Sleep Apnea, Obesity, Diabetes and Other Revelations

Tracy Nasca - October 31, 2011

Women have sleep apnea.  A couple of decades ago, when I was diagnosed, it was thought to be a disorder seen in overweight middle aged men.  That explains why I spent 14 years searching for answers to my sleepiness and weight gain.  I was treated for polycystic ovarian syndrome, hormone imbalances, depression and told to lose weight.  No one asked me if I snored, no one paid attention to my comments about being sleepy all the time.  No one looked down my throat for a narrow airway or noticed the tongue that was too wide for my narrow jaw.  No one commented on my high arched soft palate.

20 years later, sleep apnea awareness has resulted in a huge increase of diagnoses for both men and women.  Yet there are still an estimated 18 million Americans yet to be diagnosed.  I had never heard of sleep apnea, nor any sleep disorder for that matter.  Sleep is something we all take for granted until we get too much or not enough.  I am sharing my very personal story,  for continued awareness with a special focus on women.  We’ve come a long way, but many of us are still being overlooked or misdiagnosed.

The onset of sleep apnea symptoms can appear soon after puberty when the tongue and jaw reach their full adult size.  Since apnea is often caused by our anatomical make up, it’s primarily hereditary.  If mom or dad snore, chances are you do too if you physically resemble them.  For me, symptoms appeared in my early 20’s but only after I started putting on a few extra pounds.  I had sleep apnea, but as I gained weight the symptoms elevated and were much more apparent.  The more weight I gained from being sleepy and lethargic, the worse the apnea got and the vicious cycle spun out of control.  For women, the onset of apnea can be triggered by menopause.  A high percentage of women in menopause experience weight gain as less estrogen is being produced and the metabolism slows.  Throw in an underactive thyroid and watch the additional pounds mount up.  This weight gain often causes the onset of sleep apnea in women.

In 2003 as I was going through the process of qualification for gastric bypass surgery, I had to meet with a psychologist. I thought it was to help me with the new post surgery diet I would be on; adjusting and learning to eat very small portions.  The Psychologist said, “Tracy, let’s talk about obesity and identify your eating disorder.”My what?  As I blushed with embarrassment, thoughts flooded my head.  I had never thought of myself as having an eating disorder.  I blamed my weight gain on my sleepiness, the many years of having untreated sleep apnea.  Golly, I have Type 2 diabetes, restless legs syndrome and sleep apnea; now I have another disorder?  I was uncomfortable being referred to as obese.  The term “eating disorder” was not sitting well with me either. 

When I think of eating disorders, I think of people who have anorexia or bulimia; those that obsessively exercise and starve themselves or binge and purge.  People like me, who are overweight, have hereditary or metabolic problems, or just eat too much and exercise too little.  Fat people don’t have eating disorders, only skinny people do!  I had much to learn.

As a kid, I never thought of myself as overweight, although I do remember being called chubby.  I gained weight in high school but lost it. At age 19, my wedding gown was a size 9.  This newlywed began putting on weight slowly and steadily.  Three years later, after the birth of my first child, I could not lose the 40 additional pounds gained.  My second pregnancy accounted for another 40 pounds. My sleep apnea was in full bloom but not yet diagnosed.  By the time I was 35, my weight had soared to 297 pounds on my 5’3” frame.  I was miserable, even after finally finding out I had sleep apnea and it was treatable.    When you are overweight, people think you are lazy.  When you are overweight, it’s hard to find nice clothes and feel attractive.  People stare at you.  People make rude comments.  It’s embarrassing and depressing.  Although I successfully treated the apnea, I never got a handle on my weight.  So here I was now, admitting obesity, but, an eating disorder?  That had never crossed my mind.  Not once.

After the initial shock and pursuant conversation with the psychologist, I came to terms with the fact that yes, I must have an eating disorder.  Of course I did, I had managed to gain massive weight and that did not happen by itself.  But when and how did that happen?  We discussed family genes, the inheritance factor for my sleep apnea, weight gain and subsequent diabetes.  She helped me face the hard facts, release the denial and stop the blame game.

Ok, I had to take some of the responsibility.  With her help, we began to identify my bad eating habits. I still wasn’t sure I had any.  She asked me to keep a food diary and write down everything I consumed including quantities and the time of day I ate meals and snacks.    Within one week of logging, it all became clear.  You don’t realize what and how much you eat until you see it in writing!

So, how did I get here, back up to 264 pounds?  At this time in my life, I was successfully treating my sleep apnea with bilevel.  A decade ago I had lost 100 pounds on a physician controlled fasting diet; then gained most of it back.  Weight gain is sneaky, it creeps up slowly when you least expect it.  One pound at a time it is not noticeable but as life happens, and months later, you suddenly feel that “gottcha” moment.  How did I get here again?  My problem was that I could not lose that weight. I dieted until I was blue in the face; up and down like a yo-yo.  I developed uncontrolled type 2 diabetes and was on the verge of requiring insulin.   I was also in depression.  My husband had recently died of congestive heart failure and I was suffering with sleep onset insomnia bouts.   He died during the night, in our bed and in my arms.  The bedroom and our bed was no longer a pleasant place.  I had trouble falling asleep and so would wander the house at night doing things to keep the sadness out of my head.  I steam cleaned carpets, washed baseboards and….ate.  I munched out of boredom and depression, not because I was hungry.  Since I ate at night, I never ate breakfast because I was not hungry.  Ravenous by mid day, I pounded down whatever I could get my hands on.  My food choices were outrageous when I saw them on paper.  The bodies of sleep deprived people crave energy often in the form of sugars, carbohydrates and caffeine. 

Widowed and living alone, cooking for one was challenging and not something to which I adjusted very well.  I had never cooked for one, nor sat alone at the kitchen table to eat. Unnatural to me, it was a sad reminder that I was a young widow.  It was easier to drive through a fast food restaurant and I did that a lot.  The order takers behind the window could not see fat me, and did not know I was ordering for one as I left with enough food for a family of four.  I couldn’t decide what to eat, so I just ordered a variety.  Sometimes I ate it all, but often the food ended in the trash, sinfully wasteful, expensive and cause for guilt, shame and depression….again.

When I shopped at the grocery store, I threw in easy, handy prepared foods, high in sodium, fat and calories.  I shopped when I was hungry; cookies, chips and bakery goods always found their way in to my cart.  I did not even visit the produce section.  Meat consisted of whatever was on sale in the deli.  My shopping goals were: easy, quick, microwavable.  I had lost interest in life and in food and sometimes had to remind myself to eat.  As strange as that sounds, it was my reason for declaring, “I have no idea why I cannot lose weight”.  It was the food choices that got me and eating late at night.  I was a reckless out of control diabetic, how could I not see it?

I learned that depression was a key factor in my eating disorder.    I thought of myself as a strong person and never admitted to my depression until years later after it was finally resolved.  Me, depressed?  No way, not me!  When one is IN depression, it’s not easy to recognize, let alone admit to.  What I learned in hindsight was that I used food to make me feel better.  When I was sad, a sweet treat tasted good and provided pleasure.  If one Oreo made me feel better, the whole bag would soon disappear.  Chips, you can’t eat just one…..how true for me.  I could open a box or bag of something in the late morning, and it would be gone by night fall.  On my dead husband’s birthday, I ordered a butter cream birthday cake with his name on it and ate the whole thing, all the while crying.  It did not make me feel better; in fact I got sicker than a dog; no telling what it did to my blood sugar.  I never planned meals or thought of nutrition, I just wanted to open a cupboard or the fridge and grab a can, box or bag of something to eat.  Afterwards, I felt guilty for eating things that no diabetic should even consider.  Guilt, shame, depression and the cycle continued without my even realizing what was happening and what I was doing to my health and well being.

So, there it was staring me in the face, my food diary.  All of my dirty little secrets exposed.  It was clear, I had an eating disorder.  It was classified as binge-eating.  I had to take a big step back and think about all I had learned.  My reason for choosing gastric bypass was to rid myself of the diabetes.  Losing massive weight to cure the sleep apnea was a secondary hope. Losing weight for appearance sake would just be a bonus.   The psychologist and I had the heart to heart discussions about how my life would be impacted by the surgery. I could still gain the weight back if I did not change my ways. I could cause medical complications if binge eating continued.  I had to convince her that I could do it, she had to give the thumbs up or down on my surgery approval.  More importantly, I had to convince myself.  This was a risky surgery and life changing decision I was making. I passed the test.

 Choosing the Roux-en-Y procedure meant that not only was my stomach going to be reduced to the size of a golf ball, but it would be connected to the middle part of the small intestine bypassing the intestine where normally the nutrients and calories are processed.  So in my case, the food I ate would pass through in a different way, and I would need to focus on proper nutrition to combat malabsorption.  I would have to each several small but healthy meals daily to make sure I took in the right amount of vitamins and minerals;  something void in fast food, pastry and snacks!  My bingeing days were over.

Surgery day came and went with no complications nor side effects.  I was committed and followed my nutritional education and instruction to the letter.  I lost most of the weight within the first 6-9 months and was declared diabetes free.  Despite the weight loss not impacting my sleep apnea, it was a cause for joy.  Had I not come to terms with the fact that I had an eating disorder, I am sure my recovery would not have been so successful.  Old habits were hard to break but I was doing it!

I don’t believe in luck, good or bad. I believe we are put on this earth to learn lessons.  My husband was a student of PMA – positive mental attitude and he loved to quote two sayings that live on with me today:  “whether you think you can, or think you can’t, you’re probably right” and “we are dealt a hand in life, it’s how we play the game that counts”.  These words nudge at me every day; my incentives to stay on track.

I will do battle with my eating disorder for the rest of my life.  I think of myself as being in remission, but it always looms over me.  I choose to think positive.  “I think I can” play the game, the hand I was dealt, because of lessons learned.  When my journey takes me to a crossroad, I know that if I choose the wrong path, there will be another crossroad to bring me back!  It relieves the guilt and subsequent depression which for me were the biggest negative factors that perpetuated my eating disorder. 

The greatest lesson learned was my own recognition of, and admission to having an eating disorder. It was also clear to me that the eating disorder developed during my sleepy years as an undiagnosed person with sleep apnea.  Only then did I understand how to deal with it successfully.  I am, after all, human and with frailties. I learned to love myself for who I am inside and outside. Facing the temptations in life is easier when you know yourself and believe in yourself.  I have learned to honor the spiritual essence in myself, and in everyone and everything around me.  I try to live my life in balance as I continue on my journey. 

People often ask me if obesity causes sleep apnea or if sleep apnea causes obesity.  It’s a hard question; I am not sure there is one answer for everyone.  Since my drastic weight loss did not “cure” my apnea, I would say in my case, I am proof positive that sleep apnea is an anatomical and hereditary issue.  But I would also say that having sleep apnea undiagnosed for so many years contributed to my spiraling weight gain.  The more weight I gained, the worse my apnea got until it was so devastating and life threatening, that it finally caught the attention of a physician.  Did I become a binge eater because my body was so sleep deprived it cried out for energy in the form of sugars and carbohydrates?  Did I become a binge eater because I was too tired to exercise, plan meals, shop wisely and follow a diabetic lifestyle? Was it due to hormonal changes and early onset of menopause?  I’ll probably never know. But what I do know is that I lived far too many wasted years having full blown sleep apnea left undiagnosed and untreated.  My sleep disorder was not diagnosed until 1989 when I was 35 and weighed 297 pounds.  A hysterectomy at age 32 to address polycystic ovarian syndrome threw me in to early menopause.   For over a decade I sought answers for my sleepiness and weight gain, an enigma to my medical team.  Back in the 1980’s apnea was thought to be a disorder of overweight middle aged men.  My weight gain and sleepiness, according to my doctors, were of my own doing.  Fortunately, today we know that men and woman are at risk for sleep apnea.  In fact, over 18 million Americans have sleep apnea but are yet to be diagnosed. 

Obesity and type 2 diabetes are rampant in our society today.  The comorbidities between obesity, heart health issues, diabetes and sleep apnea are such that any person who has one should be evaluated for all of the others.  Sleep apnea is an obvious trigger to obesity, subsequent diabetes and hypertension.  We know that treating sleep apnea can reduce hypertension.  We know that treating sleep apnea can help with weight loss especially when the therapy precedes massive weight gain.  The message is to recognize the importance of healthy sleep and how when that is deprived, it sets in to motion an array of serious medical complications and psychological challenges.  Not only does it result in spiraling health care costs, but it impacts quality of life and can cause early demise.

Sharing my story in this way was hard to do, exposing my vulnerabilities publically.  My passion for increasing sleep apnea diagnosis has been a significant part of my life for that past 20 years.  My recent focus is even more important, helping patients become CPAP compliant.  I can only assume that because sleep apnea education is currently not reimbursable, most patients are not receiving the follow up care they need to assure rapid compliance.  Today, I am a sleep educator.  I got there, not through formal college education and post graduate degrees.  I got there by experiencing life, the good, bad and ugly.  I got there by fighting, falling off the wagon and picking myself up again.  It has been a long journey and as I continue to walk the walk, I hope that in my lifetime, I can have a positive impact on increasing CPAP compliance utilizing sleep education and after care programs.

Sharing a comprehensive overview of my life with sleep apnea, diabetes, depression, eating disorders and obesity is my way of waving the red flag to anyone who is reading this, whether physician or patient.  Look beyond one health issue, see the big picture.  For the physician, consider the comorbidities, screen for sleep apnea.  Make sure your diagnosed apnea patient receives the follow up care they deserve to reach CPAP compliance putting them on the road to better overall health. 

For the sleepy person who has any of the following:  hypertension, depression, diabetes or obesity, underactive thyroid, menopausal weight gain, please have an overnight sleep study to diagnose or rule out life threatening sleep apnea.  It is hard to advocate for yourself when living in a sleep deprived fog.  It is not just about snoring; there are many other factors that you may not have realized are red flags for sleep apnea.   It may be easier to procrastinate and when depression is involved, it can seem downright impossible to sit before yet another doctor and ask “might I have sleep apnea”?  Sometimes we feel defeated and it is just easier to give up.  Don’t give up.  The good news about sleep apnea is that it is treatable.   Challenging yes, but with delivery of the proper tools, cpap, mask and humidifier, it’s just a matter of acceptance through habit and with intense follow up care provided by your medical professional team.  You are only alone if you let yourself be.  You are not just treating the sleep apnea; you are reinstating the best quality of life that you can achieve.