June 6, 2024 • 29 mins
Unlock the secrets of a good night's sleep and its profound impact on weight management with sleep medicine wizard Dr. Ethan Emmons. Our latest episode traverses the shadowy links between sleep disorders like apnea and weight gain, especially in the bariatric world. Dr. Emmonss, with his rich background in pulmonary and critical care, decodes the body's adrenaline-laced response to sleep interruptions, illuminating how they can sabotage blood sugar and fat regulation. Whether you're a health aficionado or a medical professional, this conversation packs a wealth of insights, demystifying the complexities of sleep and weight for a healthier you.
Discover the transformative power of sleep hygiene and its pivotal role in prepping patients for bariatric surgery in our compelling dialogue. Dr. Emmons dissects the nuts and bolts of at-home sleep apnea testing, providing reassurance with non-invasive techniques that pave the way for better health. We lay out a practical blueprint for enhancing sleep quality, from screen-time curfews to curbing caffeine, guided by recommendations from the American Academy of Sleep Medicine. These nuggets of wisdom aren't just theoretical; they're life-changing rituals that could lead to sweet dreams and even sweeter health outcomes.
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 1 (00:00):
Welcome to Core Bariatrics podcast hosted by
Bariatric surgeon Dr MariaIliakova and TMA LaCose,
bariatric coordinator and thepatient herself.
Our goal is building andelevating our community.
The Core Bariatric podcast doesnot offer medical advice,
diagnosis or treatment.
On this podcast, we aim toshare stories, support and
(00:22):
insight into the world beyondthe clinic.
Let's get into it.
Speaker 2 (00:26):
Today we have with us an excellent medicine
specialist from Iowa Cityoriginally, and he has over 31
years of experience in themedical field as a sleep doctor.
He graduated from UniformServices University of the
Health Sciences in Bethesda,maryland.
We met working together onBariatric patients in Iowa City
and he currently leads a sleepprogram at Bell and Health in
Green Bay, wisconsin.
(00:47):
I'd really like to welcome youto Dr Ethan Emmits.
Speaker 3 (00:51):
Yes, thank you.
I appreciate it.
I know both of you fairly well.
Yeah, I'm excited.
Speaker 1 (00:56):
I'm going to be telling the audience that you
had bossed me around for a solidI think it was two years or so
while I worked in the clinicthere, but I loved working with
you and learned a lot.
Speaker 3 (01:07):
Thank, you, I will mirror that.
Speaker 2 (01:10):
I didn't get to work with you for as long, but I
really admire how much youhelped guide people through the
process that was otherwisereally intimidating.
So I'm really grateful andexcited that you're with us
today to talk about sleep andhow it affects everything.
Well, tell us first how did youeven get involved in sleep
medicine?
What was the draw for you?
Speaker 3 (01:29):
Actually my specialty was pulmonary and critical care
, icu medicine, and I have tothrow a shout out to one of my
someone who was a fellow with meat the time, chris Fry, and we
were at a critical carefellowship and he was going to
go out and do sleep as well andI was, ah, I don't want to do
sleep.
We're young, we're all aboutthe ICU, and I'm like, why would
I want to do sleep?
And at the time I didn't knowmuch about it.
(01:51):
So I'm like, oh, it's probablygoing to be boring.
But he made a very good pointto me.
He actually said to me he goes,when you're 50 years old, you
want to be up all night in theICU, and that, right, there was
it.
So that's what got me started insleep.
And then, once I got into it,you realize it's actually really
interesting and there's a lotof misconception in sleep Folks.
(02:12):
They read a lot on the internet, which is necessarily true.
Once you get into it, it'sreally interesting.
I continue to do pulmonary upto about 2018.
And then my sleep practicethere in Iowa City had gotten so
busy, went to sleep only, and Ihave to admit it is an
excellent job for later in yourcareer.
It's important in the bariatricpopulation to know about sleep
(02:35):
because it has such asignificant impact on things and
a lot of times patients arelike, hey, if I have sleep apnea
and I have bariatric surgery,what's going to happen?
And things like that.
So that's what I spent a lot oftime talking to people about.
Speaker 2 (02:49):
So let's dive into that a little bit.
Sleep apnea is something that Ithink a lot of people have
heard the term but may notreally know what that is.
Can you start off by telling uswhat is sleep apnea?
Speaker 3 (02:59):
Yeah, I'm going to give it a very specific term.
This is the way I talk topatients.
I've always my dad had a sixthgrade education, so that's the
level I generally try to explainthings and basically sleep
apnea is a mechanical problem.
So it really is how much roomback here do you have in the
back of your throat?
Now, some of that is genetic,some of that is as a weight
(03:21):
component.
Sleep apnea is at night.
You're sleeping and because ofrelaxation and the muscles in
the back of our throat, the backof your throat again deep down,
closes and it obstructs andyou're choking, literally
choking.
And as I say to patients, ifyou're choking and sitting there
in front of me in my office,you're gonna panic.
Right, it does the same thing.
(03:43):
Brain says while you'resleeping, brain says I'm choking
.
Your brain turns on awake fortwo seconds, just enough time to
open things up so you can begin, and then your brain goes right
back to sleep A little whilelater.
30 seconds, one minute, fiveminutes, whatever it is, do it
again.
You choke, panics.
Brain wakes up, opens things up, go back to sleep.
(04:06):
So basically, people sleepapnea at the brain level.
They're doing this kind ofawake asleep.
Awake asleep.
If you're not enough, they'renot getting restful sleep.
And then there's the all sortsof the physiologic things that
happen, because when you'rechoking it's a panic reaction,
so you actually have a releaseof something called adrenaline,
epinephrine, so people spiketheir blood pressure.
(04:27):
That can cause high bloodpressure, higher risk of stroke,
heart problems, makes refluxworse.
It also contributes to wakebecause when you have Drenaline
surge you also actually spikecortisol and so what happens is
having a spike of your bloodsugars.
And Whenever you takeadrenaline and people have heard
(04:48):
of the fight or flight responseand you combine that with extra
blood blood glucose, bloodsugar the body turns it into fat
.
People are just making fat andI saw it all the time.
People come in frustrated.
I Work out, I do all this stuffnot losing any weight, but you
can do all the right things allday, but if you're choking all
(05:08):
night and making fat all night,not gonna have any and you're
not gonna make any progress.
So that's one of the thingsabout sleep apnea is it actually
can cause weight gain and thenthe vicious circle the more
weight you gain, the worse yousleep apnea, the more weight
you're gonna gain.
So it plays a role in that andeven just disrupted sleep in
(05:30):
general.
Aside from sleep, apnea plays arole the hormones that regulate
our appetite Grayland andleptin or what their names are.
They're basically disruptedwhen people are sleep deprived
and it actually Triggerspeople's appetite.
So that's why during the night,when people have trouble
sleeping, if they get up duringthe night they want to eat.
It's because there's adisruption in that and
(05:51):
Unfortunately it's the also.
Not only do they what, do theywant to eat, that sweet, high,
sweet, salty, high-carb foods.
So all sorts of things and Idon't want to get into much into
the, the technical, but there'ssleep plays a huge role and
just weight in general,certainly in the bariatric
population.
Speaker 1 (06:11):
But also when you are getting that in interrupted
sleep, your body is waking up alittle bit, so you get tired
throughout the day, which isgoing to cause you to not want
to work out.
Not want to, you know, do much,or you're drinking all the
caffeine to try to stay awake.
But sleepiness during the dayis another thing.
(06:32):
With sleep apnea, that isanother thing that's gonna
hinder losing weight.
Speaker 3 (06:38):
It's been study.
We know that people who havesleep apnea or have disruptive
sleep for other reasons actuallyexercise less.
So that's actually been lookedat.
So you're a hundred percent.
Speaker 2 (06:47):
That's pretty fascinating because I don't
think a lot of people know thatsleep apnea or disruptive sleep
can actually cause Weight gain.
I think people realize that itmay stop people from being able
to lose weight, but that'spretty fascinating that you can
actually even cause weight gainand, like you said, be put on
this cycle as a result.
Speaker 3 (07:06):
Yes, absolutely can gain weight.
Now Maybe I'm jumping ahead alittle.
You know I get the question allthe time.
Is okay, I sleep and I'mgetting bariatric surgery as I
Fafnina go away.
Speaker 1 (07:16):
No, I am proof of that.
No, because my anatomy it doesnot yep.
So I am getting my teeth fixedto hopefully widen my palate,
and all of that because, yes, Iknow I still have sleep apnea.
I'm one of the unlucky ones.
Speaker 3 (07:34):
Yeah, it's about anatomy.
So this is what I tell folksbecause they'll ask.
First thing They'll ask is howdoes weight gain playing the
sleep apnea?
As I said before, sleep apneais mechanical tongue size,
tongue position.
How much room did mom and dadgive you back there?
And so some, no matter whatthey weigh, they got bad anatomy
, they're gonna have sleep apnea, it doesn't matter.
(07:55):
But there's other people whomight one way Okay, they don't
have a lot of extra room, butthey're actually okay.
But what happens when we gainweight?
Our tongues actually get bigger.
Our tongue become infiltratedwith fat.
They get bigger.
There are fat pads in the backof the throat.
That actually expands.
The folks, the unlucky ones, Ithink, where it's about hey, use
(08:17):
, got bad anatomy, it's notgonna matter what you weigh yeah
they're still gonna have sleepapnea, even after their.
Speaker 2 (08:25):
So it sounds like, basically, the less space there
is in your mouth and your palate, their higher risk for sleep
apnea.
Speaker 3 (08:31):
Absolutely.
Speaker 2 (08:32):
Yeah, and whether that less space comes from
anatomy, comes from beingoverweight and all the
contributing factors or acombination Depends on the
person, but that the extraweight is typically not helping
the situation.
Would that be the rightassessment?
Speaker 3 (08:45):
Oh, yeah, absolutely my rule of thumb.
I would tell the patientscertainly the patients that you
all were sending me would be, ifyou, if they had mild, the
moderate sleep apnea, it'sprobably gonna go away.
It really is going away.
But if they came with verysevere sleep apnea from the
get-go, I tell him he'll getbetter.
(09:06):
It may not be a severe thatneeds seep again.
Maybe you could use somethinglike a mouthpiece, but it's
unlikely that it will resolvetotally.
Speaker 1 (09:16):
So for our patients you always recommended, after
they probably level out withtheir weight loss, to get
retested.
Speaker 3 (09:22):
But it would depend on how severe their sleep apnea
was now mild sleep apnea, 5 to15 times an hour you're choking.
Moderate, 15 to 30.
Over 30 severe my rule of thumb, and the rule of thumb that the
American Academy of Medicineuses, is if it's a 10 to 12 and
above, I would retest.
(09:43):
If it was 10 or under and andthey had a significant amount of
weight loss, it's gonna be gone.
We could tell when I did tellthe patients who just wanted to
know, which is fine, but ifyou're really From the start,
it's gonna go away.
If you have significant weightloss, anyone who started with
kind of that mild in themoderate range plus, I would
(10:06):
retest them.
And even if they were severe, Iretest them because if they're
severe and then now they're mild, that may change the treatment
options.
Speaker 2 (10:15):
So we've talked a little bit about testing, but
I'm actually really curious howtesting works, because there
have been such massiveimprovements in how we test.
Can you talk a little bit abouthow that's changed over time
and how that looks in yourprocess?
Speaker 3 (10:28):
A lot of people heard of the traditional sleep study,
which really hasn't changed,and since I've been doing With
40 years, you go there, stickiesand wires everywhere and belts
around your chest and we haveaudio and video and it sounds
horrible and guess what it is?
It is, but now we do hometesting.
Now the thing about a homesleep that people need to
(10:50):
realize is it only tells meabout one and that is sleep.
There's a whole lot of othersleep disorders out there and
that home test doesn't reallyhelp me with those.
They need that overnight test.
But if I'm looking just forsleep certainly bariatric
problems that are beingreferring me to screening I just
do a simple home test.
(11:11):
You take it home, you wear it,bring it back the next day and
they're actually pretty darnaccurate.
The home test is, that said,they are considered a screening
test, so what does that mean?
It means if it's positive, thathelps me, I can believe that
result.
But if it's quote negative,there really is no such thing as
a negative home test.
(11:31):
The home test is that the triedand true, really the standard
now for initial screening, andit's what insurance companies
want us to do.
Speaker 2 (11:40):
And that just sounds so much more convenient for
people, because I think a lot ofpeople are intimidated as they
go through the process of beingevaluated for bariatric surgery
and a lot of people used to.
In practice, when I was afellow, for instance, I just saw
a lot of people's jaws or liketheir heart would sink.
You could see it on their face.
Oh no, I have to do this.
And then in your program, I wasso shocked because literally
(12:01):
not a single person evercomplained about the process,
which was incredible.
Speaker 3 (12:06):
Part of it is I mostly being.
My entire appointments arenothing but education.
So education, non sleep, apnea,what's called sleep hygiene.
But when I started to talkabout testing, the very first
thing I would say to them is so,just so you know, we're gonna
start with a home test, but letme tell you about all the
testing options and you couldjust see them.
The relief.
(12:26):
Frankly, it's because there's alot of misinformation to the
internet, a lot of preconceivedmisconceptions.
The days of the alien mask longgone.
Speaker 1 (12:37):
Yes, that's how I got a lot of women to you would
order their CPAP and they'rejust like I really don't think I
can do this.
I taught you.
You were right across the hallfrom me and I did many times
talk to women about.
It.
Is not this big barbaric maskanymore, it is as small as a
little nasal cannula at thatpoint.
(12:58):
But you were talking aboutsleep hygiene and you are so
into this, so talk about that,because, especially for people
that can't get to sleep, yeah,it is one of my soapbox items is
because I'm a firm believer andyou gotta help yourself.
Speaker 3 (13:15):
And so the biggest is coming to the big keys when
people come in and say, hey, Ihave insomnia, I can't sleep,
and there's a couple keys thatyou gotta be sleepy before you
even try to get into bed.
The other one is theelectronics, and this is what
Tamia, I know, is alluding to onmilitants about the whole
electronics.
Yeah, you are, and what we'retalking about is anything with a
(13:36):
screen TV, phone, ipad,computer.
These screens do a lot ofthings and, in the most
simplistic terms, as theybasically turn your brain on
wide awake Power for your brainto go to sleep as you've turned
off your TV or phone, and whathappens is People, they turn
everything off up, and then thatthey do.
They later takes up to an hourfor the brain to wind down, even
if their circadian rhythm wastrying to make him go to sleep
(13:59):
and 10.
And then again, as I said, witha warning, and they're, and so
they start to get spun up.
But then the people who say, oh, I have to have the TV on to
fall, but they don't realize,even though the body can go to
sleep eyes close.
Nor and everybody knows themsays they're sleeping.
Their brain actually stillpaying off up to an hour as well
(14:19):
.
It's still awake, essentially.
And so for those folks it's losttime, as I like to call it, and
when someone comes in tells mehow sleepy they are in the
morning, while I'm getting six,seven hours of sleep.
But if you lose it an hourbecause you're watching TV up to
the point you go to bed, you'renot getting six or seven hours
of sleep.
You're getting an hour less.
And so bottom line is theofficial recommendations,
(14:43):
american Academy sleep medicineis a one hour break from all
electronic screens before goingto bed.
That's what it is.
That is the officialrecommendation and there's real
science behind that, as I talkedabout.
And again, folks who say, hey,I got to have the TV on the fall
, sleep this or that, that'sgreat for you, but we're just
recognize you're losing about anhour of sleep time at the brain
(15:06):
level.
The other one I always you guysare always are in tune with
this caffeine we recommend nocaffeine after two o'clock.
Caffeine last ten hours.
People don't realize how longcaffeine hangs around.
They don't realize that.
And the other issue is thatfolks don't realize that
caffeine actually suppressesyour deep sleep, makes it harder
to get into deep sleep and youneed deep sleep to feel rested.
(15:28):
All this light sleep we getduring the night doesn't do
anything to make you feel rested.
You gotta get the good deepsleep and some dreaming sleep.
And so I always get people andvery proud of themselves, I took
three red bulls to go right tosleep and Michael G.
That's great, but it'simpacting your sleep quality as
well.
Nicotine we say one hour breakbefore going to bed is a
(15:51):
stimulant.
Alcohol is its own separatediscussion we can have about
that.
The bottom short version isalcohol is a depressant
initially.
But the breakdown products ofalcohol the liver breaks it down
are very powerful stimulants.
And so I get people say, yeah,I had to.
I have a few drinks before bed,I go to sleep, fine, but boy,
three, four, five hours laterI'm flopping like a fish.
(16:12):
Why?
is that it's the breakdownproducts of the alcohol.
Those are the some of the basicsleep hygiene things we talk
about caffeine and none aftertwo o'clock.
Nicotine, an hour break,alcohol, certainly, as I talked
about it, and really the onehour break from electronic
screens.
That's the big one, and it'salways amazing how many people
(16:33):
come back and say, yeah, Iturned off the TV and it really
made a difference.
I'm like, yeah, it really does.
Speaker 2 (16:39):
Yeah, I'm not surprised, because I think
that's the sleep hygiene issomething we really struggle
with because I think, especiallyin younger generations, we're
so used to having the phone withus all the time to work for our
families, for our friends, forall kinds of different
connections.
It's so common to just toscroll until you fall asleep,
essentially.
So it's a really it's in ourpatient population, even in the
(17:01):
general public.
I just really think that's a.
That's tough to hear that youneed an hour, yeah, yeah, yeah,
and some people just ignore meand that's fine.
Speaker 3 (17:10):
They can do it they want.
But yeah, there's plenty ofpeople ignore me and again, I've
been doing a long time.
I am a little cranky and littleand understand yeah sometimes
they'll come back and keepcomplaining to me about how they
can't fall asleep and I'm likedid you turn your TV or put your
phone down?
No, and I can't help you.
(17:31):
Yeah, you just stick to yourguns, which I think in sleep
medicine is a good thing, yeah,I'm just hey, I can't help you
till you help yourself, yeah.
So that's the one thing.
One thing I did want to bringup real quick is because I know
that you guys know I've put thisout there before is patients
who have sleep apnea, who are onCPAP and are getting bariatric
(17:53):
surgery.
The question comes up is hey,I've had my surgery, I've
started to lose weight.
Do I need to stay on my CPAP orcan I just stop it?
And there is, as you guys know,because I've mentioned it
before, there is that one studyout there that does show pretty
convincingly that patients whohave sleep apnea, who are on
(18:13):
CPAP and stay on their CPAP forone year after they've had their
surgery, actually lose moreweight and have less weight gain
back than those who stoppedtheir CPAP early after their
surgery prematurely.
And it makes perfectphysiologic sense because you
have sleep apnea even if you'vehad bariatric surgery and you
(18:37):
aren't getting treated.
Guess what your body is goingto be doing.
You're going to be working allday to lose weight and then
you're going to be making fatall night, just like before you
had surgery.
Speaker 1 (18:46):
That's a good recommendation, yeah.
Speaker 3 (18:49):
So I'm looking.
Yeah.
So I tell folks hey, yeah,you're on CPAP.
I know you don't, maybe yoursleep apnea will go away
Ultimately.
Stay on the CPAP.
And then down the road willtest you six, nine, twelve
months, depending on how fastyour weight loss Journey.
So that's one thing I do liketo tell folks is Stay on that
(19:10):
CPAP, because it actuallyprobably helps you lose more
weight versus those who don't.
Speaker 2 (19:15):
So that's a very important one for people to hear
, I think, because a lot offolks Well don't really know
what to expect in terms oftiming, and so setting that one
year expectation, I think,really puts people at ease,
because it's not arbitrary, it'snot oh, we want a torture, you
want to stay on something justfor the fun of it for a year,
but it's quite literally to helpyou get the most out of the
(19:36):
tool that you've decided to you.
Speaker 3 (19:38):
Exactly, if you're gonna go through having surgery
because that's not anythinganybody does lightly and and
there's a whole bunch of otherissues that come up with having
bariatric surgery If you'regonna go through that, set
yourself up for success, setyourself up to have the best
possible outcome you can.
And so I push people hey, juststay on the CPAP.
Yep, nine, twelve months, I'llretest you and we'll see where
(20:00):
you're at.
Speaker 2 (20:01):
So that's awesome.
Yeah, I think that's a reallygood expectation to be setting
for people.
That's one of the most commonquestions we get, so Glad you're
addressing it.
On and in terms of thetreatment options, actually,
since you've been, you'vementioned a couple of times that
the days of the alien mask aregone, where, yeah, yeah, the
Darth Vader voice overnight orsomething.
Yeah, what does that look likenow for people and does it vary
(20:25):
by severity?
What does what kind ofdetermines what treatment
options are available?
Speaker 3 (20:28):
Yeah, if you have moderate to severe sleep apnea,
your initial treatment is stillCPAP.
It really you've seen thesethings on TV and spire, which is
not new and spire has beenaround probably 10 years Things
like inspire and some of theseother surgical implants that
they talk about doing.
Now those are second line.
Those are for people who'vetried CPAP the mask and machine
(20:50):
and they struggled or it justdidn't work for them.
It wasn't effective for them.
Then that can make themcandidates for some of these
implantable devices like inspire.
Now everyone wants to knowinspire is what is inspire?
It's a pacemaker that'simplanted surgically.
Their wires are run to the backof the throat and at night you
have a remote and you turn theSpace maker on and you get
(21:10):
electrical stimulation to theback, your throat turning.
That helps keep the musclesactivated to keep things open so
you can breathe.
Actually works pretty well.
But again, it's a second linetype thing after CPAP.
So moderate, severe yeah,you're gonna end up on CPAP
initially Mild is where youreally have a lot of options.
Some people still do CPAP,machine mask and I'll talk a
(21:33):
little bit about that in asecond.
I'm a huge fan of thesemouthpieces.
They're called oral appliances,dental orthotics they have
different names.
They're actually a medicaldevice there, so people think
it's covered by dental insurance.
No, it's covered by yourmedical insurance, including
Medicare.
But these are mouthpieces.
They they fill your mouthpretty good, as I like to show
people.
(21:53):
But it's an upper.
It's an upper and a lower.
They're custom made to you bysomeone who does it, usually a
dentist.
They're custom made and whatthey do is they actually move
your lower jaw a little bitforward.
I'm talking millimeters hereand and you guys have done CPR
it's just like doing a chin lift.
We do a chin lift to pull thejaw a little forward to open up
(22:16):
the airway.
When we're doing CPR.
That's what these oralappliances do.
They just move your lower jaw alittle bit forward.
Super effective and mild sleepapnea.
I'm a huge fan of those.
For mild sleep apnea.
Occasionally positional therapy.
Some people only have theirsleep apnea usually on their
back only and on their side.
(22:37):
They're fine.
And I got ways to keep you offyour back.
In the old days, 30 years ago,we'd say you go buy a tennis,
tennis balls, take three tennisballs it's so many aligned on
the back of a t-shirt.
And guess what?
Nobody sleeps with three, tenon three tennis balls.
But it can be very effectivefor people who have no other
reason to sleep on their backs.
Some dude they have whateverhip pain, whatever it is.
(22:59):
But positional therapy alone itcan be beneficial.
Sometimes weight loss alone,other than bariatric surgery.
Isef sent a number of people tothe medical weight loss program
where we were at.
So medical weight loss andpeople have mild sleep apnea is
can be very effective.
So not having to go through tothe end of getting bariatric
surgery.
(23:19):
And now one of the interestingthings, or exciting things,
coming out there's been studiesnow about a pill to treat mild
sleep apnea.
It's in studies.
It's gonna start its phasethree study and I won't get into
what that means, but it's beenproven to be safe and effective
and now they're doing largestudies on this.
It's a couple differentmedicines.
I won't get into the details,but this will probably be on the
(23:42):
market the next three to fiveyears, a pill that has shown to
be pretty effective for mildsleep apnea.
So there's options and there'seven more options coming.
Again, I'm getting towards theend of my career.
A lot of these things I won'tprobably deal with, but there's
gonna be more options.
In regards to CPAP the alienmass they had talked about the
(24:04):
machines nowadays they're small,yeah, big, they are small.
If you hear your machine isbroken, everybody's worried
about compressor sounds.
I'm telling you, you hear yourmachine.
You better take it back becauseit's broken.
And as far as masks, yeah,there are still some that cover
the nose and the mouth are likethis there's some people that
need that.
There's someone cover the nose,there's some that just sit
under the nose and, as Tammymentioned, some that just go
(24:26):
into the nose, and I don't haveany sitting here in my home
office, but that's actuallyshocking yeah yeah, I would
think you have an armament ofthem in the back, but you know,
yeah so, yeah, no, I have a, butthey're in a box.
I actually should have pulledthem out.
I just didn't think about itbecause, yes, tammy, I took them
all when I left.
Oh, that's funny.
(24:47):
So that's why I had acquiredthem.
I took them with me.
But the point being is, yeah,the days of the alien mass, the
compressor sounding machine, allthose things are just long,
long gone and, as Tammy knows,when I start somebody on CPAP, I
would have a whole appointmentwhere I would do nothing but go
over, sleep CPAP with them, showthem mass, showing them machine
, tell them the key to doing it.
(25:08):
And I'll tell you right now thekey to doing well with CPAP.
You have got to put it on everynight and I could care less if
it's an hour or two hours orthree hours.
You've put it on every nightbecause it is as much a habit as
it is anything else and ittakes two weeks to develop a
habit and I just can't tell youthe number of patients would be
like, yeah, I just put it onevery night was only for a
(25:29):
couple hours, but I put it onevery night.
And they'll tell me, yeah,after two, three weeks, suddenly
I just got it and it started tostay on more and more.
I tell folks I can help anybodyit puts it on every night Can't
help the person who tries twicea week.
Speaker 2 (25:43):
That's a powerful message to hear, because I do
think a lot of the things thatwe do, we're offering tools and
we're offering support and we'reoffering knowledge and
expertise, but ultimately wecan't be there 24 seven with
people and it does requireputting it in action.
Do you find, when you havefolks maybe that are struggling
with compliance or strut,they're just struggling with
(26:04):
getting it to done in their life, what kinds of things can help
with that?
I don't know if you've ever hadpeople come to you and say this
works, this doesn't.
Speaker 3 (26:12):
As far as CPAP, yeah, yeah, yeah, a lot of it is
figuring out what works best foryou.
I'll tell you, one of the bigmessages is everybody knows the
guy who says, oh, I use thismask and you should use this
mask.
No, you've got to find whatworks best for you.
And the thing I tell folks isyou got the two keys, you got to
put it on every night andyou've got to work the company
(26:33):
you get the machine from to findthe right mask for you.
And it is common for people togo through two, three, four
masks in the first couple ofmonths before they figure out
the one that's the one for them.
And I tell them you've got to dotwo things.
You got to put it on, butyou've got to work with that
company to get into the maskthat you're comfortable with and
what I like to wear, because Ihave CPAP, I have sleep apnea.
(26:54):
Then we're in it 20, what?
Four years?
People always want to.
They always ask me what do youuse?
And I'm like it doesn't matterwhat I use.
Speaker 1 (27:02):
You've got to find.
Speaker 3 (27:03):
You've got to find the mask that works for you, and
so the big key is putting it onevery night and finding the
right mask.
And I will tell you, if someoneputs it on every night and they
work to find the right mask,98% of them do great they just
do.
Speaker 1 (27:18):
Most of your parents or parents could gravy.
Speaker 2 (27:21):
Most of your patients were very compliant, for sure,
because they got that educationfrom you and they got that role
and that approach of find theright fit for you, I think,
really resonates with ouraudience, with our folks,
because there is no one one sizefits all strategy for any of
this.
So making sure that you takewhat you can into your own hands
and you get help when you needit, I think that's a really
(27:41):
powerful message coming from you.
Speaker 3 (27:43):
Oh yeah, like I said, everybody's different and so I
tell that to folks.
You've got to find your way inall this because everybody's
different, and certainly withCPAP or any sleep problem you've
got to put the work in.
And I've often tell patientsI'm there to guide you, I'm
there to be your cheerleaderwhen you come back to see me,
(28:03):
but I can't come to your houseand put your CPAP on you.
Speaker 2 (28:09):
And I used to tell folks all the time.
Speaker 3 (28:12):
You know what I said.
Hey, I stopped going topeople's houses and moving their
TVs out of the bedroom a fewyears ago.
I can't help you if you don'thelp yourself.
Speaker 2 (28:19):
That's fair, that's fair and, on that note, I think
that's probably a great note forus to wrap up the episode.
But yeah, dr Emons, I'm just sograteful to you because such
incredible care of the patientsthat we got to work on together
I thought that was superremarkable.
You were such a greatcommunicator, not just with your
patients but also with us, andI just really want to commend
you for the kind of care and thekind of compassion that you
(28:43):
show, because it really makes atremendous difference and even
for me who's a younger surgeon,and I just I'm so grateful for
working with you.
Speaker 1 (28:50):
Yes, I appreciate that.
I am too, even though if youwere cranky and mad at me
sometimes, I learned so muchfrom you and take some of the
things that you taught me intomy career going forward, so we
do thank you for being here.
Speaker 3 (29:02):
I appreciate that.
Thank you, I appreciate it.
Speaker 1 (29:05):
Thank you, everybody.
Speaker 3 (29:07):
Yeah, anytime.
So I'll come back anytime youwant.
Sounds good, love that.
Speaker 2 (29:12):
Bye guys With that.
Thank you so much.
Speaker 3 (29:17):
All right, take care.
Welcome to Core Bariatrics podcast hosted by
Bariatric surgeon Dr MariaIliakova and TMA LaCose,
bariatric coordinator and thepatient herself.
Our goal is building andelevating our community.
The Core Bariatric podcast doesnot offer medical advice,
diagnosis or treatment.
On this podcast, we aim toshare stories, support and
(00:22):
insight into the world beyondthe clinic.
Let's get into it.
Speaker 2 (00:26):
Today we have with us an excellent medicine
specialist from Iowa Cityoriginally, and he has over 31
years of experience in themedical field as a sleep doctor.
He graduated from UniformServices University of the
Health Sciences in Bethesda,maryland.
We met working together onBariatric patients in Iowa City
and he currently leads a sleepprogram at Bell and Health in
Green Bay, wisconsin.
(00:47):
I'd really like to welcome youto Dr Ethan Emmits.
Speaker 3 (00:51):
Yes, thank you.
I appreciate it.
I know both of you fairly well.
Yeah, I'm excited.
Speaker 1 (00:56):
I'm going to be telling the audience that you
had bossed me around for a solidI think it was two years or so
while I worked in the clinicthere, but I loved working with
you and learned a lot.
Speaker 3 (01:07):
Thank, you, I will mirror that.
Speaker 2 (01:10):
I didn't get to work with you for as long, but I
really admire how much youhelped guide people through the
process that was otherwisereally intimidating.
So I'm really grateful andexcited that you're with us
today to talk about sleep andhow it affects everything.
Well, tell us first how did youeven get involved in sleep
medicine?
What was the draw for you?
Speaker 3 (01:29):
Actually my specialty was pulmonary and critical care
, icu medicine, and I have tothrow a shout out to one of my
someone who was a fellow with meat the time, chris Fry, and we
were at a critical carefellowship and he was going to
go out and do sleep as well andI was, ah, I don't want to do
sleep.
We're young, we're all aboutthe ICU, and I'm like, why would
I want to do sleep?
And at the time I didn't knowmuch about it.
(01:51):
So I'm like, oh, it's probablygoing to be boring.
But he made a very good pointto me.
He actually said to me he goes,when you're 50 years old, you
want to be up all night in theICU, and that, right, there was
it.
So that's what got me started insleep.
And then, once I got into it,you realize it's actually really
interesting and there's a lotof misconception in sleep Folks.
(02:12):
They read a lot on the internet, which is necessarily true.
Once you get into it, it'sreally interesting.
I continue to do pulmonary upto about 2018.
And then my sleep practicethere in Iowa City had gotten so
busy, went to sleep only, and Ihave to admit it is an
excellent job for later in yourcareer.
It's important in the bariatricpopulation to know about sleep
(02:35):
because it has such asignificant impact on things and
a lot of times patients arelike, hey, if I have sleep apnea
and I have bariatric surgery,what's going to happen?
And things like that.
So that's what I spent a lot oftime talking to people about.
Speaker 2 (02:49):
So let's dive into that a little bit.
Sleep apnea is something that Ithink a lot of people have
heard the term but may notreally know what that is.
Can you start off by telling uswhat is sleep apnea?
Speaker 3 (02:59):
Yeah, I'm going to give it a very specific term.
This is the way I talk topatients.
I've always my dad had a sixthgrade education, so that's the
level I generally try to explainthings and basically sleep
apnea is a mechanical problem.
So it really is how much roomback here do you have in the
back of your throat?
Now, some of that is genetic,some of that is as a weight
(03:21):
component.
Sleep apnea is at night.
You're sleeping and because ofrelaxation and the muscles in
the back of our throat, the backof your throat again deep down,
closes and it obstructs andyou're choking, literally
choking.
And as I say to patients, ifyou're choking and sitting there
in front of me in my office,you're gonna panic.
Right, it does the same thing.
(03:43):
Brain says while you'resleeping, brain says I'm choking
.
Your brain turns on awake fortwo seconds, just enough time to
open things up so you can begin, and then your brain goes right
back to sleep A little whilelater.
30 seconds, one minute, fiveminutes, whatever it is, do it
again.
You choke, panics.
Brain wakes up, opens things up, go back to sleep.
(04:06):
So basically, people sleepapnea at the brain level.
They're doing this kind ofawake asleep.
Awake asleep.
If you're not enough, they'renot getting restful sleep.
And then there's the all sortsof the physiologic things that
happen, because when you'rechoking it's a panic reaction,
so you actually have a releaseof something called adrenaline,
epinephrine, so people spiketheir blood pressure.
(04:27):
That can cause high bloodpressure, higher risk of stroke,
heart problems, makes refluxworse.
It also contributes to wakebecause when you have Drenaline
surge you also actually spikecortisol and so what happens is
having a spike of your bloodsugars.
And Whenever you takeadrenaline and people have heard
(04:48):
of the fight or flight responseand you combine that with extra
blood blood glucose, bloodsugar the body turns it into fat
.
People are just making fat andI saw it all the time.
People come in frustrated.
I Work out, I do all this stuffnot losing any weight, but you
can do all the right things allday, but if you're choking all
(05:08):
night and making fat all night,not gonna have any and you're
not gonna make any progress.
So that's one of the thingsabout sleep apnea is it actually
can cause weight gain and thenthe vicious circle the more
weight you gain, the worse yousleep apnea, the more weight
you're gonna gain.
So it plays a role in that andeven just disrupted sleep in
(05:30):
general.
Aside from sleep, apnea plays arole the hormones that regulate
our appetite Grayland andleptin or what their names are.
They're basically disruptedwhen people are sleep deprived
and it actually Triggerspeople's appetite.
So that's why during the night,when people have trouble
sleeping, if they get up duringthe night they want to eat.
It's because there's adisruption in that and
(05:51):
Unfortunately it's the also.
Not only do they what, do theywant to eat, that sweet, high,
sweet, salty, high-carb foods.
So all sorts of things and Idon't want to get into much into
the, the technical, but there'ssleep plays a huge role and
just weight in general,certainly in the bariatric
population.
Speaker 1 (06:11):
But also when you are getting that in interrupted
sleep, your body is waking up alittle bit, so you get tired
throughout the day, which isgoing to cause you to not want
to work out.
Not want to, you know, do much,or you're drinking all the
caffeine to try to stay awake.
But sleepiness during the dayis another thing.
(06:32):
With sleep apnea, that isanother thing that's gonna
hinder losing weight.
Speaker 3 (06:38):
It's been study.
We know that people who havesleep apnea or have disruptive
sleep for other reasons actuallyexercise less.
So that's actually been lookedat.
So you're a hundred percent.
Speaker 2 (06:47):
That's pretty fascinating because I don't
think a lot of people know thatsleep apnea or disruptive sleep
can actually cause Weight gain.
I think people realize that itmay stop people from being able
to lose weight, but that'spretty fascinating that you can
actually even cause weight gainand, like you said, be put on
this cycle as a result.
Speaker 3 (07:06):
Yes, absolutely can gain weight.
Now Maybe I'm jumping ahead alittle.
You know I get the question allthe time.
Is okay, I sleep and I'mgetting bariatric surgery as I
Fafnina go away.
Speaker 1 (07:16):
No, I am proof of that.
No, because my anatomy it doesnot yep.
So I am getting my teeth fixedto hopefully widen my palate,
and all of that because, yes, Iknow I still have sleep apnea.
I'm one of the unlucky ones.
Speaker 3 (07:34):
Yeah, it's about anatomy.
So this is what I tell folksbecause they'll ask.
First thing They'll ask is howdoes weight gain playing the
sleep apnea?
As I said before, sleep apneais mechanical tongue size,
tongue position.
How much room did mom and dadgive you back there?
And so some, no matter whatthey weigh, they got bad anatomy
, they're gonna have sleep apnea, it doesn't matter.
(07:55):
But there's other people whomight one way Okay, they don't
have a lot of extra room, butthey're actually okay.
But what happens when we gainweight?
Our tongues actually get bigger.
Our tongue become infiltratedwith fat.
They get bigger.
There are fat pads in the backof the throat.
That actually expands.
The folks, the unlucky ones, Ithink, where it's about hey, use
(08:17):
, got bad anatomy, it's notgonna matter what you weigh yeah
they're still gonna have sleepapnea, even after their.
Speaker 2 (08:25):
So it sounds like, basically, the less space there
is in your mouth and your palate, their higher risk for sleep
apnea.
Speaker 3 (08:31):
Absolutely.
Speaker 2 (08:32):
Yeah, and whether that less space comes from
anatomy, comes from beingoverweight and all the
contributing factors or acombination Depends on the
person, but that the extraweight is typically not helping
the situation.
Would that be the rightassessment?
Speaker 3 (08:45):
Oh, yeah, absolutely my rule of thumb.
I would tell the patientscertainly the patients that you
all were sending me would be, ifyou, if they had mild, the
moderate sleep apnea, it'sprobably gonna go away.
It really is going away.
But if they came with verysevere sleep apnea from the
get-go, I tell him he'll getbetter.
(09:06):
It may not be a severe thatneeds seep again.
Maybe you could use somethinglike a mouthpiece, but it's
unlikely that it will resolvetotally.
Speaker 1 (09:16):
So for our patients you always recommended, after
they probably level out withtheir weight loss, to get
retested.
Speaker 3 (09:22):
But it would depend on how severe their sleep apnea
was now mild sleep apnea, 5 to15 times an hour you're choking.
Moderate, 15 to 30.
Over 30 severe my rule of thumb, and the rule of thumb that the
American Academy of Medicineuses, is if it's a 10 to 12 and
above, I would retest.
(09:43):
If it was 10 or under and andthey had a significant amount of
weight loss, it's gonna be gone.
We could tell when I did tellthe patients who just wanted to
know, which is fine, but ifyou're really From the start,
it's gonna go away.
If you have significant weightloss, anyone who started with
kind of that mild in themoderate range plus, I would
(10:06):
retest them.
And even if they were severe, Iretest them because if they're
severe and then now they're mild, that may change the treatment
options.
Speaker 2 (10:15):
So we've talked a little bit about testing, but
I'm actually really curious howtesting works, because there
have been such massiveimprovements in how we test.
Can you talk a little bit abouthow that's changed over time
and how that looks in yourprocess?
Speaker 3 (10:28):
A lot of people heard of the traditional sleep study,
which really hasn't changed,and since I've been doing With
40 years, you go there, stickiesand wires everywhere and belts
around your chest and we haveaudio and video and it sounds
horrible and guess what it is?
It is, but now we do hometesting.
Now the thing about a homesleep that people need to
(10:50):
realize is it only tells meabout one and that is sleep.
There's a whole lot of othersleep disorders out there and
that home test doesn't reallyhelp me with those.
They need that overnight test.
But if I'm looking just forsleep certainly bariatric
problems that are beingreferring me to screening I just
do a simple home test.
(11:11):
You take it home, you wear it,bring it back the next day and
they're actually pretty darnaccurate.
The home test is, that said,they are considered a screening
test, so what does that mean?
It means if it's positive, thathelps me, I can believe that
result.
But if it's quote negative,there really is no such thing as
a negative home test.
(11:31):
The home test is that the triedand true, really the standard
now for initial screening, andit's what insurance companies
want us to do.
Speaker 2 (11:40):
And that just sounds so much more convenient for
people, because I think a lot ofpeople are intimidated as they
go through the process of beingevaluated for bariatric surgery
and a lot of people used to.
In practice, when I was afellow, for instance, I just saw
a lot of people's jaws or liketheir heart would sink.
You could see it on their face.
Oh no, I have to do this.
And then in your program, I wasso shocked because literally
(12:01):
not a single person evercomplained about the process,
which was incredible.
Speaker 3 (12:06):
Part of it is I mostly being.
My entire appointments arenothing but education.
So education, non sleep, apnea,what's called sleep hygiene.
But when I started to talkabout testing, the very first
thing I would say to them is so,just so you know, we're gonna
start with a home test, but letme tell you about all the
testing options and you couldjust see them.
The relief.
(12:26):
Frankly, it's because there's alot of misinformation to the
internet, a lot of preconceivedmisconceptions.
The days of the alien mask longgone.
Speaker 1 (12:37):
Yes, that's how I got a lot of women to you would
order their CPAP and they'rejust like I really don't think I
can do this.
I taught you.
You were right across the hallfrom me and I did many times
talk to women about.
It.
Is not this big barbaric maskanymore, it is as small as a
little nasal cannula at thatpoint.
(12:58):
But you were talking aboutsleep hygiene and you are so
into this, so talk about that,because, especially for people
that can't get to sleep, yeah,it is one of my soapbox items is
because I'm a firm believer andyou gotta help yourself.
Speaker 3 (13:15):
And so the biggest is coming to the big keys when
people come in and say, hey, Ihave insomnia, I can't sleep,
and there's a couple keys thatyou gotta be sleepy before you
even try to get into bed.
The other one is theelectronics, and this is what
Tamia, I know, is alluding to onmilitants about the whole
electronics.
Yeah, you are, and what we'retalking about is anything with a
(13:36):
screen TV, phone, ipad,computer.
These screens do a lot ofthings and, in the most
simplistic terms, as theybasically turn your brain on
wide awake Power for your brainto go to sleep as you've turned
off your TV or phone, and whathappens is People, they turn
everything off up, and then thatthey do.
They later takes up to an hourfor the brain to wind down, even
if their circadian rhythm wastrying to make him go to sleep
(13:59):
and 10.
And then again, as I said, witha warning, and they're, and so
they start to get spun up.
But then the people who say, oh, I have to have the TV on to
fall, but they don't realize,even though the body can go to
sleep eyes close.
Nor and everybody knows themsays they're sleeping.
Their brain actually stillpaying off up to an hour as well
(14:19):
.
It's still awake, essentially.
And so for those folks it's losttime, as I like to call it, and
when someone comes in tells mehow sleepy they are in the
morning, while I'm getting six,seven hours of sleep.
But if you lose it an hourbecause you're watching TV up to
the point you go to bed, you'renot getting six or seven hours
of sleep.
You're getting an hour less.
And so bottom line is theofficial recommendations,
(14:43):
american Academy sleep medicineis a one hour break from all
electronic screens before goingto bed.
That's what it is.
That is the officialrecommendation and there's real
science behind that, as I talkedabout.
And again, folks who say, hey,I got to have the TV on the fall
, sleep this or that, that'sgreat for you, but we're just
recognize you're losing about anhour of sleep time at the brain
(15:06):
level.
The other one I always you guysare always are in tune with
this caffeine we recommend nocaffeine after two o'clock.
Caffeine last ten hours.
People don't realize how longcaffeine hangs around.
They don't realize that.
And the other issue is thatfolks don't realize that
caffeine actually suppressesyour deep sleep, makes it harder
to get into deep sleep and youneed deep sleep to feel rested.
(15:28):
All this light sleep we getduring the night doesn't do
anything to make you feel rested.
You gotta get the good deepsleep and some dreaming sleep.
And so I always get people andvery proud of themselves, I took
three red bulls to go right tosleep and Michael G.
That's great, but it'simpacting your sleep quality as
well.
Nicotine we say one hour breakbefore going to bed is a
(15:51):
stimulant.
Alcohol is its own separatediscussion we can have about
that.
The bottom short version isalcohol is a depressant
initially.
But the breakdown products ofalcohol the liver breaks it down
are very powerful stimulants.
And so I get people say, yeah,I had to.
I have a few drinks before bed,I go to sleep, fine, but boy,
three, four, five hours laterI'm flopping like a fish.
(16:12):
Why?
is that it's the breakdownproducts of the alcohol.
Those are the some of the basicsleep hygiene things we talk
about caffeine and none aftertwo o'clock.
Nicotine, an hour break,alcohol, certainly, as I talked
about it, and really the onehour break from electronic
screens.
That's the big one, and it'salways amazing how many people
(16:33):
come back and say, yeah, Iturned off the TV and it really
made a difference.
I'm like, yeah, it really does.
Speaker 2 (16:39):
Yeah, I'm not surprised, because I think
that's the sleep hygiene issomething we really struggle
with because I think, especiallyin younger generations, we're
so used to having the phone withus all the time to work for our
families, for our friends, forall kinds of different
connections.
It's so common to just toscroll until you fall asleep,
essentially.
So it's a really it's in ourpatient population, even in the
(17:01):
general public.
I just really think that's a.
That's tough to hear that youneed an hour, yeah, yeah, yeah,
and some people just ignore meand that's fine.
Speaker 3 (17:10):
They can do it they want.
But yeah, there's plenty ofpeople ignore me and again, I've
been doing a long time.
I am a little cranky and littleand understand yeah sometimes
they'll come back and keepcomplaining to me about how they
can't fall asleep and I'm likedid you turn your TV or put your
phone down?
No, and I can't help you.
(17:31):
Yeah, you just stick to yourguns, which I think in sleep
medicine is a good thing, yeah,I'm just hey, I can't help you
till you help yourself, yeah.
So that's the one thing.
One thing I did want to bringup real quick is because I know
that you guys know I've put thisout there before is patients
who have sleep apnea, who are onCPAP and are getting bariatric
(17:53):
surgery.
The question comes up is hey,I've had my surgery, I've
started to lose weight.
Do I need to stay on my CPAP orcan I just stop it?
And there is, as you guys know,because I've mentioned it
before, there is that one studyout there that does show pretty
convincingly that patients whohave sleep apnea, who are on
(18:13):
CPAP and stay on their CPAP forone year after they've had their
surgery, actually lose moreweight and have less weight gain
back than those who stoppedtheir CPAP early after their
surgery prematurely.
And it makes perfectphysiologic sense because you
have sleep apnea even if you'vehad bariatric surgery and you
(18:37):
aren't getting treated.
Guess what your body is goingto be doing.
You're going to be working allday to lose weight and then
you're going to be making fatall night, just like before you
had surgery.
Speaker 1 (18:46):
That's a good recommendation, yeah.
Speaker 3 (18:49):
So I'm looking.
Yeah.
So I tell folks hey, yeah,you're on CPAP.
I know you don't, maybe yoursleep apnea will go away
Ultimately.
Stay on the CPAP.
And then down the road willtest you six, nine, twelve
months, depending on how fastyour weight loss Journey.
So that's one thing I do liketo tell folks is Stay on that
(19:10):
CPAP, because it actuallyprobably helps you lose more
weight versus those who don't.
Speaker 2 (19:15):
So that's a very important one for people to hear
, I think, because a lot offolks Well don't really know
what to expect in terms oftiming, and so setting that one
year expectation, I think,really puts people at ease,
because it's not arbitrary, it'snot oh, we want a torture, you
want to stay on something justfor the fun of it for a year,
but it's quite literally to helpyou get the most out of the
(19:36):
tool that you've decided to you.
Speaker 3 (19:38):
Exactly, if you're gonna go through having surgery
because that's not anythinganybody does lightly and and
there's a whole bunch of otherissues that come up with having
bariatric surgery If you'regonna go through that, set
yourself up for success, setyourself up to have the best
possible outcome you can.
And so I push people hey, juststay on the CPAP.
Yep, nine, twelve months, I'llretest you and we'll see where
(20:00):
you're at.
Speaker 2 (20:01):
So that's awesome.
Yeah, I think that's a reallygood expectation to be setting
for people.
That's one of the most commonquestions we get, so Glad you're
addressing it.
On and in terms of thetreatment options, actually,
since you've been, you'vementioned a couple of times that
the days of the alien mask aregone, where, yeah, yeah, the
Darth Vader voice overnight orsomething.
Yeah, what does that look likenow for people and does it vary
(20:25):
by severity?
What does what kind ofdetermines what treatment
options are available?
Speaker 3 (20:28):
Yeah, if you have moderate to severe sleep apnea,
your initial treatment is stillCPAP.
It really you've seen thesethings on TV and spire, which is
not new and spire has beenaround probably 10 years Things
like inspire and some of theseother surgical implants that
they talk about doing.
Now those are second line.
Those are for people who'vetried CPAP the mask and machine
(20:50):
and they struggled or it justdidn't work for them.
It wasn't effective for them.
Then that can make themcandidates for some of these
implantable devices like inspire.
Now everyone wants to knowinspire is what is inspire?
It's a pacemaker that'simplanted surgically.
Their wires are run to the backof the throat and at night you
have a remote and you turn theSpace maker on and you get
(21:10):
electrical stimulation to theback, your throat turning.
That helps keep the musclesactivated to keep things open so
you can breathe.
Actually works pretty well.
But again, it's a second linetype thing after CPAP.
So moderate, severe yeah,you're gonna end up on CPAP
initially Mild is where youreally have a lot of options.
Some people still do CPAP,machine mask and I'll talk a
(21:33):
little bit about that in asecond.
I'm a huge fan of thesemouthpieces.
They're called oral appliances,dental orthotics they have
different names.
They're actually a medicaldevice there, so people think
it's covered by dental insurance.
No, it's covered by yourmedical insurance, including
Medicare.
But these are mouthpieces.
They they fill your mouthpretty good, as I like to show
people.
(21:53):
But it's an upper.
It's an upper and a lower.
They're custom made to you bysomeone who does it, usually a
dentist.
They're custom made and whatthey do is they actually move
your lower jaw a little bitforward.
I'm talking millimeters hereand and you guys have done CPR
it's just like doing a chin lift.
We do a chin lift to pull thejaw a little forward to open up
(22:16):
the airway.
When we're doing CPR.
That's what these oralappliances do.
They just move your lower jaw alittle bit forward.
Super effective and mild sleepapnea.
I'm a huge fan of those.
For mild sleep apnea.
Occasionally positional therapy.
Some people only have theirsleep apnea usually on their
back only and on their side.
(22:37):
They're fine.
And I got ways to keep you offyour back.
In the old days, 30 years ago,we'd say you go buy a tennis,
tennis balls, take three tennisballs it's so many aligned on
the back of a t-shirt.
And guess what?
Nobody sleeps with three, tenon three tennis balls.
But it can be very effectivefor people who have no other
reason to sleep on their backs.
Some dude they have whateverhip pain, whatever it is.
(22:59):
But positional therapy alone itcan be beneficial.
Sometimes weight loss alone,other than bariatric surgery.
Isef sent a number of people tothe medical weight loss program
where we were at.
So medical weight loss andpeople have mild sleep apnea is
can be very effective.
So not having to go through tothe end of getting bariatric
surgery.
(23:19):
And now one of the interestingthings, or exciting things,
coming out there's been studiesnow about a pill to treat mild
sleep apnea.
It's in studies.
It's gonna start its phasethree study and I won't get into
what that means, but it's beenproven to be safe and effective
and now they're doing largestudies on this.
It's a couple differentmedicines.
I won't get into the details,but this will probably be on the
(23:42):
market the next three to fiveyears, a pill that has shown to
be pretty effective for mildsleep apnea.
So there's options and there'seven more options coming.
Again, I'm getting towards theend of my career.
A lot of these things I won'tprobably deal with, but there's
gonna be more options.
In regards to CPAP the alienmass they had talked about the
(24:04):
machines nowadays they're small,yeah, big, they are small.
If you hear your machine isbroken, everybody's worried
about compressor sounds.
I'm telling you, you hear yourmachine.
You better take it back becauseit's broken.
And as far as masks, yeah,there are still some that cover
the nose and the mouth are likethis there's some people that
need that.
There's someone cover the nose,there's some that just sit
under the nose and, as Tammymentioned, some that just go
(24:26):
into the nose, and I don't haveany sitting here in my home
office, but that's actuallyshocking yeah yeah, I would
think you have an armament ofthem in the back, but you know,
yeah so, yeah, no, I have a, butthey're in a box.
I actually should have pulledthem out.
I just didn't think about itbecause, yes, tammy, I took them
all when I left.
Oh, that's funny.
(24:47):
So that's why I had acquiredthem.
I took them with me.
But the point being is, yeah,the days of the alien mass, the
compressor sounding machine, allthose things are just long,
long gone and, as Tammy knows,when I start somebody on CPAP, I
would have a whole appointmentwhere I would do nothing but go
over, sleep CPAP with them, showthem mass, showing them machine
, tell them the key to doing it.
(25:08):
And I'll tell you right now thekey to doing well with CPAP.
You have got to put it on everynight and I could care less if
it's an hour or two hours orthree hours.
You've put it on every nightbecause it is as much a habit as
it is anything else and ittakes two weeks to develop a
habit and I just can't tell youthe number of patients would be
like, yeah, I just put it onevery night was only for a
(25:29):
couple hours, but I put it onevery night.
And they'll tell me, yeah,after two, three weeks, suddenly
I just got it and it started tostay on more and more.
I tell folks I can help anybodyit puts it on every night Can't
help the person who tries twicea week.
Speaker 2 (25:43):
That's a powerful message to hear, because I do
think a lot of the things thatwe do, we're offering tools and
we're offering support and we'reoffering knowledge and
expertise, but ultimately wecan't be there 24 seven with
people and it does requireputting it in action.
Do you find, when you havefolks maybe that are struggling
with compliance or strut,they're just struggling with
(26:04):
getting it to done in their life, what kinds of things can help
with that?
I don't know if you've ever hadpeople come to you and say this
works, this doesn't.
Speaker 3 (26:12):
As far as CPAP, yeah, yeah, yeah, a lot of it is
figuring out what works best foryou.
I'll tell you, one of the bigmessages is everybody knows the
guy who says, oh, I use thismask and you should use this
mask.
No, you've got to find whatworks best for you.
And the thing I tell folks isyou got the two keys, you got to
put it on every night andyou've got to work the company
(26:33):
you get the machine from to findthe right mask for you.
And it is common for people togo through two, three, four
masks in the first couple ofmonths before they figure out
the one that's the one for them.
And I tell them you've got to dotwo things.
You got to put it on, butyou've got to work with that
company to get into the maskthat you're comfortable with and
what I like to wear, because Ihave CPAP, I have sleep apnea.
(26:54):
Then we're in it 20, what?
Four years?
People always want to.
They always ask me what do youuse?
And I'm like it doesn't matterwhat I use.
Speaker 1 (27:02):
You've got to find.
Speaker 3 (27:03):
You've got to find the mask that works for you, and
so the big key is putting it onevery night and finding the
right mask.
And I will tell you, if someoneputs it on every night and they
work to find the right mask,98% of them do great they just
do.
Speaker 1 (27:18):
Most of your parents or parents could gravy.
Speaker 2 (27:21):
Most of your patients were very compliant, for sure,
because they got that educationfrom you and they got that role
and that approach of find theright fit for you, I think,
really resonates with ouraudience, with our folks,
because there is no one one sizefits all strategy for any of
this.
So making sure that you takewhat you can into your own hands
and you get help when you needit, I think that's a really
(27:41):
powerful message coming from you.
Speaker 3 (27:43):
Oh yeah, like I said, everybody's different and so I
tell that to folks.
You've got to find your way inall this because everybody's
different, and certainly withCPAP or any sleep problem you've
got to put the work in.
And I've often tell patientsI'm there to guide you, I'm
there to be your cheerleaderwhen you come back to see me,
(28:03):
but I can't come to your houseand put your CPAP on you.
Speaker 2 (28:09):
And I used to tell folks all the time.
Speaker 3 (28:12):
You know what I said.
Hey, I stopped going topeople's houses and moving their
TVs out of the bedroom a fewyears ago.
I can't help you if you don'thelp yourself.
Speaker 2 (28:19):
That's fair, that's fair and, on that note, I think
that's probably a great note forus to wrap up the episode.
But yeah, dr Emons, I'm just sograteful to you because such
incredible care of the patientsthat we got to work on together
I thought that was superremarkable.
You were such a greatcommunicator, not just with your
patients but also with us, andI just really want to commend
you for the kind of care and thekind of compassion that you
(28:43):
show, because it really makes atremendous difference and even
for me who's a younger surgeon,and I just I'm so grateful for
working with you.
Speaker 1 (28:50):
Yes, I appreciate that.
I am too, even though if youwere cranky and mad at me
sometimes, I learned so muchfrom you and take some of the
things that you taught me intomy career going forward, so we
do thank you for being here.
Speaker 3 (29:02):
I appreciate that.
Thank you, I appreciate it.
Speaker 1 (29:05):
Thank you, everybody.
Speaker 3 (29:07):
Yeah, anytime.
So I'll come back anytime youwant.
Sounds good, love that.
Speaker 2 (29:12):
Bye guys With that.
Thank you so much.
Speaker 3 (29:17):
All right, take care.
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