Pressure settings matter too. So if it feels like you're fighting against the machine every night, talk to your sleep doctor and your sleep specialist. Sometimes adjusting the pressure or using a machine that automatically adjusts pressure throughout the night can really improve comfort. The point is sometimes the problem isn't the CPAP itself, it's the setup. A better fitting mask, more humidity, clear nasal passages, or adjusted pressure can completely change the experience.

And if CPAP truly isn't workable after you tried to optimize it, there may be other options depending on your anatomy and the severity of your apnea. Now a custom mandibular advancement device moves the lower jaw forward to help keep the airway open and clinical guidelines support oral appliances for adults with objective sleep apnea who can't tolerate CPAP or who may prefer an alternative. Although CPAP generally reduces the apnea hypopnea index or AHI, improves oxygenation more effectively than the bite or mouth guard does.

Dr. Mark Hyman
Now some people's apnea becomes significantly worse when they're lying on

Dr. Mark Hyman
their back. And for selected patients, side sleeping can help. There are exercises designed to strengthen and reposition the tongue and muscles of the mouth and upper airway. Now these can be part of treatment for selected patients. And if the anatomy is a major driver, there are procedures that can address tonsils, jaw position, airway tissue, or other structural problems.

So surgery sometimes can be an answer. And there are also implanted devices that stimulate the nerve controlling the tongue to help maintain an open airway in appropriately selected patients. The point is CPAP isn't the only tool, but neither should we abandon a proven therapy because we'd rather believe there's one simple root cause. The right treatment depends on your airway, your physiology, your severity, your health. Now there's another piece of the airway conversation that I think gets overlooked.

Can you actually breathe through your nose? If you go to bed every night congested, breathing through your mouth, or feeling like one side of your nose is always blocked, I don't want to just accept that as normal. I want to understand why you're congested. Is it seasonal allergies? Is it dust mites or pet dander in your bedroom?

Chronic sinus inflammation? Maybe it's a deviated septum, nasal polyps, enlarged turbinates, or something else. Because if you have sleep apnea and chronic nasal congestion, addressing the congestion may make the nighttime breathing easier and it can also make CPAP much more comfortable and easier to stick with. Now clinical guidelines specifically recommend evaluating people with obstructive sleep apnea and nasal congestion for allergic or non allergic rhinitis. Start with your environment.

If your allergies are part of the problem, think about what you're breathing for eight hours every night. Dust, mold, pet dander, pollen. Keeping your bedroom clean, regularly washing the bedding, addressing known allergens, all that can be part of the strategy. Also, saline nasal rinses can help clear mucus and allergens from the nasal passages. And depending on what's causing your congestion, your doctor may recommend an antihistamine or a nasal corticosteroid or a dietary change for food sensitivities.

If you've done all that and you still can't breathe through your nose, get your anatomy checked. Sometimes the problem isn't inflammation, it's structural. And that's where an ENT evaluation can be helpful. That's where I take a personalized approach. In some people, certain foods, particularly dairy, make them feel more congested.

Now the research on dairy mucus is mixed, we don't have good evidence that dairy universally causes your body to produce more mucus, but I can tell you it's true for many people and especially it's true for me. I know that for sure every time. But if you consistently notice that you are more congested after eating a particular food, that's information that you should pay attention to. You can remove that food for a short period, see whether you improve, and then you can reintroduce it. The goal is to identify your individual triggers if you have them.

This is where things get helpful. Can sleep apnea improve? Absolutely. Can I promise everyone they can reverse it? Sorry, no.

If excess weight is a major driver, meaningful weight loss can improve apnea severity. Regular physical activity and exercise and maintaining a healthy weight are part of a standard sleep apnea management program. Limiting alcohol can help. Stopping smoking matters. For some people, changing sleep position helps.

Treating airway or anatomical problems can also help selected patients. This is really where I think functional medicine framework is so useful. Don't ask what device treats the apnea, ask what are modifiable factors in this particular person? Metabolic health, body composition, alcohol, smoking, nasal congestion, anatomy, medication, sleep position. And then work systematically through the things that can actually change.

But here's the really important part. Don't stop your treatment because you think you've fixed it. You might lose 50 pounds. You might stop drinking. You might have surgery.

You might feel fantastic. That's great. But feeling better doesn't prove that your apnea is gone. Get retested. Let the objective data tell you whether the disease actually improved enough to change treatment or not.

Alright. Let's finish with a quick fire round of common sleep apnea myths. I don't snore, so I can't have sleep apnea. False. Snoring is an important clue, but symptoms vary and women in particular may present with fatigue, headaches, or insomnia.

I'm thin, so I can't have it. False. Obesity is a major risk factor, but it isn't the only one. Anatomy, age, genetics, medical conditions, and other factors matter. My smartwatch says my oxygen is fine, so I'm good.

Not necessarily. A wearable can give you useful information, but it isn't a substitute for appropriate diagnostic testing. If I lose weight, my apnea will disappear. Maybe. Weight loss can meaningfully improve sleep apnea when obesity is contributing.

But anatomy and other drivers also are real. If I feel

Dr. Mark Hyman
fine, my apnea can't be serious,

Dr. Mark Hyman
also false. Apnea is often under recognized including among people with cardiovascular disease. Can I just use mouth tape instead? I wouldn't treat suspected sleep apnea with mouth tape. If your airway is repeatedly obstructing your sleep, you need to understand why and get it properly evaluated rather than trying to solve it yourself with a social media sleep hack.

So if there's one thing I want you to take away from this episode, it's this. Don't normalize waking up exhausted. Don't normalize loud snoring. Don't normalize your partner telling you that you stop breathing at night. And don't normalize morning headaches, constant brain fog, or needing three cups of coffee just to feel human.

And don't assume because you're thin, fit, or sleeping eight hours that sleep apnea couldn't be affecting you. Because sleep isn't just about how many hours you're in bed, it's about what your body is able to do during those hours. And one of the most fundamental things your body needs to do is breathe. If something we talked about today sounds familiar well, talk to your doctor or sleep specialist, get properly tested. Now there's home tests you can do that are quite easy.

If you already have sleep apnea, don't think about treatment as a choice between CPAP or addressing your health. Do both. Remember, you're the sea of your own health. Protect your airway tonight. And then ask what you can change to improve your health for the long term.

Dr. Mark Hyman
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