Sunday, May 22, 2016

Sleep, Diabetes and Obesity

Sleep is a naturally recurring state characterized by reduced or absent consciousness, relatively suspended sensory activity, and inactivity of nearly all voluntary muscles. It is distinguished from quiet wakefulness by a decreased ability to react to stimuli, and is more easily reversible than being in hibernation or a coma. Sleep is a heightened anabolic state, accentuating the growth and rejuvenation of the immune, nervous, skeletal and muscular systems. 

Sleep and DiabetesAccording to the Centers for Disease Control and Prevention, 35 percent of Americans report getting less than the recommended seven to nine hours of sleep each night. This rampant deprivation has consequences, and not just grogginess: People who don’t get enough sleep are prone to a slew of health problems, including Type 2 diabetes. 

Americans used to sleep more. Between 1959 and 2002, the percentage of people sleeping fewer than seven hours a night on a regular basis more than doubled. Meanwhile, the number of people with type 2 diabetes has soared. Could there be a connection? At the very least there’s an association between lack of sleep and diabetes. 

The first real clue that sleep deprivation could lead to type 2 diabetes came from a 1999 study published in The Lancet. Healthy young people without any hint of diabetes came to live in a lab for a week. Their sleep was restricted to just four hours for six nights in a row. By the end of the experiment, their bodies’ ability to use glucose had radically shifted. “After a week of short sleep, their glucose metabolism looked like that of old men,” says Kristen Knutson, PhD, an assistant professor of medicine at the University of Chicago who studies the role of sleep in disease. “For a long time, people thought sleep was for the brain and only for the brain. This study showed that it was for the body, too.”

Since this landmark study, similar experiments have been conducted to explore the relationship between sleep and diabetes in more detail. A 2008 study in the Proceedings of the National Academy of Sciences sought to uncover the influence of deep sleep on the risk for diabetes. During sleep, the body cycles between rapid eye movement (REM) sleep and four stages of non-REM sleep, the deepest of which is called slow-wave sleep. While volunteers in the study got a normal amount of total and REM sleep, the researchers restricted their slow-wave time. The result? Metabolic changes that increase the risk of diabetes. According to Knutson, this study showed that “it’s not just how much sleep that matters, but you need good-quality sleep.”

Evidence that sleep and diabetes are connected has been established by assessing the health and sleep habits of groups of people. A 2010 study in Diabetes Care found that people with sleep problems—difficulty falling or staying asleep, sleeping fewer than five to six hours a night or more than eight to nine hours—are more likely to develop type 2 diabetes than sound sleepers.

Sleep may also affect blood glucose levels in people with diabetes. A 2006 study in the Archives of Internal Medicine found that those who report poor sleep quality have higher A1Cs. This finding is of concern because of the prevalence of obstructive sleep apnea (OSA) in people with diabetes.

OSA affects 2 out of 3 people with type 2 diabetes. It causes people to stop breathing repeatedly while sleeping because of an obstruction in the airway. This reduces how much sleep a person gets and disrupts the sleep cycle. OSA has been associated with high blood pressure. While OSA may lead to diabetes simply because of sleep deprivation, the person with sleep apnea is also deprived of oxygen, which adds a complicating factor. Another confounding factor for scientists trying to understand the sleep-diabetes connection is obesity, which increases risk for both type 2 diabetes and OSA.

Sleep and ObesityWhat is the relationship between sleep deprivation and obesity? More than one-third of American adults are now obese. This epidemic has been worsening over the past several decades. There are a number of contributing factors, including: excessive caloric intake, decreased physical activity, the interaction between genes and environment, and cultural influences. Over this same period of time, Americans have been sleeping less, and some researchers have begun investigating whether sleep deprivation might contribute to obesity.

We sleep as much as one-quarter less than our ancestors did, with average total sleep time decreasing from 9 hours in 1900 to less than 7 hours over the past 10 years. In 2001, researchers found that sleeping less than 6 hours per night and remaining awake past midnight increased the likelihood of obesity. In 2002, a study of 1.1 million people found that increasing body mass index (BMI) occurred when habitual sleep amounts fell below 7 to 8 hours.

A study done in Virginia in 2005 showed that overweight and obese individuals slept less than subjects of normal weight. Another study in Wisconsin in 2004 showed that when sleeping less than 8 hours, the increase in BMI was proportional to the amount of decreased sleep.

Since 1992, 13 studies of more than 45,000 children have supported the inverse relationship between hours of sleep and risk of obesity. As children sleep less, they are more at risk of becoming obese. In an interesting 2005 study, Reilly reported in the British Medical Journal that short sleep duration at age 30 months predicts obesity at age 7 years, suggesting that poor sleep may have a permanent impact on part of the brain called the hypothalamus that regulates both appetite and energy expenditure.

Laboratory studies tend to support the data from all these population studies. As early as 1999, Spiegel examined sleep restriction and the effect on metabolism by sleep restricting subjects to 4 hours per night for one week. This led to impaired glucose tolerance (a marker of insulin resistance and diabetes) and changes in hormones related to weight gain and hypertension. The changes were reversible with normal sleep times.

In 2004, Spiegel examined the effect of sleep restriction on hormones related to hunger and appetite. It was found that sleep restriction reduced the hormone leptin, which suppresses appetite, by 18%. It also increased the hormone ghrelin, which increases appetite, by 28%. For comparison, 3 days of underfeeding by 900 calories per day causes leptin to decrease by 22%. Moreover, subjects showed subjectively increased appetite for calorie-dense foods with high carbohydrate content.

Consequently, disruption of the body’s natural clock, called the circadian rhythm, through sleep deprivation, appears to affect metabolic hormones that regulate appetite. 

The good news is that you can improve the quality of your sleep by making one or two small changes (see below for more information).

Insomnia
Insomnia is the inability to sleep when sleep should normally occur. Sufficient and restful sleep is a human necessity. The average adult needs slightly more than 8 hours of sleep a day, but only 35% of American adults consistently get this amount of rest.

People with insomnia tend to experience one or more of the following sleep disturbances:
-- Difficulty falling asleep at night
-- Waking too early in the morning
-- Waking frequently throughout the night

Insomnia may stem from a disruption of the body's circadian rhythm, an internal clock that governs the timing of hormone production, sleep, body temperature, and other functions. 

While occasional restless nights are normal, prolonged insomnia can interfere with daytime function, concentration, and memory. Insomnia increases the risk of substance abuse, motor vehicle accidents, headaches, and depression. 

Recent surveys indicate that 50% of people suffer from sleep difficulties, and 20 - 36% of them struggle with such difficulties for at least 1 year. Other studies show that one person out of three in the United States has insomnia, but only 20% tell their health care providers about it.

Rest, Relaxation and Sleeping Tips 
Learning how to rest and relax during the day will help to prevent yourself from becoming over-stressed or exhausted. Being able to relax will actually help to control your blood sugar level. The following is a list of ways to help improve your rest and relaxation.
  • Use deep breathing techniques, e.g. learn to breathe to slow down your heart rate by breathing in deeply, counting to 7 and breathing out, counting to 10; keep doing this until your heart rate slows down.
  • Take a walk after dinner or during the day. If you live near a mall, walk around the mall with a friend a 3-4 times a week.
  • Use guided imagery to focus on pleasant images to take your mind away from pain and focus it on something more pleasant. If necessary, obtain an imagery video tape.
  • Prayer is very relaxing and comforting for some people. You may want to make a tape recording of a soothing inspirational message.
  • Use prayer to talk to God, use meditation to listen to God.
  • Take a meditation, yoga or T’ai Chi class. They are two excellent ways to establish harmony between the Body, Mind and Spirit, get the physical activity you need, learn to relax, and prepare the Body and Mind to better handle the stress of daily life.
Sleep is even more important than rest and relaxation. The purpose of sleep is to allow the body to repair and rejuvenate itself. Sleep also reduces fatigue and stress.  Being able to get a good night's sleep on a consistent basis will help to control your blood sugar level. Healthy sleep habits are essential for treating insomnia. 

Lifestyle changes that can improve the quality of your sleep and improve or eliminate insomnia include, but are not limited to, the following:
  • Establish a consistent a regular daily routine and bedtime ritual, e.g. the same meal times, the same bedtime, the same pre-bed activities.
  • Establish the bedroom as a place for sleep and sexual activity only, not for reading, watching television, or working.
  • Keep your bedroom cool and well ventilated. Maintain a relaxing atmosphere in the bedroom.
  • Do not eat (especially processed grain and sugar carbohydrates) less than 2 hours before going to bed.
  • Reduce your caffeine intake and avoid it altogether four to six hours before bedtime. Reduce your intake of alcohol, tobacco, and other stimulants especially in the evenings.
  • Drink a glass of warm (raw) milk or a cup of chamomile or fennel tea to soothe your nervous system 15-20 minutes before going to bed.
  • Ensure you have a quality firm bed that properly supports your body’s frame and a quality pillow to properly support your neck.
  • Try to sleep in complete darkness or as close as possible. When light hits the eyes, it disrupts the circadian rhythm of the pineal gland and the production of melatonin and serotonin.
  • Sleep on your back – it’s the best position for relaxing, and allows all your internal organs to rest properly.
  • Try to avoid watching too much TV just before going to bed. TV is too stimulating to the brain.
  • Listen to calm music, or read something spiritual or religious to help to relax. Do not read anything stimulating, such as a mystery or suspense novel.
  • If possible, avoid using a loud alarm clock, which can be very stressful on the body when it is awoken suddenly. If you are getting enough sleep, an alarm clock should be unnecessary.
Nutritional Tips
Here are some nutritional tips that may help with sleeping better and preventing insomnia:
  • Eliminate all potential food allergens, including dairy, wheat (gluten), soy, corn, preservatives, and food additives. Your health care provider may want to test for food sensitivities.
  • Eat more antioxidant rich foods (such as green leafy vegetables) and fruits (such as blueberries, pomegranates, and cherries).
  • Avoid refined foods, such as white breads, pastas, and sugar.
  • Eat fewer red meats and more lean meats, cold-water fish, or beans for protein.
  • Use healthy cooking oils, such as olive oil.
  • Reduce or eliminate trans-fatty acids, found in commercially baked goods such as cookies, crackers, cakes, French fries, onion rings, donuts, processed foods, and margarine.
  • Avoid coffee and other stimulants, alcohol, and tobacco.
  • Drink 6 - 8 glasses of filtered water daily.
  • Exercise 30 minutes daily, 5 days a week. Exercising in the evening after dinner may lead to insomnia.
  • Foods rich in carbohydrates and low in protein and fat may boost the production of serotonin and melatonin, brain chemicals that are associated with sleep. A carbohydrate snack of granola, non-sweetened cereals, or crackers with milk before bed may help.
The following dietary supplements may also be helpful in promoting sleep:
  • A multivitamin daily, containing the antioxidant vitamins A, C, E, the B-complex vitamins, and trace minerals such as magnesium, calcium, zinc, and selenium.
  • Omega-3 fatty acids, such as fish oil, 1 - 2 capsules or 1 tbsp. oil one to three times daily, to help decrease inflammation and help with mental balance.
  • Coenzyme Q10, 100 - 200 mg at bedtime, for antioxidant, immune, and muscular support.
  • 5-hydroxytryptophan (5-HTP), 50 mg two to three times daily, for mood stabilization and sleep improvement.
  • L-theanine, 200 mg one to three times daily, for nervous system support.
  • Melatonin, 1 - 6 mg one hour before bedtime, for sleep and immune protection. Ask your health care provider about potential prescription interactions.
  • Kava (Piper methysticum) standardized extract, 100 - 250 mg one to three times daily, as needed for relaxation. Kava should not be used in those with liver problems or those drinking alcohol in excessive quantities.
  • Rhodiola (Rhodiola rosea ) standardized extract, 100 - 600 mg daily, for antioxidant and antistress activity.
  • Valerian (Valeriana sp.) standardized extract, 200 - 400 mg at bedtime, for sleep.
  • Chamomile (Anthemis nobilis), standardized extract, 400 - 1,600 mg daily, for relaxation. A tea may be prepared from chamomile flowers. Chamomile is not recommended for individuals allergic to flowers in the daisy family.
Note: For more information about sleep, reducing stress and the importance of spirituality, get the Death to Diabetes book or the Stress Reduction and Inner Spiritebook.

Sleep Apnea
Sleep apnea is a common disorder in which you have one or more pauses in breathing or shallow breaths while you sleep.
Breathing pauses can last from a few seconds to minutes. They often occur 5 to 30 timesor more an hour. Typically, normal breathing then starts again, sometimes with a loud snort or choking sound.
Sleep apnea usually is a chronic (ongoing) condition that disrupts your sleep. You often move out of deep sleep and into light sleep when your breathing pauses or becomes shallow.
This results in poor sleep quality that makes you tired during the day. Sleep apnea is one of the leading causes of excessive daytime sleepiness.
The most common type of sleep apnea is obstructive sleep apnea. This most often means that the airway has collapsed or is blocked during sleep. The blockage may cause shallow breathing or breathing pauses.
When you try to breathe, any air that squeezes past the blockage can cause loud snoring. Obstructive sleep apnea is more common in people who are overweight, but it can affect anyone. For example, small children may have enlarged tonsil tissues in their throats, which can lead to obstructive sleep apnea.
Central sleep apnea is a less common type of sleep apnea. This disorder happens if the area of your brain that controls your breathing doesn't send the correct signals to your breathing muscles. As a result, you'll make no effort to breathe for brief periods.
Central sleep apnea is more common in people who have certain medical conditions or use certain medicines.
Central sleep apnea often occurs with obstructive sleep apnea, but it can occur alone. Snoring doesn't typically happen with central sleep apnea.
Please Note: Sleep apnea is a chronic condition that requires long-term management. Lifestyle changes, mouthpieces, surgery, and/or breathing devices can successfully treat sleep apnea in many people.

There are a variety of sleep apnea treatments that you can try before going the route of a CPAP machine, surgery, implants or appliances:
  1. Lose some weight. People with a BMI of >30 are at a higher risk of OSA. Sometimes losing just a bit of weight is enough to reduce the obstruction to it’s not impeding your breathing.
  2. Don’t use muscle relaxants – so check your medication (it could be part of it and you don’t even know). This could cause the obstruction to “relax” and fall back into your airway. If you take a sleeping pill – make sure it doesn’t do this as well.
  3. No alcohol – it relaxes your muscles. So if you drink, make sure it’s out of your system before you lie down to sleep.
  4. Sleep partially sitting up. Researchers find that a sleeping angle of about 30 degrees can prevent an obstruction from blocking airways.
  5. Sleep on your side versus your back. Sewing a tennis ball into your night shirt or pajamas is a common way of dealing with this – it prevents you from rolling on your back.
  6. Quit Smoking. This has so many health ramifications, are you surprised it’s here too? Don’t be. Smoking affects respiration.
  7. This last one, as strange as it sounds, has been proven to work for many. Practice the didgerido! It’s thought that it strengthens the mouth and throat muscles so much that the OSA doesn’t present itself at night.
  8. Same with some selected mouth and tongue exercises – strengthening these muscles helps!
However, first, confirm with your doctor that you actually have sleep apnea – this will involve some kind of sleep study along with some discussion of your next day fatigue. Next, try the steps listed above – some of them can be lifestyle changing (losing weight, no alcohol, quit smoking, taking up the didgeridoo) but if they work, you might just live longer.
If these tips don’t work, or if your sleep apnea is pretty serious, consider some of the longer term strategies seriously – surgery, implants or appliances. They may involve more discomfort (and expense) up front, but the long term results from them is much better.
Remember that this is a very serious condition – people die from it. So take whatever steps you need to resolve it.

Note: Read Death to Diabetes Chapter 13 for tips on how to get more than 4-6 hours of sleep; and, eat melatonin-rich foods as a snack before bedtime.

References:
  1. ^ Bingham, Roger; Terrence Sejnowski, Jerry Siegel, Mark Eric Dyken, Charles Czeisler, Paul Shaw, Ralph Greenspan, Satchin Panda, Philip Low, Robert Stickgold, Sara Mednick, Allan Pack, Luis de Lecea, David Dinges, Dan Kripke, Giulio Tononi (February 2007). "Waking Up To Sleep" (Several conference videos). The Science Network. Retrieved 2008-01-25.
  2. ^ a b "Sleep Syllabus. B. The Phylogeny of Sleep". Sleep Research Society, Education Committee. Retrieved 2010-09-26.
  3. ^ a b "Function of Sleep.". Scribd.com. Retrieved on 2011-12-01.
  4. ^ a b Daan S, Barnes BM, Strijkstra AM (1991). "Warming up for sleep? Ground squirrels sleep during arousals from hibernation". Neurosci. Lett. 128 (2): 265–8.doi:10.1016/0304-3940(91)90276-Y. PMID 1945046.
  5. ^ Marshall et al., 2006, as cited in Walker, M.P. (2009). "The Role of Sleep in Cognition and Emotion". Annals of the New York Academy of Sciences 1156: 174.
  6. ^ Saper, Clifford B.; Scammell, Thomas E.; Lu, Jun (2005). "Hypothalamic regulation of sleep and circadian rhythms". Nature 437 (7063): 1257–63.doi:10.1038/nature04284. PMID 16251950.
  7. ^ Stickgold, Robert (2005). "Sleep-dependent memory consolidation". Nature 437(7063): 1272–8. doi:10.1038/nature04286. PMID 16251952.
  8. ^ New Theory Questions Why We Sleep by Charles Q. Choi, LiveScience.com, Aug 25, 2009.
  9. ^ Connor, Steve (2009-04-03). "Revealed: why we need a good night's sleep". The Independent. Retrieved 2010-12-02.
  10. ^ Hobson, J.A.; McCarley, R. (1977). "The brain as a dream state generator: An activation-synthesis hypothesis of the dream process". American Journal of Psychiatry 134 (12): 1335–1348. PMID 21570.
  11. ^ a b Taheri S, Lin L, Austin D, Young T, Mignot E (December 2004). "Short Sleep Duration Is Associated with Reduced Leptin, Elevated Ghrelin, and Increased Body Mass Index". PLoS Med. 1 (3): e62. doi:10.1371/journal.pmed.0010062.PMC 535701. PMID 15602591.
  12. ^ a b c d e Alhola, Paula; Päivi Polo-Kantola (October 2007). "Sleep deprivation: Impact on cognitive performance". Neuropsychiatr Dis Treat (Dove Medical Press) 3(5): 553–567. PMC 2656292. PMID 19300585. "Although both conditions [total and partial SD] induce several negative effects including impairments in cognitive performance, the underlying mechanisms seem to be somewhat different."
  13. ^ Kushida, Clete Anthony (2005). Sleep deprivation. Informa Health Care. pp. 1–2.ISBN 0-8247-5949-4.
  14. ^ Vioque J, Torres A, Quiles J (December 2000). "Time spent watching television, sleep duration and obesity in adults living in Valencia, Spain". Int. J. Obes. Relat. Metab. Disord. 24 (12): 1683–8. doi:10.1038/sj.ijo.0801434. PMID 11126224.
  15. Stevinson C, Ernst E. Valerian for insomnia: a systematic review of randomized clinical trials. Sleep Med. 2000 Apr 1;1(2):91-99.
  16. Attele AS, Xie JT, Yuan CS. Treatment of insomnia: an alternative approach.Altern Med Rev. 2000;5(3):249-259.
  17. Friedman L, Bliwise DL, Yesavage JA, Salom SR. A preliminary study comparing sleep restriction and relaxation treatments for insomnia in older adults. J Gerontol. 1991 Jan;46(1):1-8.
  18. Nicassio PM, Boylan MB, McCabe TG. Progressive relaxation, EMG biofeedback and biofeedback placebo in the treatment of sleep-onset insomnia. Br J Med Psychol. 1982 Jun;55(Pt 2):159-66.
  19. ^ "Sleep Apnea: What Is Sleep Apnea?". NHLBI: Health Information for the Public. U.S. Department of Health and Human Services. 2009-05. Retrieved 2010-08-05.
  20. ^ Morgenthaler TI, Kagramanov V, Hanak V, Decker PA (September 2006)."Complex sleep apnea syndrome: is it a unique clinical syndrome?". Sleep 29 (9): 1203–9. PMID 17040008. Lay summary – Science Daily (September 4, 2006).
  21. ^ "Sleep Apnea".
  22. ^ "Sleep Apnea: Key Points". NHLBI: Health Information for the Public. U.S. Department of Health and Human Services.
  23. ^ a b c d e f g h El-Ad, Baruch; Lavie, Peretz (2005). "Effect of sleep apnea on cognition and mood". International Review of Psychiatry 17 (4): 577–582.DOI:10.1080/09540260500104508.
  24. ^ a b Aloia, M.S.; Sweet, L.H.; Jerskey, B.A.; Zimmerman, M.; Arnedt, T.J.; Millman, R.P. (2009). "Treatment effects on brain activity during a working memory task in obstructive sleep apnea". Journal of Sleep Research (Wiley-Blackwell) 18 (4): 404–410. DOI:10.1111/j.1365-2869.2009.00755.x. Retrieved 17 February 2012.
  25. ^ Sculthorpe LD, Douglass AB (July 2010). "Sleep pathologies in depression and the clinical utility of polysomnography". Can J Psychiatry 55 (7): 413–21.PMID 20704768.
  26. ^ Redline S, Budhiraja R, Kapur V et al. (2007). "Reliability and validity of respiratory event measurement and scoring". J Clin Sleep Med 3 (2): 169–200.PMID 17557426.
  27. ^ AASM Task Force (1999). "Sleep–Related Breathing Disorders in Adults-Recommendations for Syndrome Definition and Measurement Techniques in Clinical Research". SLEEP 22 (5): 667–689. PMID 10450601.
  28. ^ Ruehland WR, Rochford PD, O'Donoghue FJ, Pierce RJ, Singh P, Thornton AT (2009). "The new aasm criteria for scoring hypopneas: Impact on the apnea hypopnea index". SLEEP 32 (2): 150–157. PMC 2635578. PMID 19238801.
  29. ^ Sériès, F.; Marc, I.; Cormier, Y.; La Forge, J. (1993). "Utility of nocturnal home oximetry for case finding in patients with suspected sleep apnea hypopnea syndrome". Annals of internal medicine 119 (6): 449–453. PMID 8357109. edit
  30. ^ Whitelaw WA, Brant RF, Flemons WW (2005). "Clinical usefulness of home oximetry compared with polysomnography for assessment of sleep apnea.". Am J Respir Crit Care Med 171 (2): 188–93. DOI:10.1164/rccm.200310-1360OC.PMID 15486338. Review in: ACP J Club. 2005 Jul-Aug;143(1):21
  31. ^ "Sleep Apnea: Who Is At Risk for Sleep Apnea?". NHLBI: Health Information for the Public. U.S. Department of Health and Human Services.
  32. ^ Neill AM, Angus SM, Sajkov D, McEvoy RD (January 1997). "Effects of sleep posture on upper airway stability in patients with obstructive sleep apnea". American Journal of Respiratory and Critical Care Medicine 155 (1): 199–204. PMID 9001312.
  33. ^ Xiheng, Guo; Chen, Wang; Hongyu, Zhang; Weimin, Kong; Li, An; Li, Liu; Xinzhi, Weng (2003). The Study Of The Influence Of Sleep Position On Sleep Apnea. Cardinal Health.[dead link]
  34. ^ Loord H, Hultcrantz E (August 2007). "Positioner--a method for preventing sleep apnea". Acta Oto-laryngologica 127 (8): 861–8. DOI:10.1080/00016480601089390.PMID 17762999.
  35. ^ a b Szollosi I, Roebuck T, Thompson B, Naughton MT (August 2006). "Lateral sleeping position reduces severity of central sleep apnea / Cheyne-Stokes respiration". Sleep 29 (8): 1045–51. PMID 16944673.
  36. ^ Vennelle M, White S, Riha RL, Mackay TW, Engleman HM, Douglas NJ (February 2010). "Randomized controlled trial of variable-pressure versus fixed-pressure continuous positive airway pressure (CPAP) treatment for patients with obstructive sleep apnea/hypopnea syndrome (OSAHS)". Sleep 33 (2): 267–71. PMC 2817914.PMID 20175411.
  37. ^ Morris LG, Kleinberger A, Lee KC, Liberatore LA, Burschtin O (November 2008). "Rapid risk stratification for obstructive sleep apnea, based on snoring severity and body mass index". Otolaryngology--Head and Neck Surgery 139 (5): 615–8.DOI:10.1016/j.otohns.2008.08.026. PMID 18984252.
  38. ^ Yan-fang S, Yu-ping W (August 2009). "Sleep-disordered breathing: impact on functional outcome of ischemic stroke patients". Sleep Medicine 10 (7): 717–9.DOI:10.1016/j.sleep.2008.08.006. PMID 19168390
  39. ^ Young T, Peppard PE, Gottlieb DJ (May 2002). "Epidemiology of obstructive sleep apnea: a population health perspective". American Journal of Respiratory and Critical Care Medicine 165 (9): 1217–39. DOI:10.1164/rccm.2109080. PMID 11991871.
  40. ^ Kapur V, Blough DK, Sandblom RE, et al. (September 1999). "The medical cost of undiagnosed sleep apnea". Sleep 22 (6): 749–55. PMID 10505820.
  41. ^ torontosun.com - Study links sleep apnea with higher cancer deaths, 2012-05-20
  42. ^ Nieto FJ, Peppard PE, Young T, Finn L, Hla KM, Farré R (May 2012). "Sleep disordered breathing and cancer mortality: results from the Wisconsin Sleep Cohort Study". Am J Respir Crit Care Med. DOI:10.1164/rccm.201201-0130OC.PMID 22610391.
  43. ^ "Sleep apnea ups cancer death risk five-fold". Retrieved 27 May 2012.
  44. ^ Sullivan CE, Issa FG, Berthon-Jones M, Eves L. (April 1981). "Reversal of obstructive sleep apnoea by continuous positive airway pressure applied through the nares". Lancet 1 (8225): 862–5. DOI:10.1016/S0140-6736(81)92140-1.PMID 6112294
Posted by at

No comments:

Post a Comment

Subscribe to: Post Comments (Atom)