Year: 2002

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Essential Vitamins

More people consume vitamin supplements now than ever before. Do we know what is the right vitamin to take and how much of it do we need?

This issue is discussed in a Clinical Practice article in the New England Journal of Medicine (NEJM) titled, “What vitamins should I be taking, doctor?”

Medical teaching says that a healthy individual, who eats a good diet, does not require vitamin supplements. He should be able to meet his vitamin needs from his healthy diet. But the public interest in vitamin supplements is enormous – sometimes due to misguided reasons. Almost 30 percent of our population takes vitamin supplements. And there is no control over it.

Because the food we eat contains too many nutrients, it would be almost impossible to conduct double blind trials to see if vitamins do have improved clinical outcomes. Also the users of vitamin supplements may have healthier lifestyles or behaviours than nonusers. This would distort any clinical trial results.

The good thing about vitamin supplements is that there is greater likelihood of good than harm and cost of supplements is not that high so the authors of the article in the NEJM recommend the following vitamin supplements for healthy individuals. There is substantial evidence that higher intake of:

1. folic acid (400 ug/day),
2. vitamin B6 (2 mg/day),
3. vitamin B12 (6 ug/day), and
4. vitamin D (400 IU/day) will benefit many people, and a
5. a multivitamin will ensure an adequate intake of other vitamins for which the evidence of benefit is indirect.

The authors say a multivitamin is especially important:

-for women who might become pregnant
-for persons who regularly consume one or two alcoholic drinks per day
-for the elderly, who tend to absorb vitamin B12 poorly and are often deficient in vitamin D
-for vegetarians, who require supplemental vitamin B12 and
-for poor urban residents, who may be unable to afford adequate intakes of fruits and vegetables.

Physicians who encourage their patients to take vitamin supplements should also educate their patients regarding healthy life style and about healthy nutritious diet. Foods contain many additional important components, such as fiber and essential fatty acids and vitamin pills cannot be a substitute. Vitamin pills do not compensate for the massive risks associated with smoking, obesity, or inactivity, say the authors of the NEJM.

What about vitamin E?

The authors feel that vitamin E supplements are reasonable for most middle-aged and older individuals who are at increased risk for coronary artery disease. Although the final verdict on its benefit in prevention of heart disease is not in, the authors feel that it is reasonable to take 400 IU of vitamin E daily. But this should be reviewed annually as more information becomes available.

The authors do not recommend any additional vitamin supplements at present, as the evidence required to make such recommendation is far from complete.

The message here is pretty clear. First practice healthy lifestyle: regular exercise, healthy diet (high fibre, low fat diet with lots of fruits and vegetables), no smoking, weight control, and stress management (remember ELMOSS?). Then spend money on vitamin supplements.

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Surgery for Snoring

Surgery for snoring – is it available in Medicine Hat?

Yes, it is done by Dr. Neil Harris, ear, nose and throat surgeon (Otolaryngologist). I asked him about his approach to patients who snore. This is his response:

Hi Noorali:

My approach to the management of sleep apnea and snoring is to first get a detailed history of the patient’s problem. This includes general health, daytime activity, daytime nasal obstruction, hours of sleep, frequency and severity of snoring, and frequency and duration of any witnessed breath-holding spells.

General health considerations include fatigue, excessive drowsiness, hypertension, obesity, any respiratory or cardiac illness and smoking.

It is also important to assess how disruptive the patient’s problem is on family members. Severe snorers tend to become hypertensive so treatment is not only for the benefit of the spouse or family.

Medications, alcohol consumption, and dietary considerations are important. If weight is contributing to snoring and apnea, weight management is discussed.

If true obstructive or central sleep apnea is suspected on the basis of the history, then the patient should be referred for sleep lab testing. If the results confirm sleep apnea then the patient should try CPAP. Surgical treatment for sleep apnea is also an option but surgery works better for snoring without significant apnea.

Most patients with poor sleep, fatigue, and daytime drowsiness are simple snorers and these patients generally do very well with surgical treatment.

Patients are advised before surgery that swallowing will be different for a short while after surgery and few patients have temporary nasopharyngeal reflux, or regurgitation of fluids into the back of the nose if they drink too fast. This has never been a permanent problem for anyone.

Most patients have no trouble at all. Also it is explained that the procedure is not a guarantee that the patient will not make any more noise when sleeping or that snoring will be eliminated forever.

Snoring can return as aging causes further laxity of throat tissues.

The operation is called uvulopalatopharyngoplasty or just pharyngoplasty, and takes about fifteen minutes. It can be done by laser with only local anaesthesia or under general anaesthetic in the operating room using electrocautery. The actual technique is similar with either method. I prefer to do the surgery with the patient asleep to ensure careful trimming of lax tissue and placement of dissolving sutures.

The rim of the soft palate is injected with local anaesthesia and steroid to prevent post-operative pain and swelling. The mucosal rim of the soft palate, the uvula and the part of the posterior tonsillar pillars are trimmed, and sutures are placed, leaving a smooth arch at the back of the throat.

The patient is routinely discharged from hospital on the day of surgery, with a prescription for a liquid antibiotic to prevent infection and a liquid analgesic.

When patients return for follow-up in about three weeks most are pleased with the results. They generally have longer periods of deep, restful and quiet sleep. They wake easier and have greater daytime energy and stamina.

Many have told me that their mood has improved. Some have been able to discontinue blood pressure medicine. Spouses sleep better, too. The results are not quite as good in true obstructive apnea but surgery can still be done in addition to the use of CPAP or if CPAP cannot be tolerated. Central apnea should be managed medically.

Pharyngoplasty is an easy, safe and effective operation. In properly selected patients it significantly improves the quality of life.

Noorali, I hope this information will be useful to readers of your column.

Neil Harris

This is the third column dedicated to the subject of snoring and sleep apnea. I hope after this people will get help and sleep in silence and keep their spouses happy. Good luck and sweet dreams!

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Chronic Snorer

I liked the title of my last column: “ In search of peaceful sleep”! That, of course, is everybody’s dream! Can we make that dream a reality?

As you may recollect, the last column discussed snoring and obstructive sleep apnea. We learnt that there is a fair amount of uncertainty about this disorder. Today, we will talk about treatment.

It is commonly claimed that obstructive sleep apnea is associated with premature death and illnesses of the lungs and heart. But we know that this has not been proven.

So, one would wonder, is it necessary to seek treatment for this condition? If yes, then what sort of treatment is available?

Treatment of snoring is required if a person snores to the extent that the marital relationship may be threatened. Then the choices are either you snore alone in the basement of your house or few miles away in an isolated barn! Or get help!

Treatment is also required if the sleep disorder affects daytime sleepiness and alters the function of the heart and the lungs.

The goals of treatment are to abolish snoring and eliminate disruption of sleep due to upper-airway obstruction. This will establish adequate oxygen level in the blood and adequate ventilation system.

Treatment strategies are divided into three general categories:

-Behavioural modification
-Medical treatment
-Surgical treatment

Counselling for behavioural changes includes losing weight, avoidance of alcohol and sedatives. Most patients snore sleeping on their back. These patients should be asked to train themselves to sleep exclusively on their side.

Medical management of sleep apnea revolves around positive airway pressure, dental appliance and medications. There is no good medication to help sleep apnea so we won’t discuss that here. Sometimes oxygen therapy helps.

The positive airway pressure (PAP) is delivered through a mask to be worn when a sleep. The machine that creates PAP weighs two kilograms. The cost of the system may run into couple of thousand dollars. PAP keeps the upper airway open during sleep.

Compliance of this method of treatment is not hundred percent. One study demonstrated 46 percent of patients used PAP for more than four hours per night for more than 70 percent of the observed nights. Some people may find system difficult to use. Others have adapted quite nicely. Some studies have shown improved survival in patients who use PAP.

Oral appliance has been promoted as a useful alternative to PAP. There are varieties of appliances. The appliances are worn only during sleep and are generally well tolerated. Not all patients have clinically proven response. It is considered as a second line of treatment compared to PAP.

Surgical treatment for snoring and obstructive sleep apnea has become quite popular recently. Probably due to the inconvenience of PAP and oral appliance. Several surgical procedures are available, each one with advantages and disadvantages. These procedures are done by Otolaryngologists (specialists in ear, nose and throat surgeries).

Not all snorers require major surgery involving the palate. Fixing simple problems in the nose and throat can make a significant difference. Major surgical procedure involving the palate and pharynx is successful in abolishing snoring in about two thirds of selected patients. There is some amount of complications associated with surgical procedures – failure and pain.

There isn’t one solution to the problem of snoring and obstructive sleep apnea. So, Mr. Snorer, and all other snores, if you don’t want to snort with the pigs in the barn then seek help. Some thing may work for you. Besides, you have to help yourself first before anybody can help you!

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Sleep Apnea

Dear Dr. B: I snore and my doctor says I have obstructive sleep apnea. Can you please tell me more about this? Yours, Mr. Snorer.

Dear Mr. Snorer: Normally, breathing is regular. Apnea means cessation of breathing. Sleep apnea is a condition that interrupts breathing during sleep.

Sleep apnea may be central – that is due to instability of the feedback system that regulates breathing. Or sleep apnea may be obstructive – due to recurrent obstruction of the upper airway. Or it can be mixed – central followed by obstructive.

Today, we will confine our discussion to obstructive sleep apnea.

Obstructive sleep apnea affects two percent of women and four percent of men. It is a condition of middle-aged adults.

A typical individual with obstructive sleep apnea starts snoring shortly after going to sleep. The snoring proceeds at a regular pace for a period of time, often becoming louder, but is then interrupted by a long silent period during which no breathing is taking place (apnea). The apnea is then interrupted by a loud snort and gasp and the snoring returns to its regular pace. This behaviour may recur repetitively and frequently throughout the night.

Obstructive sleep apnea causes frequent night awakening, feeling of tiredness in the morning, abnormal daytime sleepiness, headaches, memory loss, poor judgement, personality changes and lethargy. It may also raise the blood pressure.

Who suffers from obstructive sleep apnea?

Obstructive sleep apnea occurs most frequently in obese middle-aged men. Contributing factors may include use of alcohol or sedatives before sleep, anatomically narrowed airways, and massively enlarged tonsils and adenoids. Genetic and environmental factors may also adversely affect airway size. The condition may run in some families.

Diagnosis of sleep apnea is made by sleep studies. One article on this subject says that a sleep study should be strongly considered for two groups of patients: those who habitually snore and report daytime sleepiness, and those who habitually snore and have observed apnea (regardless of daytime symptoms).

Are there any medical or physical side effects to obstructive sleep apnea?

Once upon a time, sleep apnea was thought to imply poor prognosis. It was thought to arise from the diseases of the brain and heart. It is now known that periodic breathing generally occurs during sleep. That it may occur in healthy persons.

During periodic breathing, there is change in the partial pressure of carbon dioxide and oxygen in the blood and this results in the fluctuation of heart rate (with irregular rhythm) and blood pressure and in the autonomic nervous system. Heart failure, heart attack and stroke are other likely complications.

Chronic sleep deprivation caused by sleep apnea increases risk for motor vehicle accidents. The accident rate for such patients has been reported to be seven times that of the general driving population.

Does obstructive sleep apnea really damage our health?

In 1997, a review article in the British Medical Journal evaluated all studies published between 1966 and 1995 on the association between obstructive sleep apnoea and mortality and morbidity, and on the efficacy of nasal continuous positive airways pressure. The authors concluded that there was limited evidence of increased mortality or morbidity in patients with obstructive sleep apnea.

They also concluded that the evidence linking the condition to cardiac irregular rhythm, coronary artery disease, heart failure, high blood pressure, pulmonary hypertension, stroke, and automobile accidents was conflicting and inconclusive. They concluded, that there were insufficient data to determine its effect on quality of life, morbidity, or mortality.

So, is there a need to do anything about snoring and obstructive sleep apnea? Well, Mr. Snorer, stay tuned for an answer next time!

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