The following tracks my journey through the medical system, and my increasing understanding of Sleep Apnoea, Diabetes, and High-Functioning Depression. My intention is to tell my story in a way that the reader may be able to recognize their own struggles with sleep, weight, and mood, and to reach their own conclusions as to how best to proceed — with appropriate medical support, of course. I have included links to relevant material to aid in holding that appropriate medical support’s feet to the fire if you’re not getting what you need.
This piece will likely be of interest if you suffer from more than one of the following: Sleep apnoea, insomnia, excessive daytime sleepiness, impaired glucose tolerance, impaired fasting glycaemia, metabolic syndrome, pre-diabetes, Type-2 Diabetes, or any form of depression, including dysthymia or high-functioning depression.
Let us assume that there is a (somewhat) lawful relationship between Sleep, Obesity, and Depression, and let us call it SOD’s law.
Let us say that SOD’s Law states that, if one has issues with…
1) Sleep: insomnia and/or sleep apnoea, or;
2) Obesity: poor eating habits, or some metabolic disorder, i.e. diabetes, or;
3) Depression: a predisposition to some kind of neurotransmitter imbalance, or ruminative thought processes
…then one is likely to, at some point, have problems with others on this list.
Let’s face it, we’ve all heard of eating because you’re depressed, and we all know that sleep-deprivation leads to bad choices; whether to eat that gateau, or to give in to the existential dread.
If someone presents with a number of these problems, does it make sense to attempt to deal with the one that is the least expensive and/or least difficult to resolve, or does it make sense to look into the patient’s history and ascertain which one seems to have been primary and causal? Or does it make sense to just start with sleep? The answer to all of those is yes, depending upon the context.
My history (briefly)
I have experienced what has come to be called High-Functioning Depression for at least the last three years, but probably longer. I have also struggled with my weight for much of my adult life. I’ve certainly never been the 83kgs (185 lbs) that would (just) have put me in the healthy weight category. Equally, I’ve seldom looked anything more than (just) overweight, when in fact the BMI scale has always said I’m obese (even when I looked the least overweight).
I have had a problem with Obstructive Sleep Apnoea (OSA) for at least as long as I’ve had weight issues, but probably longer. I think that my OSA came first because I had glue-ear as a kid, and that meant I had trouble breathing through my nose for many of my formative years. I can breathe through my nose, now, as an adult, but I have to remind myself to do so — it is a conscious effort, rather than the habit that most people have. So, when I sleep, I tend to default back to mouth-breathing, and as such I snore.
Due to mouth-breathing “children do not sleep well at night due to obstructed airways; this lack of sleep can adversely affect their growth and academic performance. Many of these children are misdiagnosed with attention deficit disorder (ADD) and hyperactivity.” It’s worth noting, here, that ADHD and Depression are often comorbid (occur together) in adults diagnosed with ADHD.
Yes, I like diphthongs and digraphs, I think they look prettier than when replaced with the Anglicized ‘e’, as in apnea… but accessing the proper diphthong is time consuming, so I just go with the semi-Anglicized ‘apnoea’. I’m sure George Michæl would be proud (he actually did sometimes stylize his name that way, see below).
But I digress.
So what’s the big deal about sleep apnoea? (Aside from the spelling.) Well, if you were to look at my medical history, or rather at the history of my conversations with medical professionals, you’d have to assume, not much. Any time my sleep apnoea has come up in conversation, the response has been, ‘lose weight.’ From the doctor I saw in my teens and twenties (and who was well aware of my background with glue ear) through the doctor I was seeing in my mid-30s (who was maybe less aware of my background, but who was at least at the same surgery), to the procession of doctors I’ve seen at my local GP clinic, here in London.
My diet has never been terrible, but — even coupled with a fairly active lifestyle — my weight was always stubbornly resistant to change. The thing is, I’ve never been in to sweet stuff, except for the very occasional slice of cheesecake, or carrot cake (I’m not a chocolate fan). My weaknesses have always been protein-based. At a buffet I’m more likely to have seconds from the seafood and salads section than to head for the desserts.
Yes, OK, more seafood than salad.
I also used to cycle a lot. This has notably reduced since being in London, especially in the last year or so. That having been said, I was cycling for a job whilst at University, in London, for six months or so, doing around 20kms (12½ miles) a day. Two-thirds of which was with a heavy trailer attached to the bike (resistance training, yo!). My diet was reasonable, and the calorie intake reflected the amount of exercise I was doing, and yet I never even dropped into what the BMI would categorize as merely overweight. I remained obese.
When I first started at this job, one of my colleagues nicknamed me ‘pregnant man’. She did admit, after a few weeks, that the name was no longer relevant, but it stuck, nevertheless. So I lost a noticeable amount of weight in a relatively short time, but never dropped out of the obese category, according to the BMI.
I finally sought help for my depression in the last year of Uni (which I was attending as an adult student). It was probably my procrastination seeking something for me to do that was not my dissertation. In reality, my mother had expressed concern about the possibility of depression for at least a few years prior, so it made sense to actively do something about it.
At that time I was able to get on to CBT-based counseling relatively quickly and tackle some long-standing issues. This helped lift my mood, as did switching my iPod listening habits from purely non-fiction audio books to a broad mix of music (everything from classic pop to house to breakbeat to thrash metal). This, however, didn’t last long, and two years later the waiting list for NHS counselling were much longer (and much harder to get on to).
As it happens, my degree is in psychology, so I was reading outside my main area of interest (psychology of morality), and reading more about depression, anxiety, and the aetiology (the set of causes) of these.
Imagine my surprise when one of the first papers I read suggested that there is a link between sleep apnoea and depression. Indeed, let me quote the first sentence from that paper’s abstract:
“For over two decades clinical studies have been conducted which suggest the existence of a relationship between depression and Obstructive Sleep Apnea (OSA).”
And then another:
“We found that sleep apnea patients used 23 to 50% more resources (defined by physician fees, physician visits, and hospital nights) in the 5 years prior to diagnosis than did control subjects. We examined the diagnoses made and found that apnea patients are at higher risk for hypertension … congestive heart failure … cardiac arrhythmias … cardiovascular disease … chronic obstructive airways disease … and depression.”
(Odds ratios and other statistical details removed from the above to ease reading — the footnote contains a link if you want to check out the specifics.)
I would characterize my usage of physician visits and hospital nights as very low. So that’s something. But that also makes me think that I’m surprisingly healthy sleep apnoea and obesity notwithstanding. So then, to bring it back around, I looked at sleep apnoea and obesity/diabetes:
“Recently, there has been increased interest in the metabolic effects of SDB [Sleep-disordered breathing] and the association of SDB with impaired glucose tolerance, insulin resistance, and type 2 diabetes. One study found a 2-fold increased risk of developing type 2 diabetes in subjects with habitual or regular snoring who were followed up for a 10-year period.”
This last one is of note. The idea of “impaired glucose tolerance” and its poorer cousin “impaired fasting glycaemia” came up in conversation in my most recent GP visit. It turns out that after a poor night’s sleep, whether due to sleep apnoea or insomnia (which I also suffer from) that instead of having relatively low blood sugar with the attendant need to break one’s fast to bring it back up, glucose levels in the blood remain high. It may be that this sleep-moderated glucose response is impaired fasting glycaemia, or that it is a more chronic manifestation of the same problem.
Impaired Fasting Glycaemia
Here’s what Diabetes.co.uk have to say about Impaired Fasting Glycemia (IFG), aka pre-diabetes/metabolic syndrome (paraphrased):
IFG is when blood glucose remains unusually high during periods of fasting. This implies that the person is unable to process glucose efficiently, and can eventually lead to type-2 Diabetes and cardiovascular disease, though these risks are lower than for people with Impaired Glucose Tolerance.
Just how closely related are Obstructive Sleep Apnoea and Impaired Glucose Tolerance? You know, I’m so glad you asked:
“OSAS [Obstructive Sleep Apnoea Syndrome] was diagnosed in 494 patients, while 101 patients were non-apnoeic snorers. Type-2 diabetes was present in 30.1% of OSAS patients and 13.9% of non-apnoeic snorers. IGT was diagnosed in 20.0% of OSAS patients and 13.9% of non-apnoeic snorers. Fasting and postload blood glucose increased with severity of sleep apnoea. Insulin sensitivity decreased with increasing severity of sleep apnoea. In addition to body mass index and age, the apnoea/hypopnoea index independently influenced postload blood glucose and insulin sensitivity.
The authors conclude that in a clinic-based sample of patients, obstructive sleep apnoea syndrome is associated with a high frequency of type-2 diabetes and impaired glucose tolerance.” [emphases mine]
I’ve clipped the last line of the summary quoted above in order to present it separately because it’s so important:
“The relationship between sleep-disordered breathing and impaired glucose-insulin metabolism is independent of obesity and age.”
This paper was published 15 years ago!
Most of the reading and research noted above took place in the last few months. So, rewinding a bit…
As I’m 45 at my next birthday I’d been making some changes to try and address my Sleep/Obesity/Depression issues. In truth, I have no idea why 45 suddenly seemed so important; it would’ve made sense to do something at 42 (over and above my Meaning of Life-themed birthday party).
As I mentioned above, my area of interest in psychology is morality. And I’d been debating about the virtues of vegetarianism for some time. Sam Harris had somewhat of an epiphany about how eating meat was at odds with his ethics, for which, the best example seems to be this. And I will admit to feeling a bit of a tug in that direction. However, I felt more of a tug towards Richard Carrier’s analysis of why vegetarianism can’t be justified on ethical or environmental grounds, and it predates Sam’s.
As it happens, I had reduced my intake of both bread and dairy products for about a year before seriously considering whether or not to go vegetarian. I’ve been experimenting with being mostly vegetarian for the last eight weeks. What that means is that I mostly eat like a vegetarian, but will occasionally eat meat, mostly at dinner, if I feel like it. This change doesn’t seem to have had any real impact, aside from discovering just how many genuinely delicious vegetarian meals are available these days. So that’s a thing.
Side note: I’ve been trying to coin a neologism that denotes this actually quite common idea of being borderline vegetarian, but not some kind of ovo-lacto-pescetarian (I do occasionally eat chicken, lamb, game, or beef, in roughly that order of priority). The best I can manage, so far, is semi-veggie, which, I admit, is kinda lame.
In mid-April I finally got around to setting up my AppleWatch and making use of AppleHealth (having done many of the same things with my Android phone previously, so this change is more one of provider, than behaviour). I’m consistent at hitting my daily targets:
1. Stand-up 12 times a day during sedentary activities
2. Move for at least 30 minutes
3. Burn 600 calories through movement/activity
In addition, because I got my watch through Vitality, I tend to hit targets two and three by taking at least 7000, but ideally 12000 steps per day. I smash these goals 4 or 5 days out of seven (by a factor of two), and I at least complete, or get very close, 1 or 2 days a week, and then I’m thoroughly slothful on the remaining days.
In addition, my lunch is heavy on colourful vegetables, e.g. dark leaf salad, tomato, yellow or orange pepper, plus hummus and Quorn slices (fake turkey/stuffing or chicken being my favourites).
Right at the start of this piece I mentioned that, in order to be just inside the healthy weight range for my height (183cms, six foot) I’d need to be 83kgs (185 lbs). Throughout all of the above changes to activity and diet my weight remained resolutely around 112 kgs (248 lbs). Then I thought about Impaired Fasting Glucose and this idea that my crappy sleep quality was screwing with my blood glucose in the mornings.
So what about not eating in the morning?
I’m sure I’m not the only person that has been bombarded with ads (on YouTube, primarily) for Matt DeLauer’s Science-Based Six-Pack/Six-Pack Abs. And it so happened that I was watching a clip from the Joe Rogan Experience where he was talking to Peter Attia (who has a similar attitude to Richard Carrier on the health impact of red meat). He was talking about the effect of diet, and especially fasting, on longevity. So I decided to revisit intermittent fasting (of the ‘eat all your daily meals between 2pm and 10pm’ variety).
I had tried intermittent fasting in a fairly undisciplined way previously, and it was an unmitigated disaster. No change in weight, and I was miserable. This time I decided that, with an improved diet, I might be able to make a go of it. And all I had to do was take my breakfast (which is often just an oats and whey protein bar) and move that to my afternoon tea. I tend to have lunch around two anyway, and have tended to not have a big breakfast. In fact, I think the only reason I had breakfast at all was that ‘breakfast is the most important meal of the day’ thing. In retrospect, I wonder if my long-standing distaste for breakfast was because of my elevated, post-sleep blood glucose.
Anyway, I have been doing this for a mere two and half weeks. And I have lost five kilos (11 lbs)! It would probably have been more, but I indulged in a large tub of popcorn when I went to see Deadpool 2, last night.
I’m sure you’re thinking, ‘So?’ It’s hardly worth writing a rambling blog post about a mere five kilos of weight loss. That’s what LiveJournal is for.
So let me clarify why I think this is important:
I have not been 107kgs (237 lbs) for years
I have not changed what I eat, merely when I eat it
I have not appreciably changed my exercise levels
I got there in two and a half weeks
Now, it could be a delayed reaction to the (relatively minor) change in diet and the consistency of exercise, but I don’t think so. My daily walking habits haven’t changed much, and I’ve canceled my gym membership — my attendance at which was sporadic anyway.
The major unexpected benefit of intermittent fasting, and one that I really hadn’t seen discussed that much, despite being part of the science, has been a major improvement in mood.
“Many clinical observations relate an early (between day 2 and day 7) effect of fasting on depressive symptoms with an improvement in mood, alertness and a sense of tranquility reported by patients.”
Of course, now that I know this, I can see it mentioned all over the blogosphere :-/
SOD’s Law revisited
- If sleep is the thing you’re trying to deal with, remember it may be a symptom, not the problem:
a. Obesity can impact on your sleep quality.
b. Depression, especially intrusive ruminative thoughts, can make getting to sleep difficult.
- If obesity is the thing you’re trying to deal with, remember it may be a symptom, not the problem:
a. Sleep can change the way your body deals with food, especially glucose levels in the morning.
b. Depression can lead to food-related problems, and makes even contemplating exercise difficult.
- If depression is the thing you’re trying to deal with, remember it may be a symptom, not the problem:
a. Sleep can help with the mental clarity and focus that depression inhibits.
b. Obesity can make engaging in depression-lifting behaviours more difficult to engage in, and can be a focus for depressive self-criticism.
Small changes to your habits, and ideally ones that deal with two or more of the above will always be a good place to start. For me, I’ve found that intermittent fasting and breath-centred meditation (NOT mindfulness, which I will talk about in a future post), have been incredibly helpful, with no negative impacts.
Boring but necessary notes of caution
That last quote does come with the proviso that “The persistence of mood improvement over time remains to be determined.”
However, for me, so far (18 days), so good.
It should also be noted that fasting can raise cortisol levels so, if your depression (or sleep disorder, or whatever) comes with anxiety, or if you’re feeling especially stressed, it would be a good idea not to also be fasting. Then again, to modulate your cortisol levels, you could just cut down on social media usage until life is less stressful. Of course, this depends on the nature of your social network use, and the particulars of your health concerns.
I can attest to the impact of stress on blood sugar whilst fasting, I had a particularly stressful day the other day, and I was getting a very bad headache. A quick hit of blood sugar was exactly what I needed. However, that was once in nearly three weeks.
 Jefferson, Y. (2010). Mouth breathing: adverse effects on facial growth, health, academics, and behavior. Gen Dent, 58(1), 18–25. https://www.unboundmedicine.com/medline/citation/20129889/abstract/Mouth_breathing:_Adverse_effects_on_facial_growth_health_academics_and_behavior_
 Knouse, L. E., Zvorsky, I., & Safren, S. A. (2013). Depression in Adults with Attention-Deficit/Hyperactivity Disorder (ADHD): The Mediating Role of Cognitive-Behavioral Factors. Cognitive Therapy and Research, 37(6), 1220–1232. http://doi.org/10.1007/s10608-013-9569-5
 Schröder, C. M., & O’Hara, R. (2005). Depression and obstructive sleep apnea (OSA). Annals of general psychiatry, 4(1), 13.
 Smith, R., Ronald, J., Delaive, K., Walld, R., Manfreda, J., & Kryger, M. H. (2002). What are obstructive sleep apnea patients being treated for prior to this diagnosis?. Chest, 121(1), 164–172.
 Babu AR, Herdegen J, Fogelfeld L, Shott S, Mazzone T. Type 2 Diabetes, Glycemic Control, and Continuous Positive Airway Pressure in Obstructive Sleep Apnea. Arch Intern Med. 2005;165(4):447–452. doi:10.1001/archinte.165.4.447
 Meslier, N., Gagnadoux, F., Giraud, P., Person, C., Ouksel, H., Urban, T., & Racineux, J. L. (2003). Impaired glucose-insulin metabolism in males with obstructive sleep apnoea syndrome. European Respiratory Journal, 22(1), 156–160.
 Fond, G., Macgregor, A., Leboyer, M., & Michalsen, A. (2013). Fasting in mood disorders: neurobiology and effectiveness. A review of the literature. Psychiatry research, 209(3), 253–258.