Dear Bethany: Why Do You Promote CPAP Instead of Weight Loss for Sleep Apnea?

In honor of the one-year anniversary of me getting my CPAP machine and life being just awesome, I’m kicking off the first ever installment of “Dear Bethany!”

Content Warning: discussion of weight stigma, the belief in fatness as pathology, intentional weight loss, and medical treatment choices for sleep apnea that are NOT weight neutral.

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Year in Review: Outcomes of My Second Year of Habit-Based Self-care

When I started two years ago, deciding to track healthy habits instead of a number on a scale or clothing size was unfamiliar territory for me. I decided I wanted to be open to whatever outcomes would come.

Last year, I listed the following outcomes I experienced after one year along on a habit-based, weight neutral health journey:

Looking back on what I wrote last year, I am happy to say that most of those outcomes have continued throughout year two. I did have some depression and back pain creep back in when an injury required me to stop lifting for a few months. With adding lifting back into my life, both of these conditions are improving again.

I also experienced some other cool things in year two.

Looking back, I feel really proud of what I accomplished this year. It didn’t seem like I did much of anything until I actually went back and read all my older posts. What I feel most proud of is keeping up a consistent self-care routine during a very challenging year.  My family had a lot of challenges: my husband got injured, I got injured, we lost our pet, we had a terminal illness and death in the family. I feel so proud that I took excellent care of myself so that I could face these challenges well.  Honestly, the self-care felt like the easiest part and I know that is because of the habit-based approach.

So…..to give credit where credit is due, I feel very proud of myself this year. I’m excited to see what year 3 brings!

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My Biggest CPAP Fear Came True

The first time a healthcare provider told me that I had symptoms of sleep apnea and I should ask my doctor about a sleep study, my first thought was “I don’t want my kid to see me using a breathing machine.” Back in the days I used to watch the Biggest Loser, I saw people with families crying because they had to use a breathing machine. You were supposed to feel sorry for / disgusted by the poor sad fatties who had medical conditions. I internalized the belief that using a breathing machine is shameful, and I didn’t want my kid to see that weakness.

And then I told myself “wait a minute. That is fucked up that I would actually consider not finding out if I have a medical condition so I don’t have to show my son that I am treating it. There is NO shame in getting medical help for a serious medical condition and I will gladly tell my son THAT. Fuck TBL.

Well, today, my son said something to me that made me skip a beat. We were about to take a nap and I said “okay, you lie down and I’ll get my machine ready.” He said, “okay, you get your machine ready.” And then he said “someday, I’ll have a machine too!”

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What My CPAP Has Done For My Bloodwork Numbers

….absolutely nothing.

But there is something cool and dramatic to share. Read on.

Backstory:

I have been getting regular blood work every three months for over a year now, mainly for monitoring purposes. Last year, I went to my doctor because I was having extremely infrequent and heavy periods. My doctor ordered bloodwork for a full hormonal panel, adrenal function, thyroid function, and more.

When the results came back, my cortisol was deemed to be too low, and I was deficient in Vitamin D. My blood sugar was also slightly outside of the normal range (by one point), so in subsequent follow ups, my A1C was tested as well.

My doctor has been really happy with the results over the past year. Everything has been slowly and steadily improving. My blood sugar has been in the normal range in every follow up reading. My cortisol levels and Vitamin D levels have been steadily improving. My thyroid hormone levels are all within normal ranges. My A1C is hovering just above the high range of normal, and it hasn’t budged much, but my doctor isn’t worried because everything else is looking great.

But I just got a CPAP machine in the past three months, and so many things have dramatically changed for me, along with my sleep. My energy levels. My ability to focus. My motivation levels. My recovery from heavy lifting.

So because everything has been going SO. MUCH. BETTER. for me, I was expecting Dramatically Different Results on this quarter’s blood work.

What Actually Happened

Well, I got my test results back this week, with a note that said “the doctor wanted me to let you know they look amazing.” And I saw them, and I saw that they were pretty much the same as last time, and I was actually disappointed, because I was hoping for some really dramatic difference.

So I Examined My Self-Talk

Why is it that we want drama and drastic changes to see if something is working? Is it not enough that I am doing things around the house I have never done, and actually able to sustain a healthy lifestyle now, and that I am a better parent and friend and can focus at work again, and that I don’t need to be sedentary for 23 hours per day to recover from a one hour workout? Why do I need dramatic blood work results too?

The Answer: Comparison

A friend of mine on Facebook, Patrik, has been posting about his own health journey, and it has included some dramatic changes in his blood work numbers. Within the past year, his A1C levels have dropped from 9.6 (diabetic) to 4.9 (normal).  His doctor has taken him off the medication he takes for diabetes, high blood pressure, and high triglycerides. He went from spending hundreds of dollars per month on medication, to spending just $5 per month, as only one medication remains. He no longer needs the CPAP machine he needed before.  He was previously sedentary, and now he has recently run his first 5K and is getting stronger in the gym all the time. In the process of changing all these numbers, his body weight also reduced by about 30%, give or take.

Now, Patrik improved his health using a very different approach than I have been using. Instead of making small changes over time, he made some very big changes. He went from a sedentary lifestyle to doing regular CrossFit workouts, and adopted a lower calorie ketogenic diet.  I started questioning, momentarily….should I go back to CrossFit? Should I do what he does?

And I realized that I need to keep my eyes on my own journey and not compare myself to someone else.

See, Patrik and I come with different health histories, different needs, and different responsibilities. While I am beyond excited for him that he got off almost all his medication doing a restrictive diet and regular CrossFit workouts, I have already tried that route, and it didn’t work with my life in a way that I could sustain and it didn’t make me healthier. Does that make it “wrong?” Not for Patrik, it doesn’t. For me, it does.

So, let’s talk about those “dramatic” blood work changes I was wanting, and how I was disappointed to see stability. Patrik was on several medications, and his levels were still high, before he made lifestyle changes. He had room for dramatic changes. Whereas I am on zero medications. Shouldn’t I be grateful that I don’t have far to go? Yes, I should. Instead of being disappointed that I didn’t see any dramatic change, I should be grateful that my body functions normally without medications. How’s that for perspective?

For Patrik, his medical reasons for adopting a restrictive diet are obviously compelling. For me, with a history of disordered eating, any potential benefits do not outweigh the risks. I know, because I have done it in the past, and after years, it led to bingeing and weight gain and disordered eating patterns. So, even though I know I could probably nudge A1C down into the normal range by restricting certain food groups, the benefit is not worth the cost to me at this time. I am healthier and happier being more free with my food. And I am grateful that I have the luxury of doing so. Instead of being disappointed that my A1C is stable, I should be thrilled that it is stable, that my blood sugar is in the normal range, and that my body can handle the food I need to eat to maintain my mental health. Again, instead of being disappointed that I didn’t see a dramatic change, I should be grateful that I don’t NEED to see a dramatic change.

Patrik was able to stop using his CPAP machine in the past couple months. His energy levels and sleep improved on his new lifestyle, with his healthier habits. Whereas I have tried maintaining healthier habits throughout my life, and something always was wrong, even when I was much thinner. I recovered incredibly slowly from workouts that gave most people my age no problems. My hunger levels seemed abnormally high. My motivation at home was always low, and my motivation and focus at work took a lot of effort to maintain.

And I tried to make drastic changes, like Patrik did, over the years. I’ve done restrictive diets and high intensity workout regimens in the past….and they always ran me into the ground, more than they should, and I couldn’t continue. (Isn’t exercise supposed to make you feel better, not worse, over time?)

….Until I got my CPAP machine. Now MY energy levels are off the charts. My motivation levels and focus are at an all time high. I’m finally able to recover well from the workouts I do. So, while Patrik was thrilled to get rid of his CPAP machine, they may have to pry mine from my cold, dead hands.

In addition to having different health histories, we also have different responsibilities in our current lives. His daughter is a teenager, and my son is a preschooler. Until last month, I was still a breastfeeding mother.  Our day to day (and nighttime) parenting demands are different (I know nothing about parenting teenagers, so I am not going to say it is easier. Just different). So, the food and exercise routines that fit into Patrik’s life are different than the ones that will fit into mine. Again, I should be grateful that I don’t have health challenges that require me to make more drastic changes to my life.

So, there is no good reason for me to be dissatisfied with my own progress because it doesn’t look like my friend Patrik’s. We are completely different, and my progress is great too.

Three years ago, I had hypothyroidism. Now, even with a 40% weight gain (some muscle, some fat), my thyroid function consistently tests as healthy and normal.

One year ago, I went to my doctor to talk about extreme fatigue. I needed frequent naps. Now, I almost never need naps. I feel as energetic as I did 10 years ago and 50% lighter.

Since my pregnancy, I had severe brain fog that didn’t go away for years after I had my son. Now, I am thrilled with how mentally sharp I feel.

Even alongside a weight gain, my blood work is healthier today than it is one year ago. My cortisol levels are back in the normal range.

Now, my hunger and thirst levels feel much more manageable. I no longer need to eat or drink frequently to keep my energy levels up.

So, clearly, I need to be more grateful. My health has indeed improved dramatically. I realized that instead of hoping for “dramatic blood work results,” I can choose to be grateful that I don’t need to see dramatic blood work results in the first place, and be grateful for the amazing changes I HAVE experienced.

And remember how I said that one year ago, my periods were extremely infrequent and heavy? Well, I just got an unexpected menstrual period…..one month after my last one. For the first time in at least 6 years. So, I got my dramatic result after all, just not the one I was expecting. I have never been more happy to menstruate.

Moral of the story? Eyes on my own journey. Patrik is doing an amazing job, and I am doing an amazing job. Both of us are improving our health and quality of life, even though that looks different for each of us. I can be just as happy for myself, too.

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I Have Questions About Obstructive Sleep Apnea

Since getting my diagnosis of obstructive sleep apnea and being on CPAP therapy, I have been talking to others who have it (or those who have family members who do). I’ve been reading and learning more about it. And I have some questions.

We may not know the answers to all of these questions yet, but I would love to see them researched.

Weight Stigma and Accurate Diagnosis of Obstructive Sleep Apnea

Before I knew much about obstructive sleep apnea, I had only heard of it as a vague threat of something that could happen to fat people. At the time, the only other person I knew of who had sleep apnea was fat too, so there was nothing to challenge this belief.

Since I started talking about the fact that I have sleep apnea, four people told me that their (thin) husbands also had it, and one thin woman told me that she had it. Of these five people:

  • one had his symptoms blown off by doctors. They initially told him that his symptoms were probably related to stress. The fact that he had issues with his airway were not discovered nor tested until it came up while looking for another issue.
  • one pushed back against his wife’s insistence that he go get a sleep study to address his snoring and witnessed apneas. Why? He thought it wasn’t possible for him to have sleep apnea because he wasn’t fat.
  • after having many medical issues come on fairly quickly, and finding sleep apnea in the process of testing these issues, one had her doctors tell her “you don’t LOOK like you have sleep apnea.”

So, I wonder: If patients and doctors think that sleep apnea has a “look,” how many people go undiagnosed and untreated?

Not all doctors think that sleep apnea has a “look.” My sleep specialist told me that she has patients of all sizes with sleep apnea. Some thin people have very severe cases. But obviously other doctors, as well as the public perception, has some catching up to do.

And insurance companies certainly have catching up to do. My insurance company, United Healthcare, denied my doctor’s request for authorization for an in-lab sleep study, on the basis that I did not have a serious heart or lung condition OR a BMI of over 50. They would only have paid for it if I was fatter or sicker than I already was.

I’m not pretending that there aren’t higher percentages of fat people with sleep apnea than thin people with sleep apnea.  Data says that there are. But that doesn’t mean that thin people with symptoms should be assumed not to have it based on their weight (after all, if thin people are going undiagnosed, that may further skew the data!). And we must also remember that risk factors are not the same thing as causes, and that correlation does not equal causation.

Biological Sex and Accurate Diagnosis of Obstructive Sleep Apnea

According to the Mayo Clinic and almost any other list of sleep apnea risk factors, men are almost twice as likely to develop sleep apnea.

However, almost all other moms I know complain of being tired, and feel that being tired is a normal part of having small children. And they are probably right, however….

I wonder…how many women go undiagnosed and untreated, because they believe their fatigue is normal? If those women were properly diagnosed and treated, would the data still show that men are at higher risk?

Personally, I think my diagnosis was delayed because many of the symptoms I experienced were also common in pregnant and postpartum mothers. It’s just….they didn’t go away.

So, for that matter:

How many people would receive a more timely diagnosis if doctors asked more questions about sleep in their annual physical exams?

Weight Stigma and CPAP Compliance Rates

Though CPAP therapy is considered a highly effective treatment for sleep apnea when used consistently, compliance is extremely low (anywhere from 50-80 percent do not use it at all or frequently enough, depending on which studies you read). Some factors that effect compliance are physical, such as not feeling comfortable with the mask, or even claustrophobia.

But I wonder if some of them are due to stigma around needing a CPAP machine.

If people feel negativity towards their treatment because they subconsciously think it is some kind of punishment for being fat, or because it brings up feelings of fear about their own mortality, are they less likely to try and stick it out and get used to it?

Those are some questions on my mind about how we handle obstructive sleep apnea in our culture.

And one other question on my mind:

My kid was a shitty sleeper and woke up frequently as a baby and toddler. I wonder if my snoring woke him up?

We’ll never find out the answer to that one!

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Ripple Effects – Helping Friends and Growing Things

Yesterday was a great day. I felt great physically and mentally. I had gone to bed by 9:30pm for the prior two nights.

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Ready to take on the day!

One thing I feel really great about was that I was able to spend some time helping a friend who had been in a car accident last week. Kiddo and I went grocery shopping for her, and then I folded some laundry when I got to her house while our kids played together. I feel really satisfied and happy that I was able to do this, not only because it helped my friend, but also because in the past, doing this would have wiped me out and taken a lot of “spoons” for me.

Truth: In past years I have accepted a lot of help from family and sometimes from friends, for basic tasks around my house. Everyone says that is normal when you have a baby, and to be grateful for any help offered to you. And I am very grateful. But part of me always felt guilty accepting the help, because I knew that I would likely not be able to offer similar help to others in the same position, because I didn’t have the energy. So I am really glad to be able to offer help to others now.

Afterwards, kiddo and I walked over to the garden to water. No germination yet. Maybe today we will see some lettuce sprouts.

Another thing I feel great about is that my legs were recovered enough from the prior day’s deadlifts to work some olympic weightlifting technique in the morning….and still feel energetic on my feet throughout the day afterwards! Took my kid to gymnastics, did the grocery shopping for our friend, walked to the garden, walked back home uphill with my tired kid in a carrier….and my legs managed all of it without feeling too spent!

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One Weird Downside of Using A CPAP Machine

When I started researching CPAP machines, I learned that while they are a highly effective treatment for obstructive sleep apnea, compliance can be pretty low (around 50%). Reasons for non-compliance include discomfort with the mask, inability to fall asleep with the mask on, feeling claustrophobic, and not wanting to wear an unattractive piece of headgear to sleep.

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Twinsies!

Thankfully, I have not had any of those issues beyond the first week, and CPAP therapy is going amazingly well for me.

The downside….is that sometimes it makes me feel a little too invincible. Now that I can stay up late and still be functional and clearheaded during the daytime, it was easy to get a little carried away binge watching Orange is the New Black for a couple weeks. Yes, I know I am late to the party.

So, I stayed up until 11pm a few too many days. And while I am still MUCH more functional than I was before I had the machine, I could tell that I would feel better if I went to sleep earlier. If I can get my workouts in first thing in the morning, I’m much more likely to do them. And I am much more likely to get them in first thing in the morning if I go to bed at 9:30pm instead of 11pm.  I also am less likely to feel “snacky” at night if I go to bed early.

So, while my CPAP may feel like magic, I have to remember not to rely on it to the exclusion of other healthy sleep habits. To feel my best, I still need to practice good habits.

Last night I went to bed around 9:30pm, and had a great day today. I’m thinking of changing my habit goals by shifting the sleep habits a few minutes earlier. Maybe instead of “bed by 10pm,” I’ll change the goal to “bed by 9:45pm.” Or instead of “no TV shows started after 9pm,” I’ll change it to “no TV shows started after 8:30pm.” I’ll give it some thought.

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