Apnea, and Other Matters of Sleep

Earlier this year, I was diagnosed with obstructive sleep apnea, a surprisingly common condition where people stop breathing due to collapse of their airways when they go into deep sleep and lose muscle tone. Many people have sleep apnea and don’t know it, which is a serious issue, because untreated apnea can cause serious cardiovascular complications. People with mild to moderate apnea can sometimes treat it with things like keeping their sinuses clear, wearing oral devices, and even doing meditation exercises — depending on the patient. The gold standard, though, is Continuous Positive Airway Pressure (CPAP) therapy, ‘that thing where you wear a mask to bed.’ CPAP keeps the airway pressurized so it can’t collapse, making it easier to breathe and stay breathing, which is critically important if you have severe apnea. Which is why I went directly to CPAP, do not pass go, do not collect $200 (more like ‘pay out $800’ since durable medical equipment — like CPAP and wheelchairs — isn’t covered under the ACA).

Some 22 million people in the US alone have apnea. Often, the signs go unrecognised, or they’re written off to other things. They get insomnia, which is attributed to stress or other factors. They’re sleepy during the daytime, which is written off to poor sleep (but no one explores why the patient is sleeping poorly). They get up in the night a lot to urinate, which is dismissed as a bladder retention issue. Rarely, a patient is referred to a sleep lab for diagnostic evaluation (which, for the record, involves a take-home test these days, not a sleep study). Upon diagnosis, the patient gets to explore a variety of treatment options.

My experience with CPAP was, overall, very positive. I adapted very quickly after a rough first couple of nights as I got accustomed to wearing the mask  and tubing (I think of it now as being like a jet pilot, although hopefully pilots don’t go to sleep as soon as they put their masks on and hit the pillow). I noticed an improvement in terms of sleeping through the night and going into deep sleep — and staying there (apnea continuously jerks the patient into light sleep, which is the least restful sleep stage). I was less tired during the day.

My experiences with everyone else in response to my diagnosis were not so positive. I viewed my diagnosis as good news: I finally had an explanation for my fatigue, which had been an issue for years. I understood why my depression was so severe at times (depression and apnea are linked — apnea can make depression worse). I understood why I was such a restless sleeper. I understood why I got up a great deal at night. Having a diagnosis for something that has been plaguing you is a huge thing, as is the ability to access a treatment: I don’t want to understate how amazing it was to be told I had apnea, and that there were concrete solutions for it.

Not everyone viewed my diagnosis in the same way. A lot of people seemed to think it was very tragic I had apnea (as though being diagnosed meant it had suddenly appeared) and were extremely sympathetic about having to go on CPAP (for some people, it’s a frustrating hardship — for me, it wasn’t, and was literally a lifesaving and wonderful treatment). Many people, though, zeroed in on one particular thing: My weight.

I was informed that I wouldn’t have apnea if I wasn’t fat. I was given numerous anecdotes about every fat person ever that people had interacted with who snored or had apnea — I was told that being fat obviously caused apnea and that I brought the condition upon myself. This is a common issue with any medical condition and fat people: We’re repeatedly told that whatever it is, we caused it by being fat — and, by extension, that we don’t deserve respect, sympathy, or even treatment for it because we didn’t care for our bodies and landed irresponsibly in this situation.

This infuriates me, because all people deserve health care, and fat people should not have to justify or explain themselves, let alone fight for basic humanity. And in general, I am opposed to models of discussion about fat from fat people where people explain that they’re ‘good’ fatties because they’re healthy — the ‘fat and healthy’ model discards and actively harms fat people who are unhealthy, for whatever reasonHowever, in this case, I want to expand on the issue a bit, because this myth that fat causes all medical problems is so engrained that people — including members of the medical establishment — repeatedly fly in the face of medical research to tumble all over themselves and attribute something to weight.

And sleep apnea happens to be a classic example. Some common risk factors for the condition include being of African descent, being a man, being older, having a narrow airway or thickened neck, smoking, family history, the use of certain medications (including tranquilisers), and nasal congestion (which is why keeping the nasal passages clear can help with some patients). One thing that…may not actually be a factor? Fat. Here’s the American Sleep Apnea Association:

Surprisingly, there have been few formal studies of how effectively weight loss leads to lesser, lighter snoring and diminished incidents of apnea and hypopnea during sleep. Despite this, anecdotally practitioners report striking improvements in both OSA and snoring among patients who lose weight.

Note a couple of things about this: Despite the fact that few studies have been performed to establish a positive link, care practitioners assume fat is a risk factor. Additionally, they rely on anecdotes — which are not reliable data — to establish their case. This is, put bluntly, bad science. It wouldn’t be accepted for any serious discussion about a medical condition, and it reveals significant underlying bias about fat and health. If you think fat will cause apnea, of course you weight fat patients in your practice more heavily.

This isn’t just about how fat is blamed for apnea and it’s offensive to fat patients who happen to have apnea. It also means that patients with apnea may receive inappropriate and ineffective treatment recommendations for the condition — and that the outcome of this can be fatal.

That’s just bad medicine.

Apnea isn’t the only condition managed by this. Compound that across the number of fat people in the world. And start asking yourself how many fat people are receiving useless and sometimes actively dangerous medical advice (‘just lose weight!’) for their serious medical conditions.