Health Connection - January 2022

An “Inspired” Approach to Treating Sleep Apnea

By Annick Aubin-Pouliot, MD

Sleep apnea can be a nightmare – provided you can even sleep long enough to have one. The condition’s trademark heavy snoring and gasping disrupt your sleep and can repeatedly awaken your spouse or partner. You wake up to a headache and spend the day in a fog. You can’t concentrate at work. You worry about getting behind the wheel. You’re cranky and distracted and frequently pass on activities you used to enjoy because you’re just too tired.

The universal treatment for sleep apnea is the C-PAP machine. Some users have no difficulty tolerating this but others find the mask and hose cumbersome, note that the forced air dries out the airway, or develop a rash on their face.

An increasing number of sleep apnea sufferers are discovering an alternative to the C-PAP machine: Inspire. While surgery on the upper airway has long been an option that can reduce sleep apnea in selected patients, newer techniques can avoid some of the side effects of these kinds of operations and can be an effective tool, providing the same degree of symptom relief as C-PAP without the hassle. This small, FDA-approved implantable device works inside your body while you sleep. It comes with a remote that you simply click on when you’re ready to go to bed. As you drift off to sleep, the device keeps pace with your breathing. Every time you draw a breath, it sends a pulse to the hypoglossal nerve under your chin. This triggers a forward movement of the tongue that unblocks the airways.

The Inspire Process

1. The first step is a sleep study and a diagnosis of sleep apnea through a sleep clinic. If your sleep doctor thinks Inspire could be an option for you, you will be given a referral to an ear, nose, and throat specialist, or ENT. This is the doctor who will perform the Inspire surgery.
2. If you are determined to be a good candidate after a thorough history and physical exam, the ENT schedules a sleep endoscopy, which is performed in a surgical facility. A small camera is inserted into your airway while you sleep, and the doctor observes your nose, tongue, and larynx while you are asleep to determine whether your tongue, or another area, is what’s blocking your breathing. If you are a good candidate, the next step is having the procedure.
3. The Inspire procedure is performed in an operating room under anesthesia. The implant is inserted through one or two incisions in the chest. An additional incision is made under the chin, where a tiny cuff is placed around the nerve that controls the tongue. Most patients go home the same day.
4. The next step is to calibrate the device to fit your specific breathing pattern. This is done by your sleep specialist, at the Sleep Center, about a month after surgery. Once the Inspire device has been customized to fit your needs, the sleep specialist activates it. It may take several visits to the Sleep Center to arrive at the ideal calibration for you. You will be given a small remote control to keep by the side of your bed. This turns the device on and off.
5. Once the device is turned on and calibrated, you will turn on the device nightly at bedtime, and go to sleep. Inspire will do the rest.

Who Qualifies for the Inspire Device?

Inspire may be right for you if:

• You are over the age of 18
• You cannot tolerate a C-PAP machine
• You have an AHI (apnea-hypopnea-index) between 15 and 65
• Your BMI is less than 35 (sleep apnea is sometimes due to excess fat in the neck area)
• Your tongue is the structure that interferes with respiration when sleeping – sleep apnea can be caused by other anatomical issues such as a retracted jaw, enlarged tonsils, or a problem with your epiglottis
• You do not have insomnia

Until recently Inspire has not been available in Marin or Sonoma Counties, but the MarinHealth® ENT, Head and Neck Surgery group is working with local sleep medicine specialists to enable patients to undergo placement and management of Inspire locally. If you are interested in evaluation for candidacy as this collaboration is rolled out, please reach out to your Sleep Medicine group to discuss referral to MarinHealth ENT, Head and Neck Surgery.

Learn more about Head & Neck Surgery at MarinHealth.

Dr. Aubin-Pouliot is an Otolaryngologist at MarinHealth Medical Network, and practices the full breadth of Otolaryngology – head and neck surgery, with particular interest in thyroid surgery, head and neck oncologic surgery, facial plastic and reconstructive surgery, nasal and sinus surgery, and sleep surgery.

The Cardiovascular Performance Center: Your Heart in Action

By Brian G. Keeffe, MD, FACC

John has been biking with the same group of guys for the past two years. Now, all of a sudden, he can’t keep up.

Faith is turning 55, the age her mother was when she died of a heart attack. Should Faith intensify, change, or slow down her daily workouts?

Todd wants to evaluate his heart health before signing up to compete in his first triathlon.

Audrey’s heart starts beating strangely in the middle of her daily run. Could it be AFib?

All four of these people need answers and the best place to get them is MarinHealth® Cardiovascular Performance Center. The Center focuses on sports cardiology care for adults, including college, professional, amateur, masters, recreational, and occupational athletes. Typical clients include:

• Athletes another provider has deemed to be at risk for a cardiovascular event. Our experts can determine the degree of risk and whether an individual can safely participate in sports.
• Athletes experiencing symptoms during physical exertion such as chest discomfort, excessive shortness of breath, fainting, or heart palpitations.
• Middle-aged athletes who want to keep playing sports without jeopardizing their heart health.
• Athletes who have either been diagnosed with heart disease or have experienced a cardiac event. They want to understand their degree of risk and determine whether, and how, they can safely participate in their sport.

Whatever your reason for visiting the Cardiovascular Performance Center, you can count on hands-on, highly personalized care. At the Center, we operate on the premise that everyone —even the most stubborn couch potato — is an athlete at heart. Our program is designed to prevent acute or chronic cardiovascular disease, enhance fitness and athletic performance, and extend athletic careers.

Services

The Cardiovascular Performance Center provides the following services:

• Comprehensive cardiovascular screening
• Evaluation of potential cardiovascular symptoms
• Assessment of any unexplained deterioration in performance
• Evaluation of cardiovascular risk factors, along with advice on ways to limit risk
• Clearance to participate in sports following a cardiovascular event or surgery, or after being diagnosed with a cardiovascular condition
• Comprehensive cardiovascular and physiological testing, including medical history, a physical exam, electrocardiogram, echocardiogram, and cardiopulmonary exercise testing
• Assessment of resting metabolic rate (RMR) and body composition
• Addressing impaired athletic performance due to previous medical issues
• Cardiac rehabilitation

The Care Continuum

While individual recommendations are extremely varied and personalized, our care continuum can be broken down into 3 or 4 steps.

1. One-on-one consultation with the heads of the Performance Center, Sports Cardiologists Dr. Brian Keeffe and Dr. Arvind Nishtala. This will include questions about your concerns, your exercise routine, any family history of heart disease, and any symptoms or changes in performance you may have experienced. This initial consult also includes a basic checkup and an EKG.

2. Highly personalized testing based on the results of your initial consultation. Testing is provided at the Performance Center using leading-edge equipment to determine your ability to exercise. You will also be prescribed lab tests for lipids and other parameters to assess your long-term heart disease risk. Depending on your individual goals or issues, you may be scheduled for further cardiovascular imaging or asked to wear an ambulatory heart monitor for a week or two to evaluate your heart’s rhythm over an extended period of time. The team also can assess the data you collect on your own, including Apple Watch or similar EKGs, GPS exercise data, and other wearable health information.

3. Follow-up visit with our doctors to review findings and conclusions, voice your concerns, and get answers to any questions you might have.

4. Patients who are interested can get a program plan from our on-site exercise physiologist. If you decide to have this consultation, you can expect a 45-minute session in which you will be asked a variety of questions about your lifestyle, diet, schedule, and goals, and any chronic orthopedic issues. The exercise physiologist will then tailor your exercise program based on your answers and your heart health.

Rehabilitation at the Cardiovascular Performance Center

In addition to working with athletes, the Cardiovascular Performance Center offers rehabilitation for people who have suffered a cardiac event or have had recent heart surgery. The Ornish Lifestyle Medicine program consists of two 4-hour sessions per week for 9 weeks. Each session includes an hour of exercise, stress management, nutrition, and group support. Each specialty provides individual coaching to modify lifestyle and promote reversal of heart disease. Nutrition is a whole-food, plant-based diet.

Insurance companies are increasingly willing to cover sports cardiology care, as it helps keep their customers healthy and out of the hospital. Insurance or Medicare will cover rehabilitation services for those who:

• Have had a cardiac event within the past year
• Suffer from documented, stable angina
• Are recovering from a recent valve or coronary artery bypass surgery

To learn more about the Cardiovascular Performance Center and the importance of heart health for athletes at all levels, listen to this short podcast.

Dr. Keeffe and Dr. Nishtala are Co-Directors at the MarinHealth Cardiovascular Performance Center. Dr. Keeffe is board certified in cardiology and has been practicing cardiovascular medicine in Marin County since 2004. Dr. Nishtala is a board-certified cardiologist at the MarinHealth Cardiovascular Performance Center and has an interest and expertise in cardiovascular performance. He has been practicing in Marin County since 2021.

Alcohol and Sugar: Two Things to Do Without Right Now

What was your December downfall? Fine wine? Rummy eggnog? Fancy microbrews? Or did you give in to your sweet tooth and binge on pumpkin pie, Christmas cookies, or Hannukah cake? Whatever your winter weakness, it can’t hurt to start the new year with a break from alcohol and sugar.

The pandemic has inspired a rise in alcohol use. A recent RAND corporation study found that drinking went up by 14% among adults over age 30. In women, heavy drinking is estimated to have increased by 41%. Drunk driving deaths increased by 9% in 2020 even though vehicle miles traveled fell by 13%. A break from alcohol can be good for your health. If you’re already participating in Dry January, good for you! If not, why not give up alcohol for the next 30 days and enjoy health benefits that include:

• Better sleep. Alcohol may make you drowsy initially but it’s not conducive to the deep sleep your body needs. More than two drinks and you’ll likely experience a “rebound effect”, where you wake up at 4 am and can’t go back to sleep.
• Healthier skin. Alcohol is dehydrating, which is bad for your skin–and your entire body. Abstaining from alcohol will reduce facial dryness and puffiness.
• Weight loss. Calories count, whether you eat them or drink them. One study found that 58% of people who stuck to their Dry January resolution lost weight without even trying.
• Stress reduction. Are you using alcohol to get over a bad day? Put that habit aside and you just might find some new ways to relieve stress, such as meditating or expandiing your exercise routine.
• Better relationships. Many people find that they are calmer, nicer, and slower to anger when they abstain from alcohol.

Participating in a one month sobriety challenge is more popular than ever. In fact, an estimated 20% of all Americans plan to abstain from alcohol for 30 days or more to help jump start a healthier 2022. Taking a break from alcohol is easier than you might think, especially at this time of year, but it helps to have some support. Try getting a partner or a good friend to take the challenge with you. Move your liquor supply out of the house so you won’t be tempted. If you slip up, don’t be too hard on yourself. Take it one day at a time and have a dry tomorrow. Once your 30 days is over, you don’t have to go back to your old habits. And if you DO indulge, be mindful of your newly reduced tolerance and drink in moderation.

Signs Drinking Just Isn’t for You

Even if you think of yourself as a moderate or social drinker, these are signs that perhaps you should abstain:

• You don’t feel like you’re doing or being your best, at work or at home
• Your drinking is having a negative impact on your relationships
• You feel like you “need a drink” and plan when you can have one
• You can’t socialize or have fun without drinking
• You often feel irritable
• You often feel dehydrated and/or bloated
• You can’t remember what you did while drinking
• You're spending more money than you want to on alcohol
• Once you start drinking, you have trouble stopping

If you think you might have a drinking problem or a dependence on alcohol, talk to your doctor. You may need to quit under medical supervision.

The 30-Day Sugar Challenge

Maybe you’re a very moderate drinker, or even a teetotaler. But when you’re confronted by a plate of Christmas cookies or a slice of pumpkin pie, you lose all control. If that sounds like you, try the 30-day sugar challenge. You don’t have to worry about eating foods with natural sugar, like vegetables, fruits, and dairy. The goal is to eliminate anything with ADDED sugar. That means more than skipping dessert. You need to start reading labels to avoid the sugars found in peanut butter, crackers, cereal, soda, condiments, and other processed foods. You might be surprised at the amount of sugar lurking in savory soups and frozen dinners.

Eliminating sugar–especially in the long term–can help you:

• Reduce your blood sugar. Diets high sugar have been linked to high blood sugar and insulin resistance, which increases your risk of developing diabetes over time.
• Keep smiling. Sugar feeds the microorganisms that promote tooth decay.
• Stabilize your weight. Foods high in sugar tend to be low in healthy, filling nutrients like protein and fiber, but loaded with empty calories. High sugar consumption is also associated with visceral fat. This type of fat accumulates deep in the belly and is associated with diabetes and heart disease.
• Avoid liver disease. High sugar diets raise your risk of non-alcoholic fatty liver disease.
• Protect your heart. Diets that limit added sugar lower your levels of triglycerides and LDL cholesterol, both risk factors for heart disease.

After a month of controlling your sugar intake, you may be surprised to find that your favorite desserts now taste too sweet, or that one or two bites are enough to satisfy you. That’s your body talking. Is it time to listen?

The Many Health Benefits of Massage

By Sylvia Goodman, MS, CMT

Difficult bosses. Bills. Deadlines. Family conflicts. Relationship problems. Health issues. If it feels like it’s too much, that’s because it is. Stress is a fact of modern life, and the ongoing pandemic hasn’t helped. While you gamely soldier on, all that pressure and anxiety take their toll on your body. Stress triggers the release of the hormone cortisol. Tension accumulates in your neck, shoulders, and lower back. The blood that’s supposed to be nourishing your entire body pools in your arms and legs. Our “flight or fight” mode may have been useful in prehistoric times during a sudden encounter with a saber-toothed tiger, but today’s unrelenting stress affects you emotionally and physically by depressing your immune function over time.

One of the healthiest and most beneficial things you can do to reduce stress and manage anxiety and fear is to get a massage. This ancient healing art benefits the whole person, quieting the brain, centering the mind, relaxing the musculature, and allowing you to experience the care and nurturing you deserve. Massage enhances your health and well-being in a variety of ways. In addition to reducing pain and relaxing stiff, sore muscles due to tension, it enhances breathing and circulation, reduces the heart rate, lowers blood pressure, and facilitates healthy sleep and digestion.

In keeping with our philosophy of caring for the whole person, MarinHealth offers massage and other mind/body modalities to the public at our Integrative Wellness Center. Massage is also a supportive option for MarinHealth inpatients, offering the following benefits:

• For cancer patients dealing with the anxiety of an unexpected diagnosis or the side effects of treatment, massage helps reduce pain and quiet the mind. Patients often find that they have more energy, can sleep better and focus more on enjoying their families. Patients struggling with lymphedema can schedule specialized Manual Lymphatic Drainage massage to reduce swelling.
   
• Pregnant women can work with a massage therapist who specializes in reducing edema and back pain. Massage can also help women stay focused and calm during labor and delivery.
   
• Patients with chronic conditions such as diabetes or heart disease find that massage is a powerful addition to their care regimen, helping them to stay centered and grounded.
   
• Provided there are no medical contraindications, any of our hospitalized patients can place a massage request through their nurse.

All of our MarinHealth massage therapists are certified and licensed by the state of California and have many more hours than the minimum 500 hours of study and practice, 100 of which are focused on anatomy, physiology, health, and hygiene. Continued education is required to maintain certification. Currently, our massage therapists use combinations of Swedish, deep tissue, acupressure, and Esalen massage techniques. The Integrative Wellness Center also offers Jin Shin Jyutsu®, an energetic healing modality supporting body, mind, and spirit balancing through noninvasive gentle touch, as well as acupuncture. You do not have to be a MarinHealth patient to uses our services. Learn more about massage therapy at MarinHealth Integrative Wellness Center or call 1-415-925-7620 to make an appointment.

Sylvia Goodman is Esalen trained and a certified massage therapist as well as a certified Soul Lightening International Process Acupressure Practitioner at MarinHealth Integrative Wellness Center. She received her massage certification from the National Holistic Institute and completed an internship at MarinHealth Medical Center.