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Introduction to Dr. Steven Park [1:09]

Matt Feret:

Hello everyone. This is Matt Feret, author of Prepare for Medicare and Prepare for Social Security Insider's, guidebooks, and online course training series. Welcome to another episode of The Matt Feret Show, where I interview insiders and experts to help light a path to successful living in midlife retirement and beyond. Steve, welcome to the show.

Dr. Steven Park:

Thanks for having me, Matt.

Matt Feret:

I'm glad you're here. So, tell everybody what you do, how long you've been doing it, and how you help people.

Dr. Steven Park:

Okay. Well, I'm an ENT surgeon or an otolaryngologist, that's the long-term. I'm also a sleep medicine doctor. I've been doing this for over 20 years, and my passion and mission is to help people breathe better, and that's basically my field in ENT to help people breathe better. And then if you can breathe better, then you can sleep better. And as a result of that, you have a much more fulfilling and healthier life.

Matt Feret:

That's a very unique calling, but also a very helpful one. So, give me a sense of how many people have problems with breathing and structural problems with breathing in, I don't know. In a population in the United States, are we talking 1%, 10% here? How many people?

Dr. Steven Park:

Well, I can argue that 100% have at least some degree of breathing, at least one point in their lives. For example, if you have a pollen allergy attack, right? But what I deal with most is on the spectrum of breathing disorders, way up here is something called sleep apnea, the work incident a little bit later, but my focus is actually what happens here before you get into sleep apnea. And so, my basic premise, which I rather about in my book Sleep, Interrupted, is that most modern humans have crowding of the airways because their jaws are getting smaller and smaller. This is why everyone needs braces. Now, have you noticed these younger people these days have these triangular faces, these long narrow, tall faces?

Matt Feret:

No, I haven't, but now I'm going to start looking now.

Dr. Steven Park:

But if you look at these pictures from 1930s or forties, even in the seventies, people had much wider jaws and faces. And even a hundred years ago, people didn't need their wisdom teeth taken out because they had that much more space. So, there's a lot of different reasons why this is happening, but as a result of that, our airways are getting smaller and smaller, and so it more difficult for us to breathe at night and also affects your nasal cavity too. So that's the basic premise of my concept that I write about in my book. But this can lead to just, we can talk about any health condition, but as a result of this, as you get older, obviously it's going to cause more problems breathing and sleeping, and it's going to lead to other health problems.

Matt Feret:

Okay. The historian in me, or at least the anthropologist in me, wants to go, okay, wait a minute.

Dr. Steven Park:

Great.

Matt Feret:

I'm neither. Whatever amateurism I have in even one of those categories makes me go, wait a minute, people's faces are changing over time, their heads are changing. Can you talk, how is this happening or why is this happening?

How the Modern Diet Influences Facial Structure with Dr. Steven Park [4:23]

Dr. Steven Park:

Yeah, so traditionally before we had modern processed foods, you have to physically chew and rip, grind and cut. And basically, with modern technology, our food got softer and softer. So, we had processed foods and the meats got cut up and made us softer for us to eat and easier to eat. But in the old days, we really had to work to eat. You had to chew a lot, and we didn't have modern technology to cook all our foods really soft and tender. And so, when we moved away from eating lots of plants and vegetables and roots and meats and whatever to really work our jaws to soft processed foods with no nutritional value, with other also added sugar and all the other toxic chemicals, as a result of that, we're just not working your jaws. And if you don't work your jaws, your face doesn't grow.

Matt Feret:

Never thought of it that way. So, are we talking an evolutionary trait that's quickly happening or are we just talking about muscle and then bone composition?

Dr. Steven Park:

Actually, in the past a hundred years or so, actually there was an interesting book by B. Wilson, it's called Consider the Fork, and it's a really fascinating book. She actually looked at modern cooking technology over the centuries, and this one chapter about, I think this anthropologist studied ancient skulls in England and China around the time that they developed cutlery. So, they metal technology to create knives that were much cheaper to make and much easier to make, but only the rich people had access to knives. And so, once they started using knives to cut their meats, they started to get dental crowding. And so even 200 years ago, people had what called edge bites. So, the front teeth, the bottom teeth met like this, but modern humans have their jaws, the lower jaw gets pushed forward. So, you have this overbite, so now everyone has an overbite. But what they found is that rich people had the over overbite first, then the peasants had the overbite last.

Matt Feret:

I can't be the only one that's putting his teeth together listening to this. I guess I have an overbite. Doesn't every human have an overbite?

Dr. Steven Park:

Everyone does, yeah.

Matt Feret:

But when orthodontia wasn't available, it was just you got the teeth that you got and that was that, right?

Dr. Steven Park:

Back then, you didn't really need orthodontics that much. For example, there's a classic book by Dr. Weston Price, he's the dentist that traveled the world in the 1920s to ‘40s, and he and his wife looked at indigenous cultures throughout all the different continents. And we found across the board was that as long as you ate naturally off the land, you had perfectly aligned teeth, no cavities, and they're healthy wild.

Matt Feret:

Okay, so we've got, you said is the word devolution. That's not devolution.

Dr. Steven Park:

Well, I made out that word devolution.

Matt Feret:

Okay, so you're saying in modern society you've got processed foods easier to chew, not hard on the jaw. So, I'm imagining on not only the muscles not being worked as they did as they were 100 plus 1000 and 10,000 years ago, but I guess is there the bone structure of the jaw is probably impacted, ha, no pun intended, for my dentist. The bone structure and the bone strength and the bone size along with the muscle, that's also impacted, I would imagine.

Dr. Steven Park:

Absolutely. And so, there's less space to breathe through, and then if you gain weight, it's going to get worse because now when you gain weight on the outside, you gain weight on the inside, it narrows the airway. But there's a couple other factors. Like I said, it's multifactorial not just about the chewing, but with modern infant feeding methods so there's less breastfeeding and more bottle feeding. So they found that an infant suckling on the mother's breast, the mechanism to swallow is very different than suckling on the bottle nipple because when you're sucking on the mother's breast, the mother's nipple conforms to the mouth of the infant, whereas with the bottle nipple, your jaws and your teeth conform to the artificial bottle, which is harder. So, bottle feeding is a risk factor for crooked teeth that's been documented in dentistry. Also, nasal congestion, if you breathe through your mouth, your face gets long. And I can also add lots of different toxins that are in the environment that prevents your face from growing properly.

Matt Feret:

This is fascinating. I've never run across this in anything that I've ever read. So, the way we're now feeding our kids is impacting their facial structure for life.

Dr. Steven Park:

Yes.

Matt Feret:

Wow. I had no idea. It makes sense. I just had never, I mean, you probably don't run into it. Maybe you're looking for it, but I've never even read anything like this before. It's amazing.

Dr. Steven Park:

But if you look at it, you're going to find it. It's been around for decades.

How Orthodontics Affect Facial Structure with Dr. Steven Park [09:43]

Matt Feret:

I'm going to go look for it now. Okay, so we've got narrower jaws and therefore crooked teeth. And then people go get their teeth fixed, especially in the United States with the orthodontia. And then wisdom teeth come in what age, 19, 20, 21, somewhere in there? And most people get them taken out. You're saying that, okay, let's say I'm 20, I've been bottle-fed, I've eaten modern food, I'm 20 years old, spitting image of health. I'm young, I'm vibrant. What happens over the next decades?

Dr. Steven Park:

Well, it depends on where you are on the spectrum. So, like I said, most modern people eventually need some or all of their wisdom teeth taken out. But in the old days, maybe even 10, 20 years ago with modern orthodontics, what they used to do is to take out an additional four by cuspids. So, you can imagine some people need eight teeth removed, four wisdom teeth, and four by cuspids, right? So, you have perfectly aligned teeth, but your mouth is tiny. And these people have major breathing problems and health problems. And these are the dentists that kind of had this revelation with these patients that they had these tiny mouths with perfect, perfectly aligned teeth, but they're really sick. The doctors couldn't help them. So, then they start to have this revelation that maybe we're doing the wrong thing. So, there's this schism in dentistry and orthodontics about can you take out teeth, or is it too aggressively, we taking out too many teeth, for example? So now the general consensus is to widen the palate in the jaws as opposed to extracting. So, if you widen the palette with palette expanders, appliances, braces, there's so many different ways of doing it. We're kind of shifting towards that philosophy as opposed to extracting.

Sleep Apnea and Facial Structure with Dr. Steven Park [11:58]

Matt Feret:

Let's go into the sleep problems that have to do with this. So, what can they be? We've all heard of sleep apnea, for example, but what else? Okay,

Dr. Steven Park:

Well, let's define sleep apnea. That is a very generic term, but the formal diagnosis is obstructive sleep apnea, meaning that when you're sleeping, you stop breathing because your throat closes off. And that typically happens, especially if you're overweight and you have the classic storing middle aged man that snores a lot. That's your typical sleep apnea patient. But we know that even young thin women that don't snore can have severe sleep apnea because if you're not snoring, you're not breathing.

Matt Feret:

Okay, so functionally what happens when one has obstructive sleep apnea? What's going on in their heads?

Dr. Steven Park:

What happens is that because your muscles start to relax when you're sleeping, especially in REM sleep, when you're dreaming, that's when your muscles relax the most, especially if you're on your back. So, if you sleep on your back in REM sleep when you're dreaming with a small mouth, then you'd be more prone to obstruction the muscles kind of cave in your throat, so you stop breathing for a couple of seconds or even up to a minute or two. So that's called an apnea. Now, on a sleep test, if you're found to have an obstruction that lasts for more than 10 seconds, and that's called an apnea, and hypopnea are just lesser versions of that, but it has to be 10 seconds or longer. So, you have to meet certain criteria, let's say five or more apnea or hypopnea per hour to say that you have mild sleep apnea. And then if you go over 20 or 30, that's severe sleep apnea and as a result you get low oxygen. So, you're struggling to breathe for 90 seconds of the time, 20, 30 times an hour. And it causes long term, it causes a lot of medical problems. So high blood pressure, diabetes, heart disease, heart attack, stroke, cancer, dementia, arthritis, digestive issues, skin problems, it's endless.

Matt Feret:

Not mention your body's not recharging, it's waking up every 90 seconds. It is basically the premise, right?

Dr. Steven Park:

Your body is in a constant state of stress.

Matt Feret:

And is it just old middle-aged men or can this happen with children with teens?

Dr. Steven Park:

Yeah. Well, if there's certain phases throughout life where it kind of peaks, so for example, children around three to five, that's when they start to get large tonsils, and that's when they start to have lots of sleep apnea. So that's why a lot of kids get their tonsils taken out. But they've done studies showing that if you apply palatal expansion to kids that need tonsillectomy, you can avoid tonsillectomy.

Matt Feret:

How do I know if I've got sleep apnea? Just if I snore?

Dr. Steven Park:

Well, that's a typical symptom, but basically, it's how well you sleep at night and how you feel or function during the daytime or if you have any other medical complications like diabetes, anxiety, heart disease, high blood pressure. Actually, one of the most common symptoms of a sleep breathing disorder is nighttime urination. People say that that's what happens when you get older. For men, prostate issues for men, a bladder issue, what happens is that every time you stop breathing, you stretch your heart because your clothes off here and you're trying to breathe in against a closed throat and you create this tremendous vacuum or negative pressure in your chest cavity, and as a result, the heart gets stretched and the heart thing is that there's too much blood coming in. So, it produces a hormone that goes through kidneys called atrial natriuretic peptide, which makes you pee more than usual throughout the night. So typically, if you wake up once per night, it's going to be around 3:00 AM, that's the first long period of REM sleep. So, you're making more urine throughout the night, and then you have one apnea during REM sleep and you wake up and you think you have to go to the bathroom. And if you wake up multiple times, it's about 90 minutes apart, which is one sleep cycle.

Matt Feret:

So, if I'm waking up once a night to go to the bathroom and it's around 3:00 AM, it may not just be me getting older or my prostate, it may be sleep apnea.

Dr. Steven Park:

Right. And it could be a prostate issue, but first and foremost, make sure it’s not sleep apnea because that's an easier thing to treat. Plus, not only do you help the nighttime urination, but you’re also going to be healthier as a result of you us your sleep apnea.

Matt Feret:

Okay, so let me ask this then. So will my partner know if I've got sleep apnea, do I wake them up? Will they know?

Dr. Steven Park:

Typically, yes. If you sleep someone for a long time, you see them stopping breathing and gasping for air and you get really scared. Scared for their life. But snoring is a very common symptom and not everyone who snores has sleep apnea, but most do. But they've even shown that snoring would not sleep apnea increase your risk of stroke.

Matt Feret:

Gosh, I'm starting to rethink the way I sleep. Does everyone need a sleep test? Let me just answer that. Should we go at some point kind of like a checkup?

Dr. Steven Park:

Yeah, I joke that there should be a natural screening test for sleep apnea because there's such a high preponderance of it and there's certain countries, I think there's a study in one of the Scandinavian countries, more than 50% of middle-aged women had it. They're not that overweight over there either. So, the more overweight you are, the more likely you're going to have sleep apnea. Unfortunately, in our country, there's such a high rate of obesity right now and overweight. So, I would say the vast majority have some degree of it, and that's why we also have diabetes and high blood pressure and heart disease and everything else. All comorbidities.

Matt Feret:

You’re saying sleep apnea can exacerbate the other pieces.

Dr. Steven Park:

It's like a vicious cycle. One aggravates the other no matter what starts it.

Addressing Sleep Apnea and Sleep Disorders with Dr. Steven Park [18:02]

Matt Feret:

Okay, how can I determine whether or not I've got sleep apnea or some other obstructive sleep disorder during the day while I'm awake? What will I feel? What will I not feel?

Dr. Steven Park:

Poor energy, for example, poor concentration, memory issues, anxiety over the anxious. What else? Yeah, just poor energy, lack of focus, memory problems, just basically you can't function that well like you used to.

Matt Feret:

Okay. And then are there hormonal changes that happen at midlife or older adulthood or when you get up in your seventies or eighties that occur that can lead to sleep apnea or sleep disorders in general?

Dr. Steven Park:

Well, one particular thing that happens in women that's very common is during menopause. Now, one of the hormones that women have is progesterone, and you have estrogen plus progesterone, but progesterone specifically has this property of being a respiratory stimulant. It actually helps you to breathe better and faster. It increases muscle tone in the tongue too. So, a joint menopause progesterone goes down, it actually started in late thirties, early forties, and then about the mid-fifties it goes down to nothing. But as progesterone drops, the tongue gets more relaxed and you start to have more breathing problems, breathing issues. It is one of the symptoms of menopause because you're not sleeping well.

Matt Feret:

So, if I'm feeling like that or I've got a partner that feels like that, you're telling sleep study, that's what your recommendation is, at least for a diagnosis or at least a rule of something out.

Sleep Hygiene Tips with Dr. Steven Park [19:50]

Dr. Steven Park:

Yeah. Well, before you go see a sleep doctor for a sleep study or an ENT, try the conservative options first. So first of all, go through all the sleep hygiene checklists that you see online about sleep hygiene. Going to bed regular time, but if you're overweight, even losing five or ten pounds can make a big difference. And also sleep habits. Let me just give you three simple tips for everybody and it's good for everyone's health in general. Number one, don't eat or snack within three to four hours of bedtime. That is the single most important advice I give to all my patients. And the reason is the more stomach uses you have in your stomach, every time you do stop breathing, even a little bit, it's going to come up. You're going to vacuum it up into your throat, which causes inflammation. So, this gives me the classic throat reflux symptoms like throat clearing, coughing, hoarseness, lump in the throat, difficulty swallowing, but that also causes inflammation in your throat causing more narrowing. And what they've also found is that when acid comes up into your throat, it's not just acid that's irritating, but you also have bile food particles, bacteria and enzymes like pepsin. And surprisingly they've found pepsin with your enzyme in your middle ear, sinus cavities and your lungs.

Matt Feret:

Wow. So, make sure you're doing your sleep hygiene and going bed every night and not eating three to four hours. You said, I think I knew that. Something in my brain tells me that says it takes your body or your stomach to digest a meal two hours. Is that not right?

Dr. Steven Park:

Two hours is the bare minimum, but everyone's different and people have different thresholds and the older you get, they show that time becomes, sorry. The longer the time becomes, that's what elderly people have to eat much earlier, otherwise they don't sleep.

Matt Feret:

Okay. So, what goes on during a sleep test if I get to that stage?

Dr. Steven Park:

So, it has to be ordered by any doctor, but typically it's going to be a sleep doctor or an ENT depending on what kind of symptoms you have. So, if you go for neck congestion, they find out you snore the order sleep test. But most of the time these days, people for routine sleep apnea don't sleep in a sleep lab. They order home tests which are much more convenient and simpler. They hold off on the in-lab sleep studies for more complicated cases, like if you have heart failure or some of seizures or something like that. So, the home test is really easy. It's just a nasal cannula, like an oxygen probe finger probe for the oxygen and a chest probe to measure breathing. So, it measures how many times you stop breathing every hour.

Matt Feret:

I didn't know this existed. So, you can just get your doctor to order it with home and you slap it on, wake up in the morning and give it back to your doctor.

Dr. Steven Park:

And there's very many different options. The standard ones have the nasal probe, finger probe, and the chest probe. There are even other ones that are using high technology. That's a finger probe with a wristwatch and it measures sympathetic arousals. It's called the watch pad, and it correlates highly within lab sleep studies. And then you have what the consumer type options, like the finger probes that measure oxygen. It's not as good as a sleep study, but just looking at the oxygen levels at night will give you some indication as to how many times you stop breathing and how low your oxygen gets if it's severe.

Matt Feret:

Wow. What should your oxygen not dip below when you're sleeping?

Dr. Steven Park:

Nothing below 90% and oftentimes with severe sleep apnea, you see it dipping into the sixties or fifties even. Not compatible with life.

Matt Feret:

No, that doesn't sound very good. 50% of the oxygen.

Dr. Steven Park:

The good news about sleep apnea is that when you stop breathing long enough, you'll wake up and you start breathing again. But that causes other problems, right?

Matt Feret:

Yep. A lot of other problems. You said wait three times. I think I was counting right? You said it three times. So, talk about, I mean we all know, right? The average American is, what did I read the other day? It was 70% of all Americans are either overweight or obese. So, when you gain weight, it's obviously not just in your posterior or your belly, but it's in your face as I'm looking at my face, which is not as thin as I'd like it. So, you gain weight in your face and I'm assuming that then you gain weight inside your face as well. What does the weight do to your facial structure and your sleeping and the stuff in behind your mouth?

Dr. Steven Park:

Well, you have fat cells in your throat and especially in your tongue. So, the fat cells get bigger, so it narrows the airway. So, when you're awake, it's okay because he has the muscle tone, but as your muscles relax less, it gets sucked in easier. There are different areas in the throat that can cave in or collapse.

Matt Feret:

Okay, so I have fat around my throat, is what you're telling me.

Dr. Steven Park:

Yes. Especially in your tongue.

Matt Feret:

Does my tongue get fatter if I'm fatter?

Dr. Steven Park:

Yeah.

Matt Feret:

Physically I have a fatter tongue if I'm overweight.

Dr. Steven Park:

Yeah, they've actually seen it go away with MRIs after weight loss.

Matt Feret:

Your tongue gets smaller after weight loss. Yes. I'm sorry, I'm laughing. I just never knew that. Just start looking at my tongue now and I have a lot of things to look up and look at after this interview. Thank you for that. So, weight loss, you said even 10 pounds, or does it have to do with the BMI or ideal weight?

Dr. Steven Park:

Yeah, so the whole BMI concept, it's a little bit flawed because obviously bodybuilders have very high BMIs, but they're healthy, right? They have no fat, but it depends on your jaw structure. So the larger your jaw structure, the more give you have or room for you can gain a lot more weight, not having any symptoms, but the smaller weight you start out with, you don't have that much of a margin, but losing weight that actually shown that if you lose 10% of your body weight, I think the severity of the CPCO is down to about 20% or 30%. So that's significant.

Matt Feret:

Wow. Yet another reason to not have that Friday evening pizza and then Saturday morning leftover pizza. Okay.

Dr. Steven Park:

Oh, one thing about weight is that poor sleep promotes weight gain.

Matt Feret:

How does it do that?

Dr. Steven Park:

Because it drives up your hunger hormones. And also, if you don't sleep because you're sleep deprived, you're going to crave unhealthy, sugary, fatty unhealthy foods.

Matt Feret:

Which makes you fatter. Gosh, mother nature is evil. She doesn't say, oh, you're overweight. You should only want to eat kale when you're overweight. Nope, nope. Mother Nature says, eat more sugar and salt. That's not really nice of her, is it?

Dr. Steven Park:

Well, mother nature doesn't stay that, it's the food industry.

Options for Sleep Apnea Treatment with Dr. Steven Park [27:13]

Matt Feret:

We've done it to ourselves, and we have all these wonderful options to satiate our deepest cravings no matter the time. Alright, so sleep apnea, we've all seen and know the big vacuum cleaner ends, the big machines next to there. And I've also then now seen commercials where some guy hits a button, and you can't see. It must be embedded. So, what are the surgical ways, I guess, or that's nonsurgical? Maybe it is both. What are the nonsurgical and the surgical ways of treating sleep apnea?

Dr. Steven Park:

Sure. Well, we'll go through the continuum from conservative to more aggressive, but you mentioned the vacuum cleaner. It's interesting, the inventor of the CPAP, a machine, Dr. Colin Sullivan, I think in the seventies is an Australian pulmonologist. What he did was he took a vacuum cleaner machine, the pump reversed the pressure and made this makeshift mask with a person with sleep apnea and cured sleep apnea patient with really, really severe sleep apnea. So, he woke up like young man. It was literally a vacuum cleaner. Yes, it's a reverse vacuum cleaner.

Matt Feret:

Not with that kind of suction hopefully.

Dr. Steven Park:

Right? Very, very small pressure. But it, it's become very advanced these days with the different algorithms and very comfortable masks. But that is the standard treatment option that most sleep doctors will recommend, especially if you have mild to moderate sleep apnea. Now obviously with any kind of intervention, not everyone's going to tolerate it or like it, but for some people it's a lifesaver. For some people it makes things worse. And for some people, not many, about 10% of people, it actually causes you to gain weight. Not too many doctors know about that.

Matt Feret:

Why is that?

Dr. Steven Park:

My theory is that even though it helps to get rid of the apnea, the severe episodes, so oxygen levels don't drop below 90% because there's something on your face and pressing air, it causes this micro arousal in your brain. So, it causes more sleep fragmentation and on a more microscopic level as opposed to the major apneas.

Matt Feret:

Wild. Okay. So, there's the vacuum cleaner and then what are the other ones?

Dr. Steven Park:

So, the other option that the dentist can help you with is this something called a mandibular advancement device. These are dental mouth guards that move your lower jaw forward to pulls your tongue forward. And so, these are generally better tolerated than CPAP. And in terms of effectiveness, they're pretty equal. People will tolerate the dental device more, but the CPAP machine works a little bit better. So, it's a wash and they both have their problems with a CPAP machine, you have air in the stomach and air leak and keeping working up the dental devices can cause bite problems, TMJ problems, but you don't know if it's going to work until you use it. Basically, rule I have this rule of thirds with all these devices in general, about one third will love it, one third will hit it and one third will be okay with it.

Matt Feret:

Is there something that you can surgically implant?

Dr. Steven Park:

Yeah, well, that's the absolute last resort. But traditionally with surgery, for example in kids tonsillectomy, if you have huge tonsils that does wonders. But then as you get older, the tonsils shrink. And then once you become an adult, what happens is the soft palate becomes really floppy and redundant. So, it vibrates when you snore and then when the muscles relax, you just obstructs. And on top of that, the tongue base can obstruct in some people. And then there's some other areas like what's called the epic otitis, which is the top of the voice box. But there's different levels. But the palette and the tongue are the two major areas. So, when I started doing this over 20 years ago, that's what I did. I did major surgery of the tongue and the soft palette, the tonsils and also the epiglottis. Now I don't do jaw surgery, but the oral surgeons do double jaw surgery called the max maniple advancement where they move the upper and lower jaw forward about this much. So that one has a 95% cure rate. The soft tissue operations that I do, that's more in the 60% to 80% success rate. So, these are bigger operations. But now about 10 years ago, this new technology came along called the Inspire procedure. Actually, I was involved in one of the early versions of a same device for a different company called Apex. So, I was one of the first surgeons in the northeast to do this in the investigational setting. And so basically, it's a pacemaker that you implant like about this. Then like a regular heart pacemaker, you implant it under the chest wall here and then you make a little incision under your neck, and you find the nerve that goes to your tongue. So, you connect the lead under the skin here and basically there's a sensor in your chest rib cage. So, when it sensors that you're breathing in, it pulls your tongue and it feels like you don't feel a shock. You just feel like you're moving your tongue forward. These are the same level of simulation that your brain sends to your tongue.

Matt Feret:

That's wild. Is it in production?

Dr. Steven Park:

It's been now for about 10 years, and they've gotten very good at it, but yet not everyone's a good candidate for it. They're very strict criteria. So, for example, you can't be too overweight. Your BMI has to be under 32. You can't have more than I think 40% central apnea where your brain doesn't send signals to your lungs to breathe. You have to have try to fail CPAP. And also, you have to undergo what's called a drug induced sleep endoscopy, where we put you on their anesthesia to take a look how they throat is collapsing. So there four or five specific criteria that you have to meet. And some people, they like the idea of not having to use the device, but other people don't like the idea of having something implanted. So, it's also a psychological issue too.

Matt Feret:

That's wild. Okay, so aside from that, I'll ask another maybe silly question because I'm full of silly questions. What about those breathing strips that you see sometimes athletes wear? Does that work?

Dr. Steven Park:

Well, that gets to the question of do these nasal breathing options help treat the sleep apnea or the storing? Now for the storing it may help, but in general we know that when you do any kind of nasal surgeries, that's much more aggressive nasal procedures in general, it doesn't cure sleep apnea. It may help with the storing a little bit, and patients definitely feel better after nasal surgery. Maybe in 10% of people with mild sleep apnea, it does help treat the sleep apnea. But overall, it doesn't do very much. But the main reason why I recommend improving your nasal breathing to begin with is that it allows the other option to work much better, especially CPAP in the mouth guard. So, for example, there was a study looking at people who couldn't tolerate CPAP, who also had nasal congestion. And when you treat the as congestion with surgery, the CPAP usage went from 30 minutes to five and a half hours. The big difference because if you notice the stuff, you can open your mouth and when you open your mouth, you get a mouth leak and you're going to take the mask off.

Matt Feret:

And you probably still stay asleep and take your mask off.

Dr. Steven Park:

Yeah, that too. But in general, you have the conservative options like decongesting, your nose of allergy medications, nasal saline, irrigation allergy medications, intranasal steroid sprays, and then the breed by trips to keep your nostril caving in. So, you have a deviated septum that's crooked like this, the terminate these wings inside your nose that swell up due to inflammation. Allergies allows you to nostrils cave in. So those three things contribute to congestion. So typically, what I recommend to start with is to use breathe right strips or they have these cones or these clips that go on the inside that work much better. It's about 20 different options online. You can find; I use breathe rights every night because it helps me to sleep better. It's a simple thing to try. And then another option you can experiment with is mouth taping. So, what you can do is they have these commercial options you can buy online. It tapes your lips together with a little hole here so you can breathe. The key is to keep your mouth closed so that if you open your mouth, what happens is the tongue moves back, and you stop breathing more often. You think you get more air and when you open your mouth, but it's the reverse. Now I modified that rather than doing this, I go vertically down the middle with a little one-inch medical tape. And purpose of this is to suspend your jaw close a little bit easier so that your jaws don't open. If they tip your lips together, you can still open your jaws and you're not going to choke where I have any medical problem.

Matt Feret:

That’s got to be weird. I'm thinking of every horror movie I've ever seen or kidnapping movie with a duct tape across your mouth.

Dr. Steven Park:

But the one-inch tape is down in the middle so you can breathe out through the corners. And like I said, worst case scenario, you're going to wake up and if it's uncomfortable, you just take it off.

Matt Feret:

Are there sleeping positions that you can choose? I mean, I’ll say this, I had a guest on the podcast. It was much more general in terms of sleep and mattresses and everything, and it was, I admitted, I'll admit it again, that I start off every night on my belly. I've been doing it as long as I can remember, but invariably during the night I'll switch off. I can't fall asleep on my side. I can't fall asleep on my back, but I can fall asleep in my belly and then I go to a side, or another side and I flip and I flop and I hardly ever wake up on my back. Should I be forcing myself or should anyone be forcing themselves to sleep in a certain way if they think they have these issues? And does that even help?

Dr. Steven Park:

That's a big loaded question. I guess the other way you can ask this question is what is the best sleep position for you? It is your stomach. Okay, so whatever position that you prefer, stay there. Actually, when I was in practice, what I would see is once a month or so, I would see a middle-aged woman who comes in with let's say six weeks of sinus infections, headaches, fatigue, just poor sleep. And she's coming in for sinus problems. And I ask her just the general questions about her sleep and I ask her, do you sleep on your back side of the stomach? And she says, I sleep on my back. But looking at her anatomy, I don't believe her. So, because I know she sleep on the stomach or her side. So, I asked her, when you were younger, how'd you sleep? On my stomach. Well, when did that change? Oh, maybe about six or seven weeks ago. Why? My dermatologist told me not to sleep on my stomach. It causes wrinkles.

Matt Feret:

Okay, makes sense. If you don't want wrinkles, I guess.

Dr. Steven Park:

But the wrinkles are from the sheets, it's not from the sleep positioning. Now I can argue that you can get more wrinkles because your sleep's going to go downhill.

Matt Feret:

If you get no sleep, then your skin's going to go south.

Dr. Steven Park:

And you see that advice from dermatologist all the time still.

Matt Feret:

So, sleep in the way that you normally sleep, don't make any forced changes if your body isn't naturally doing that.

Dr. Steven Park:

Right. However, if you get injured or undergo surgery, you're going to have problems. So, imagine if you got a shoulder surgery and you can't sit in your normal position, you're going to be in trouble. So, I saw this, for example, one of the things I wrote in my book, Sleep, Interrupted was during my surgical internship I would see all these people having heart attacks and codes around 3:00-5:00 AM, three or four in a row. It was crazy. And then when I started to study sleep, realized that that's when you go into REM sleep. When you're dreaming, that's when your muscles relax the most. But these patients, let's say that you're normally a side stomach sleeper all your life, you're in your fifties or sixties, you have a little bit of high blood pressure, diabetes, and you undergo abdominal surgery, and you can't sleep on your side or stomach anymore, and you fall asleep on your back. And on top of that, you're given narcotics for pain, which suppresses your drive to breathe. So, like a triple whammy, REM sleep on your back given narcotics, of course you're going to stop breathing all of a sudden at three to 5:00 AM when you're in REM sleep.

Matt Feret:

And then the heart expands, tries to figure out if it's got too much blood. Is that what you were saying? Too much blood?

Dr. Steven Park:

It's a totally different issue.

Matt Feret:

Totally different thing. I'm trying to tie the two together and it's not working right.

Dr. Steven Park:

Because all of a sudden, you're having multiple apneas because you've never had this before, because you would always sleep on your side or stomach, but now you're forced to sleep on your back, plus you're given narcotics, which you relaxes your muscles even more. And then you go into REM sleep when you're dreaming, when your muscles are most relaxed. So actually, they've shown that people who have sleep badly have heart attacks more between 12:00AM and 6:00 AM Once people without sleep a may have heart attacks between 6:00 AM and noon.

Matt Feret:

I mean, this has got to be unnerving for most people that you tell, right? You got to lose a lot of weight, you got to get a sleep study. There's a high chance that because of the way you were fed as an infant, right, the foods that you've eaten your entire life, that your face looks different now than it would've 50 or even a 100 years ago. What else can I do about this if I'm getting bad sleep or if I'm raising kids or I've been sleeping the same way for 60 years?

Dr. Steven Park’s Holistic Approach to Breathing Better [41:20]

Dr. Steven Park:

Yeah, I realize it sounds like a doom and gloom situation, but basically what I do as an ENT surgeon is to try to avoid surgery. And I have this holistic approach. And so obviously if you're overweight, that's the first thing you have to address. And there's different ways we're not going to get into that. That's a huge topic in itself. But my focus is to help you sleep better. Because if you sleep better, the weight will come off easier too. So, we talked about not eating late, maybe reposition your sleep position based on what your doctor told you or told you not to do. So, kind of see how you were sleeping when you were younger. They even have these wedged pillows that were, for example, I can't sleep on my side either because my arms get numb. So, there's a wedge mattress, there's a hole that's cut up in the middle and you put your arm through that hole and there's a pillow that goes over here.

Matt Feret:

That's my couch. I have my couch cushion. I do that when I nap.

Dr. Steven Park:

Yeah, actually, my best sleep ever many years ago was, I don’t know why, but somehow, I had to sleep on my couch in the office. I got the best sleep ever because my head was cocked on armrest and was like this. So basically, when your neck is like this, you stop breathing more often. So, you want to be neutral or up like this a little bit. That's why these contour pillows work because they put more, give you more height here, and this part goes up like this. So that helps with snoring too.

Matt Feret:

And it keeps the, this is going to sound gross, but it keeps the fat in your throat from closing up.

Dr. Steven Park:

Well, it's just that all the tissues, especially your tongue, because tuck to tongue, the base of the tongue is the biggest dilator of your airway, the strongest dilator. And so, when you're sleeping, it gets relaxed. And again, when you want into REM sleep, it gets even more relaxed. And so that's why again, these math cards to move your jaw for that helps too. Now, one other thing you can do before you start thinking about medical treatment are tongue exercises. It's called myofunctional therapy and there's different names for it and different variations of it, but it's been shown to help lower the severity of sleep apnea by 50% on average, which is big. And for children it's 60%.

Matt Feret:

Tongue exercises. That's fun. Yeah. Okay, let me do an age-based question. Let's say again, you are sixties, seventies, eighties. I've always heard you sleep less and less people going to bed way earlier but then getting up at 4:00 AM and I've always heard or read that it's hormonal or it's just they don't need as much sleep. Is that true? Or are these sleep issues potentially that have just exacerbated and now over time you're sleeping five hours a night, six hours a night?

Dr. Steven Park:

So, the textbook answer is yes, it is true. That's what you have to answer on the test and board exams. My personal opinion is that it's not, because I've seen so many airways as people age. And if you take what I'm telling you to be true, that means as you age, it gets worse and worse. Now, another scary thing that I found was if you look at the voice box during when you first born, when the voice box and the soft palette overlap the touch, that's when you look inside the infant's mouth, you can actually see the top of the voice box. But as you develop, the voice box drops, and it separates away. So, there's a gap between the soft palate and the voice box that's called the oral pharynx. That's where the tonsil sits on the side, but then the voice box keeps dropping. That's why in men, the voice gets deeper in adolescence, and it keeps dropping in men until about 21. And women, it stops dropping around 16 or so. So, I was taught that if voice box stops dropping at 21 for men, it actually drops another full vertebral body length upon the age until like 60 or 70. So it keeps dropping. So, as the voice back keeps dropping, the airway gets more destabilized

Matt Feret:

In just men, it keeps dropping.

Dr. Steven Park:

Well in women too, but not to the same degree as men.

Matt Feret:

So, my voice is going to get lower as I age.

Dr. Steven Park:

Well, it's very slight. Slight. Yeah, that's a theoretical concept, which it's interesting, but it's not very practical.

Matt Feret:

Well, no, I can't change any of that. Right? I can't, no, I can't reach in there and get it back up.

Dr. Steven Park:

So, getting back to your other question, my feeling is that as you get older, these airway issues are going to be more and more common. And so of course you're going to wake up earlier than four, three to 4:00 AM because you stop breathing to go to the bathroom. And because you had this sudden jolt of waking up because she's not breathing, you get the sympathetic stress response. It's hard to go back to sleep. And then because of these sleep disruptions, a lot of older people also want to go to bed earlier and earlier it's called advanced sleep face syndrome because you haven't slept that well.

Matt Feret:

And what does that do to one's body when your normal bedtime in your forties or fifties was 10:30-11:00PM, but now you're in your seventies and it's 8:30PM. What does that do?

Dr. Steven Park:

You're waking up at 4:00 AM you're going to be tired and sleepy. So, you want to go to bed earlier and earlier. What ends up happening is it disrupts your social life. You can't spend time with your loved ones or your family members. The prime time, eight o'clock to 10 o'clock time period.

Matt Feret:

Right. What is it again?

Dr. Steven Park:

It's called advanced sleep phase syndrome.

Matt Feret:

Advanced sleep phase syndrome. And that is typically in older adults.

Dr. Steven Park:

Compared to teenagers that have delayed sleep phase syndrome because they stay up too late, still sleep like a shifted later. Elderly people, they shifted more earlier.

Matt Feret:

And why does advanced sleep, I messed it up again. Advanced sleep stage syndrome-

Dr. Steven Park:

Right? Sleep phase? Darn it. You have to have a different name for this.

Matt Feret:

Yeah, maybe it's an acronym that needs three instead of four. Why does that start?

Dr. Steven Park:

Well, in sleep medicine, there's a lot of theories as to why that happens and there's some genetic predispositions, but that's pretty rare. My feeling is, again, if you're not sleeping, if you stayed up for three nights in a row, if you're given a chance to sleep, you're going to fall asleep much earlier than usual. So, if that's been happening for years, naturally you're going to want to go to bed earlier. But because once you go to bed because you stop breathing about five, six hours later, you wake up earlier than usual. And so this is why elderly people tend to sleep. They need less sleep. So, I wouldn't say they need less sleep, but they just can't sleep that long because they stop breathing a lot. So that's my personal theory. But the textbooks say that older people need less sleep, but I don't think that's necessarily true.

Matt Feret:

And so for the folks that say, it doesn't matter when I go to bed, I wake up at 5:00 AM on the dot every morning when I'm older. You're saying that may be true, but it may be sleep issues that have been there for a long time and they're just changing as you get older.

Dr. Steven Park:

Exactly. So, the breathing issues are contributing to the sleep issues. For example, insomnia, when people have trouble sleeping, it's a huge problem in this country. And one of my colleagues, Dr. Barry Crico, he actually looked at people who had what's called treatment resistant complex, complex insomnia, meaning that they'd been suffering from insomnia. They couldn't fall asleep for hours or even stay up the whole night. They tried multiple medications, checked everything in the book, nothing worked. And what they did was he did sleep studies on all of them and found that about two thirds had undiagnosed sleep apnea. And then he did another study. He looked at insomniacs without any history of sleep apnea and you gave them a CPAP machine versus a more complicated machine called the ASV machine. I won't get the details, but basically the more sophisticated CPA machine, I think it cured the insomnia in about three quarters of the patients was with a CPA machine. It curated in about 40%. So just going to show that people who have these traditional sleep symptoms like insomnia or waking up too early or going to bed too late, a lot of it is connected to a sleep breathing problem.

Matt Feret:

Sleep breathing problem, and the person who goes to bed at a normal time wakes up between one and two and then it can't get back to sleep until 4:00 AM Is that classified as insomnia or just waking up in the middle of the night?

Dr. Steven Park:

Right. So, if you go to a sleep doctor, that is considered a sleep maintenance insomnia there. The sleep onset insomnia. You can't fall asleep when you want to. The sleep maintenance, maintenance insomnia is you can't stay asleep. You keep waking up. But again, there's probably two or three different reasons for that, but the first thing you have to roll in and roll out is a breathing problem because so many people have it.

Dementia and Sleep Health with Dr. Steven Park [51:39]

Matt Feret:

Okay. Wow. This has been fascinating. Really. It has been. I think you've given me some homework to go do and poke around the internet and see what I can find on this stuff. Really, really interesting. And I'm going to be thinking about my fat tongue for a while. Sorry for implanting that image into your mind. I'm going to be, I don't think I'll be the only one, but if I lose weight, well, how about this? When I lose weight, I'm going to look at my tongue and see if I can tell. Weird. Never knew that. Thank you very much for being on the show. The last question I always ask, is there anything about sleep and breathing issues or sleep apnea or anything else related to sleep health that we didn't cover or questions that I didn't ask that I should have?

Dr. Steven Park:

Well, I'm going to bring up this topic because I'm working on a video that I'm doing right now, and it's a topic of cognitive impairment and dementia memory problems. I'm sure that's a major problem for people in your audience. And we know that poor sleep is a major risk factor for memory impairment and dementia. In fact, they've shown that people with untreated severe sleep apnea have much higher risk of this dementia and Alzheimer's. And when they treat those patients, it doesn't cure it, but it slows it down.

Matt Feret:

So, people with current dementia diagnoses can benefit from sleep health.

Dr. Steven Park:

Yeah, not all, but many. For example, there was one study that looked at brain imaging and people with severe sleep apnea, and they found that there are certain parts of the brain that were basically dead, multiple areas in brain. But then after six months of CPAP use, the brain areas started to generate partially, and their memory got better a little bit too. So not completely, but it got better.

Matt Feret:

Wow. So, if someone's dealing with potential age-related dementia or just dementia diagnosis, including Alzheimer's, which is one of the many, many, many dementias related diseases looking into sleep health, ask your doctors.

Dr. Steven Park:

Yeah, absolutely. I mean, even if you don't have it, least if you checked it off the list, but I would say I'm going to guess maybe 20%, 30%, even 50% of the time, it's a treatable condition.

Matt Feret:

Wow. Well, I knew that sleep was very, very important, but gosh, you've given me a whole bunch of other motivations to A, lose weight and B, pay attention more to my partner and her sleep habits and C, pay attention more to mine because I certainly don't want to be in a position where I'm sleeping the way I'm sleeping and it's going to cause me damage later on in life. Thank you very much, Steve, for being on the show. This has been really fascinating.

Dr. Steven Park:

It was my pleasure.

 

Matt Feret:

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