← Extend Podcast with Darshan Shah, MD
Extend Podcast with Darshan Shah, MD
184. Dr. Sahil Chopra & Sagar Chopra: Why Your Sleep Apnea Machine Might Be Lying to You
01:06:06
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- [00:00]
A
Before we get started with this episode, I'd like to invite all of you to the first ever next Health Longevity Summit happening in Nashville, Tennessee at the Conrad Hotel on Saturday, September 12, 2026. This is an all day summit where you're going to be hearing from some of the best speakers in longevity medicine, including Dr. Vonda Wright, Dr. Luisa Nicola, many of the podcast guests that you've heard here on the Extend podcast. And of course I'm going to be there curating the entire day. We also have incredible vendors coming so that you can try the latest technologies in health, wellness and longevity. Go to next health.com summit and buy your ticket today. We only have 400 spots and they're going quickly. That's next health.com summit. I look forward to seeing you all there. Welcome to Xtend with me, Dr. Darshan Shah, a podcast dedicated to cutting edge science, research, tools and protocols designed to help you extend your health span. One of the youngest doctors in the country at the age of 21 and trained and board certified at the Mayo Clinic, I've accumulated three decades of practice as a board certified surgeon and longevity expert. Over that time I've discovered that a mere 20% of health knowledge yields 80% of the results. When it comes to your health span, we are living in a new era where we are creating a new healthcare system no longer focused on disease management, but achieving optimal health and vitality. Join me as I interview world renowned experts offering you a step by step guide to proactively avoid disease and most importantly, extend your health span. Welcome to xtend, the podcast dedicated to helping you live a longer, healthier and more vibrant life. Today we're diving deep into the often overlooked yet profoundly impactful work of sleep. With true innovators in the field. I'm thrilled to introduce brothers Sahil and Sagar Chopra. Dr. Sagar Chopra is a co founder of a groundbreaking venture aimed at fixing our broken sleep care system. They were inspired by a personal journey through family illness and through a deep dive into continuous health monitoring. These brothers are at the forefront of expanding our understanding of sleep beyond just apnea into the comprehensive realm of circadian science. We'll discuss their revolutionary device for longitudinal sleep monitoring and how it differs from traditional wearables and the astonishing findings from their recent study published in the prestigious journal Sleep, which challenges conventional wisdom about CPAP efficacy. Get ready to rethink everything you thought you knew about your sleep data and about sleep apnea. Sahil and Sagar thanks so much for joining me today on xtend I'm so finally happy to have you guys here.
- [02:44]
B
So nice to be here. Thanks for having us.
- [02:46]
A
It's been a long time coming. So both of you have created together a revolutionary new device for people to monitor their sleep at home in a longitudinal fascia, meaning they can do it day after day after day. And I'm really excited to talk to you about this device, why it's important, why it's different from what else is out there. A lot of people have wearables. What makes it different from wearables, and also, really to dive in on some of the things that you've learned in your experience with the thousands of patients that you've done this sleep study on. So I'm excited to dive right in. What about you guys, man?
- [03:18]
C
I'm thrilled to be here, man.
- [03:19]
A
Yeah. So good to meet you guys. Super pumped. Okay, so anyone watching this on YouTube, we gotta cover this first. They're probably looking at this, like, are they related or something?
- [03:27]
C
So just tell us the story real quick.
- [03:29]
A
How did you guys.
- [03:30]
B
We've known each other for a long time. Sil and I are brothers.
- [03:34]
A
Yep.
- [03:35]
B
So we've obviously known each other for a long, long time. And you want to go through the origin story?
- [03:39]
C
No. Well, I mean, so I was doing my sleep medicine fellowship, so I'm pulmonary critical care sleep medicine trained. Did. I am at ucla, Palm crit at Loma Linda. Loma Linda, by the way, is a blue zone.
- [03:55]
A
Yeah.
- [03:55]
C
You know, so, like, I think that's where I. The. The. The seed of wellness and longevity was kind of planted.
- [04:02]
A
Yes.
- [04:02]
C
That was my sort of segue into sleep medicine. Luckily did sleep medicine at Harvard. Was at Boston. Was in Boston. And what was happening there when it comes to sleep was very different than what was happening in the community. And the community was like this. They're like sleep apnea clinics. Yeah, right.
- [04:24]
A
Exactly.
- [04:25]
C
But when you're at Stanford or Harvard or any of these big university centers, they look at sleep as a system. My mentor, Dr. Thomas and PD at the time, he would say, sahil, your job as a sleep medicine doctor is to understand human physiology. When someone is sleeping, like, what's happening in the brain, what's happening in the GI tract, what's happening to blood pressure, what's happening in the hepatobiliary system, what's happening to hormones. That is your job as a sleep medicine physician. And then when I finished, like, there was no practice like that that existed.
- [05:00]
A
Right.
- [05:01]
C
And so I wheeled this guy in. He was doing his MBA at Wharton, but I'LL let you share your story. Yeah, yeah.
- [05:12]
B
I come from more of a tech background. So what's actually funny is growing up like Sahil and I would always talk about entrepreneurship. And I remember, you know, just kids or like teenagers, they'd be like, man, one day we're gonna like, start a hospital together. Just something like we love, like, businesses and grew up in a family of, you know, Indian parents. Parents owned gas stations. And so we would like go in on the weekends and stock the coolers. I think we've, like, talked about this before, so I think that hustle and the grind of just like building a business, having a team, sort of, it just always existed. Yeah, I was pre med for a few years in undergrad, but decided to eventually go down the tech path. And so how's that? Uber focused on product growth and expansion, launching new countries across the world, and also just had a very personal tie to healthcare. I mean, Sahel and I grew up, our father was chronically sick. He passed away when I was 18. Sahel was 26. And so when you go through these formative experiences when you're so young, you just like the idea of like a broken healthcare system just becomes seared into your mind.
- [06:14]
A
Right? Absolutely.
- [06:15]
B
And so that was always, for me, at least it was always there. And after that, ended up doing my MBA and sort of between first and second year, I didn't really have like an internship lined up. Most people do. And I was like, I want to work on something of my own. And Sahil was like, hey, I'm going to this sleep medicine conference. You should hang out for like a weekend. Come with me. And I was like, yeah, sure, let's. Let's do it. And I remember coming out of that weekend just kind of thinking like, wow, I can't believe more people are not talking about this. And I had started experimenting with like whoop and aura and levels and CGMs. And I think to me it became very clear that at some point this idea of continuous longitudinal health monitoring will become a thing. And then kind of seeing that overlap with this idea of like a very broken healthcare system where people only have like a one night sleep study. And I think for me it was just like, okay, this can be productized and it could be done better. And so, yeah, it's funny because it was like a very initial curiosity that turned into an obsession.
- [07:11]
A
I love it.
- [07:12]
B
And I jokingly say I'm like, sal, you just wrote me into this thing.
- [07:15]
C
First I told him, don't go into medicine. And then I Looped him into like everything that we're doing.
- [07:20]
A
It's very similar. Obviously it reminds me of me and my family because my brothers are in our business together too. And it's like sometimes your brothers are the only ones that'll like, believe your craziness. So it's an incredible time we live in though right now, because I think so much is changing so rapidly. You have the advent of longitudinal tracking with wearable devices, combined with this renewed interest and acceptance in the community, in the world, that sleep is actually important. Right. We need to sleep and we need to figure out how to get good sleep. And people are now getting hyper obsessed with their data and bringing it all together. Plus, like you said in medicine, our broken medicine system, there was only one focus of sleep, which was sleep apnea, which is just an anatomical problem create in your throat area as you age, or if you are overweight or there's many real talk, we'll dive deep into sleep apnea. But sleep is so much bigger than that. Right. It's connected to everything. And so we live in this entire, like, misconception, like probably as when we were kids. And now everything has changed. And you guys are leading the charge of really trying to figure this out because it needs to get figured out.
- [08:30]
C
Yeah, Darshan. To the point where even the timing of chemotherapeutic agents, like our entire physiology is circadian. Our alertness. There's a peak and a trough of alertness. There's a peak and trough of when growth hormone goes up and down. There's a peak and trough of everything oscillates in this sort of 24 hour cycle. Right to the point of like now there is enough evidence that suggests what is the best time in the day to even give a chemotherapeutic agent so that it is more effective. Right. For that person as an n of 1. And when you start to look at sleep and circadian science that way, it's like this massive unlock of entering a new dimension and you just see like, wow, there is so much work to be done here.
- [09:15]
A
Right? Absolutely. Yeah. And I think expanding the definition of sleep to really be circadian science is also critical, right?
- [09:23]
C
Totally.
- [09:24]
A
It really is. Because if you are minimizing your sleep, you're basically breaking your whole circadian system for the next 24 hours. Right. And that has severe physiological consequences besides just what happened at nighttime. Right.
- [09:38]
C
100%.
- [09:39]
A
Okay. So we know why you guys came together. You're trying to fix this broken sleep care system and just expand the knowledge base and the think around sleep. And you recently published a study which was very interesting, and it's on sleep apnea, is that correct? And published in one of the largest sleep journals, Sleep. And I think that's a really good place to start this podcast conversation. Tell us about that study and then we'll dive into the specifics there.
- [10:04]
C
Yeah, so let me. I'll take a step back for, for the audience who might not be familiar. So if someone typically has, like, sleep apnea, they are usually prescribed a device called a CPAP machine. And in the standard care model, if someone uses a CPAP machine, they look at the app, the companion app of that CPAP machine. The doctors do the same, and they tell you that your CPAP is working. This is the number of, like, pauses in breathing that you still have on cpap. This is the leak, this is the usage and some of these, like, very rudimentary metrics. And it's not the standard of care to do a sleep study or measure someone's sleep when they are using a CPAP machine. We use subjective symptoms and say, hey, Darshan, like, how do you feel right while you use your CPAP machine? So what we did was all of our patients, which, can I just say,
- [10:57]
B
that's crazy that we do that. It's like, imagine you give someone metformin and then you never measure their glucose again.
- [11:05]
A
Right?
- [11:05]
C
Or basically, what's happening? Yeah, 100. And it's wild, right? Like, it's like you do an intervention and then you never measure. Like, did this work or not?
- [11:15]
B
Right.
- [11:15]
C
And.
- [11:16]
A
And how many people are on CPAP machines in the United States, for example?
- [11:19]
C
Like, 3 to 5 million.
- [11:21]
A
Yeah, I mean, I mean, I'm sure there's a lot of people listening to this that have a CPAP right now that should have the take home study. Just because your CPAP is telling you that your sleep apnea is better, don't believe it. And why is that? What did you guys find?
- [11:35]
C
So when we looked at 25,000 nights of data, and this is like one of the largest data sets that exist of longitudinal sleep testing data on people who are using a CPAP machine, in about 500 people, we've discovered like, a very massive discordance. So if the average number of pauses in breathing on your cpap machine is two, if you do a sleep study, it's close to 12. That is, that puts you in the category of mild obstructive sleep apnea, even on cpap. And the really, like, wild thing is, as that number on the machine goes Up. Like, let's say you have seven to ten pauses in breathing per hour and someone might say, no, you're fine. If you do a sleep study, you might have like 25 to 30 pauses in breathing per hour, which is like moderate to severe sleep apnea. So there's a lot of people out there who think that their sleep apnea as well controlled based on the data from the CPAP machine, but they still have significant, 88% of them have still significant disease.
- [12:42]
A
So these people are using CPAP night after night after night. And I hate to say, like, CPAP is not fun to wear. So they're doing this, but they're really getting no benefit from it, right?
- [12:52]
C
They might be getting some.
- [12:53]
A
Yep.
- [12:53]
C
But there might be. And you know, we talk about optimization and they might be getting some benefit, but there's probably still work to be done from a titration optimization, adding an additional solution, weight loss, it could be anything. Right. So there's work to be done. It's not necessarily well controlled sleep apnea and it's not even healthy sleep because sleep was never measured when someone is using a CPAP machine.
- [13:21]
A
Right.
- [13:21]
C
We're just asking the, how do you feel?
- [13:23]
A
Exactly.
- [13:24]
B
And this is, it's interesting because this is only the cohort of people that actually comply with cpap, which is generally compliance is, it's pretty low. It's about 40 to 50%. But you imagine the other remainder, the other 50% that actually stopped wearing it. And then it sort of, you ask the question of, well, could we have prevented that just by kind of doing these like post efficacy, post treatment efficacy testing to see, okay, like, how do we now optimize that therapy for that individual? If you're able to do that, then that makes a lot more sense and people actually have the therapy that they need to feel better.
- [14:00]
A
Yeah, I think, you know, a lot of my patients, and this explains it perfectly, they have, they get the CPAP when we discover they have sleep apnea. And then they, I talked to them maybe a couple months later. They're like, I don't use it anymore. I'm like, why? Well, it was weird to wear, it's uncomfortable. And I don't really think it helped at all. And it's probably because the machine was never optimized based on data to tell them that it's actually working or not. So just getting a CPAP machine and putting it on doesn't mean that it's actually working. And so what you're saying is to keep looking at the data from your body to see if it's actually working. Right. And don't trust the data that's coming back from the sleep AP machine because that is not the correct data.
- [14:38]
C
That's not the place of truth.
- [14:39]
A
Right.
- [14:40]
C
And for those patients who like struggle with sleep apnea, the symptoms of sleep apnea and they had intolerance to CPAP machine, there's so many different solutions available and like, and we can talk more about this at some point, but like sleep apnea does not equal a CPAP machine.
- [14:55]
A
Right. And we need to talk about that because I think that is the fear out there. Some of my patients even say, I don't want to know if I have sleep apnea or not because I'm never going to wear a CPAP anyway. And they think they have that mental kind of doom of coming of the diagnosis of now having to wear this machine every night. Right. And CPAP is getting better. It's getting less intrusive. It's getting better, I think, but it's still not the funnest thing in the world.
- [15:18]
B
The Darth Vader mask.
- [15:19]
A
Yeah, exactly. Okay, so I think this is a really good time about the how. So let's take a look at the device. If you don't like, can you show it to us? So this is the Empower Sleep device that you're showing us and it's this little kind of bigger than a, than a ring. It looks like about the size of a, of a football championship ring there.
- [15:35]
B
Yeah.
- [15:35]
A
And you just wear it on your index finger like that?
- [15:37]
B
Yeah, you wear it on any finger that's comfortable. And one thing to actually clarify is, you know, this sleep study, Empower Sleep is the consumer layer that sits on top of these medical grade devices. So we didn't create the hardware, but what we're doing is we've built this amazing app, experience and platform where our members can come to us, they can get all of their data in an app similar to what levels has done with CGMs. They get all of these insights and they're able to talk to their physicians and their care teams.
- [16:03]
A
How is this device different from like an OURA ring measuring your sleep?
- [16:08]
B
So there's a couple of things. It's sampling data at a much higher frequency. Right. So because of that, if you wanted to look at the number of apneic events that are occurring every hour, it's going to be able to do that with a higher level of accuracy. The other thing is it's also a medical grade device. Right. So as a physician, you're not going to use an OURA ring to prescribe medical devices, sedative hypnotics. You know, maybe you can do some cbti, but what you ideally want is a device like this which is giving you much higher resolution data. And then the third piece is if we go through the backend experience as a physician, you can see all of the inputs that are going into this device and coming out of the device. So if you look at an aura, it's kind of hard to see a composite score of like 91 out of 100. And as a physician, it's kind of hard to know like what's driving that. Is it the breathing? Is it circadian timing? Is it fragmentation at night? But with this you kind of get about like 25 to 30 different biomarkers. That's amazing around sleep.
- [17:12]
A
And so when you say higher sampling frequency, what you're saying is that this is measuring your apneic events, meaning when your oxygen level drops more frequently throughout the night, Right?
- [17:23]
C
Correct. It's called the PPG sensor, the photoplatysmography sensor.
- [17:27]
A
Right.
- [17:28]
C
And like for any of us who have ever liked been to a doctor's office and they put that little oximeter on your finger and the doctor's looking to see like that waveform that pops up on the chart. That's basically what's being measured.
- [17:39]
A
Right.
- [17:40]
C
And through that signal, along with movement, heart rate, breathing, sleep, all of these things are extrapolated. And because it's sampling data every second, you can detect an apneic event that is a pause in breathing of 10 seconds or less. 10 seconds or more.
- [18:00]
A
Got it. And from what I read, and I don't know if this is true, some of the home wearable devices are only really sampling maybe once every hour or something, or even less, right?
- [18:09]
C
Yeah, more frequently. So for example, if anyone uses a wearable ring or a ultra human, you'll see when you're sleeping, the light that's on the inside, it goes from green to red.
- [18:21]
A
Ah, it does. Okay.
- [18:22]
C
Yeah. So you'll, when it changes to red, it's using more battery and it's sampling data at a higher frequency.
- [18:28]
A
Ah, okay, I know.
- [18:29]
C
And so it's a different sensor, different sampling frequency. And some of these consumer devices might sample like one time a minute or during the nighttime when it thinks that you are sleeping. But it might sample once every five minutes when you're during your daytime activity. And then when you turn it to like exercise mode, it might sample once every one to two minutes. So it's like it's like an evolving thing.
- [18:55]
A
Got it. And is the home wearable devices? Is that not a PPG sensor? Is that a different sensor?
- [19:00]
C
It is a PPG sensor. It's a similar sensor. Just like the sampling frequency is much lower.
- [19:05]
B
Sorry.
- [19:06]
C
Much more spread apart.
- [19:07]
A
Right.
- [19:07]
C
And then like with these sensors, we can run this through FDA cleared software as a medical device system to get like a proper sleep study output.
- [19:16]
A
Got it. Got it.
- [19:17]
B
What we've also done, I think it's important to call out. Is it typically it's not really one or another. What we've actually done is we integrate with most of the consumer wearables too. Oh, you do aura garmin 8 sleep apple watch.
- [19:31]
A
Whoop.
- [19:32]
B
And I think that's really powerful because again, if you're looking at a patient who came to you and this happens all the time where they might want to talk about insomnia and nighttime awakenings and it's really helpful to say, hey, integrate your aura. Let's understand what your sleep looked like six months ago. Sleep timings. Oh, this seems interesting. This fragmentation sort of started like three months ago. What happened in your life. And I think that's really powerful. Right. Or it's really powerful to know what's happening during the day.
- [19:58]
A
That makes total sense.
- [19:59]
B
Typically it's not even like using one device over another, but combined is way more powerful than just using one of them.
- [20:06]
A
That's a really good point. Really good point. So if someone thinks they have sleep apnea or they're not sleeping well and they need to get some help figuring it out, what we do at NextHealth is we refer them to Empower Sleep. You guys ship them this device, they wear it for a few nights, you get some data on them, and then what's really cool is then this data goes to an app, of course, and it's medical grade. It's very highly frequent. The frequency of the sampling is much higher. So you can actually make a diagnosis of sleep apnea on somebody, which is something you couldn't do with a standard wearable. And then also in your app, you can speak with a sleep coach or a sleep doctor to act like a real human to look at this and kind of coach you through. Right. And so I think what's important here also is it goes way beyond just sleep apnea. I think a lot of people think of these home sleep study devices as just for sleep apnea, but it's much more than that.
- [20:56]
B
Yeah. And unfortunately they're called home sleep apnea tests, which is a pretty bad name yeah, we need to change that.
- [21:03]
C
Yeah, no, totally. You can understand sleep health in a fundamentally different way. Is their heart rate dipping or not? What's happening to movement? What is their overall sleep architecture looking like? Is it. I mean, I saw a girl, 12 year old, just a couple days ago, referred from a colleague who's also a patient, Darshan. Her entire, you know, during sleep we should have about three to five REM periods. Right. We go through these cycles. During the course of the night, she had only one REM period that was in like the latter just before she woke up. Like it is such a pathologic sleep architecture.
- [21:43]
A
Yeah.
- [21:44]
C
She has symptoms of depression. She's on Lexapro. It's like sleep is this like really unique window into understanding your physiology and your health. And that's how we try to look at this. Because it's possible that if we help her change her, address her depression, anxiety, all of these things maybe come on to a lower dose of Lexapro, improve her sleep habits. Like she can have a more physiologic sleep architecture. And that's what we talk about a lot. And you guys do this too, right? The goal is not to give a drug or do a solution. The goal is to restore physiology as best as we can.
- [22:20]
A
Sure.
- [22:21]
C
And that's where this whole optimization idea comes in. And the same thing is true from a sleep medicine standpoint. How do we restore your housekeeping process to a more physiologic level with any kind of data that we can understand about your sleep?
- [22:38]
A
Right, Right. And I think it's really important because I think one of the most misunderstood things about sleep is the seven, eight hour rule. Right? Yeah. Everyone thinks that as long as I'm getting seven, eight hours, that's probably good sleep. But you don't know, right?
- [22:52]
C
You don't know.
- [22:53]
A
So what else can be going on? Like this is, this is one example,
- [22:58]
C
just getting one session of REM sleep, totally 100%. And there could be a lot of circadian rhythm dysfunction. I mean, we do these things called office hours with physicians who are doing a trial and they're testing in power sleep and then we invite them to come to office hours. And I feel like physicians unfortunately have like the most circadian swings in their sleep because either they're traveling, they're working, they're documentation at nighttime, and they have like family responsibilities. And. But from a normal like circadian standpoint, like we should be going to bed around the same time and waking up around the same time. Like this oscillation that Happens on a nightly basis is it's not physiologic, it's not healthy. And so there's a. There's a ton of room from circadian optimization. There's the ability to identify diseases like sleep apnea. There's the ability to understand sleep architecture. There is the ability to understand, like, how much fragmentation and microarousals of sleep do you have. There is the ability to identify movement disorders. These are called periodic limb movements that can happen, that can be disrupted. Restless legs. Yeah, absolutely. There is even the ability to understand, like, hey, if I'm taking this new antidepressant or antipsychotic or anti hypertensive medication, like a beta blocker, how does that change the architecture of my sleep? And, man, we see this so often where, when patients come to us from like a psychiatrist, they're on a stimulant during the day, and then they're on a sedative at nighttime. Right. And then you start peeling the layers of this and it's like, dude, there was like an underlying sleep disorder. All this in this entire time.
- [24:45]
A
Wow.
- [24:45]
C
They had like significant obstructive sleep apnea or there was a circadian rhythm disorder. So they were on a. Someone put them on a sedative as like insomnia equals trazodone. Sort of like, you know, like.
- [24:58]
A
Like a knee jerk reaction.
- [24:59]
C
Like a knee jerk reaction. And then. Then they feel tired during the day and then they're on a stimulant like methylphenidate, modafinil, something during. So it. It can be like this really vicious cycle and.
- [25:10]
B
Which is kind of crazy within the pediatric population as well. Where do you think about, like, the underlying driver of whether it's like add, adhd?
- [25:18]
A
There's so many more kids being put on medication now, but maybe. Right.
- [25:22]
B
Like, it's a sleep dysfunction at the end of the day that could be causing it.
- [25:25]
C
And there. And there's enough evidence to support that.
- [25:27]
A
Yeah.
- [25:27]
C
Like, kids who have some degree of inattention, their sleep, like a substantial proportion, a substantial portion of them have pathologic sleep. They're like mouth breathers. They have these cranial facial, like, abnormalities. And they may have sleep disorder breathing or some degree of sleep apnea. And it's a really big problem, man. Like, this whole thing is a. It's all screwed up.
- [25:52]
A
A lot of. A lot of my clients that they're talking about their kids and even, even my neighbors, and they're like, yeah, I think I'm gonna have to put my kid on ADD medication. I'm like, well, have you had a sleep study done, an evaluation of their sleep first? Because a lot of it is coming from, like you said, from disordered sleep. Right. And before starting the medication, it might be a good idea to check that out 100%.
- [26:15]
B
And they're so easy to do now.
- [26:17]
A
Yeah, they're so easy to do. Like order the ring and you can get a sleep study. And really a really good one, I think, you know, going back to that point too. And this ties back into sleep apnea. The way people are breathing now is also very different. Palette shapes are different. Right. You mentioned mouth breathing. A lot of people have really constricted palates and kids are being born that way almost. And you probably read the book Breathe.
- [26:39]
C
Yeah.
- [26:40]
A
Right?
- [26:40]
B
Phenomenal.
- [26:40]
A
Yeah, phenomenal book. It goes over the history of our palate shrinking over the last few generations,
- [26:46]
B
all the societal changes and soft food diets and all that. It's fascinating.
- [26:49]
A
And now there's palate expansion actually as a treatment that could completely fix this. Right. And so there's so many other avenues that we can explore before going to, like a CPAP machine or even while you're on CPAP to look at, especially for kids. Right. Because kids, kids, they don't do sleep. Ap.
- [27:07]
C
No, for sure.
- [27:08]
A
Yeah.
- [27:08]
C
No, my kids are an expenditure. So I'm like, I openly share. Yeah, yeah. Because, like, I. So I have three boys, we were talking about this, and they had like, crowding of their teeth. And I can see that they're becoming like more and more mouth breathers. My younger one, my middle one, he was starting to get like this jetting of the mandibles in front of the upper teeth. And so they have underdeveloped jaws.
- [27:33]
A
Yeah.
- [27:34]
C
There's this maxillary mandibular complex is smaller than what it should be. And like expansion, like instead of like tooth extraction.
- [27:43]
A
Right.
- [27:43]
C
Like expansion, creating space. So, like, this whole complex can grow in a healthy fashion. Is like we're setting them up for healthy breathing in the now and in the future.
- [27:55]
A
Yeah, yeah. I think this is important. Double click on this a little bit too. Because for decades, you know, people would just have their wisdom teeth removed. Right. And now also with just our diets being so much softer and more processed. Everything is processed. We're not really exercising our jaw muscles. That's creating this like, basically a small mouth. Right. And that's where you have problems not just with eating and speaking, but breathing, especially at night when you're sleeping. So I think this is a. This is something that we're seeing more and more kids being born with this and growing up this way, growing into this, growing into this, Right?
- [28:31]
B
Yeah.
- [28:31]
C
And I think, like, for the audience who's listening, the way to think of this is if you imagine like a triangle, like the roof of the mouth is the floor of the nasal cavity. Right, Right. So if the mouth is smaller, then guess what happens to the roof of the mouth? It becomes higher arched.
- [28:52]
A
Right.
- [28:53]
C
There's less side to side dimension. And as a result, the nasal cavity volumetrically gets smaller. You have smaller maxillary sinuses. As the arch of the palate goes up and it's smaller, then the septum becomes deviated. It has to move in some direction. It'll move to the left or the right. So now you have difficulty with nasal breathing. So this whole, like it's a contiguous structure. So when the mouth is this mandible and maxillary complex is small, teeth are crowded. That's a sign that the overall craniofacial complex is smaller than what it should be. The nose, nasal cavity is small, the back of the pharynx is constricted. So you have this sort of weak foundation from an anatomy standpoint. And then on top of that, obesity, allergies, like all of these things start to play a role. So now you have like this sort of framework is small. And then now the, the drywall is sort of, you know, on top of this, like, small framework to begin with. Now you've, now you're kind of stuck with these like narrow passages.
- [30:01]
A
Yeah.
- [30:02]
B
And then also with like 30 to 40% of people who have any form of sleep apnea will then end up having some form of insomnia because they create these like, poor associations around.
- [30:12]
A
Right.
- [30:12]
B
Their sleep because they're just not breathing well during the night. And that becomes like a whole can of worms as well.
- [30:19]
C
Totally. And then, and then if, like that, if someone's housekeeping process is impaired.
- [30:24]
A
Yeah.
- [30:25]
C
One of my mentors used to use this metaphor. Like you're, you can get like the newest iPhone, but if it's not charged properly, like, dude, good luck, man. It's like, what's, what's the point?
- [30:34]
A
Right.
- [30:34]
C
It's like, I'd rather have like an old iPhone that's properly charged and like a new iPhone that's improperly charged and doesn't work. Doesn't work well.
- [30:42]
A
Right.
- [30:42]
C
And so then if our physiology at night is impaired and broken, then hypertension, atrial fibrillation, cognitive decline, metabolic syndrome, diabetes, dementia, like all of these chronic diseases that we're trying to mitigate from, like, a health optimization longevity standpoint, like, you're kind of going uphill.
- [31:06]
A
Yeah, yeah, absolutely. It makes it a lot harder to treat those and actually might be that the poor sleep and sleep apnea are causing those. So you have to go back to the root cause and fix the apnea for sure. You know, going back to when people have problems with sleep apnea, I think of another big group of people that come in with sleep apnea all of a sudden, and that is women going through menopause and men going through, like, andropause. Right. I see that a lot in that age group, that late 40s, mid 40 age group. Why. Why does that happen?
- [31:37]
C
There's a couple of things, particularly in menopause. For.
- [31:41]
B
For.
- [31:42]
C
For women, the. There's this thing called the arousal threshold.
- [31:48]
B
So.
- [31:49]
C
So if. If we take a step back and you know how, like, diabetes comes in, type one, type two, and, like, there's these different sort of endotypes.
- [31:55]
A
Sure.
- [31:56]
C
Heart failure comes in heart failure with reduced ejection fraction. Heart failure with preserved ef. Similarly, like, sleep apnea comes in a lot of flavors, really.
- [32:04]
A
Okay.
- [32:04]
C
Yeah. In terms of, like, different pathologic mechanisms, one of the mechanisms that drives sleep apnea is what's called the arousal threshold. And that. And the easy way to think of that is like, a child who's a very deep sleeper. There can be a whole bunch of, like, there can be an earthquake, and they won't wake up because their threshold to be awoken out of sleep is much higher. But someone who is, like, highly stressed for whatever reason, their threshold to be awoken out of sleep might be much lower. Just like the creak of a door might wake them up. So when people are going through these hormonal changes, their arousal threshold can drop. As that arousal threshold drops and sleep becomes unstable, breathing also becomes unstable.
- [32:53]
A
Okay.
- [32:54]
C
Okay. So if breathing is unstable, then the likelihood of developing sleep, some degree of sleep apnea or sleep disorder, breathing, is higher. The other thing that happens is people gain weight. So one is, like, the physiology of sleep is changing. Second, our body composition is changing. That results in more potential weight in the upper airway. The third reason is, like, the tone of our muscles is changing. So if the muscles are also now getting weaker, that's. That falls into the category of muscle responsiveness.
- [33:28]
A
Okay.
- [33:29]
C
Like a weak muscle. Like, you've probably heard of this thing called myofunctional therapy.
- [33:33]
A
Yep.
- [33:33]
C
It's like physical therapy for your tongue. Yeah, Right. Physical therapy for the upper airway. So, like, if the muscles are getting weaker. And that's why it's useful, because it's, it's targeting this idea of muscle responsiveness.
- [33:45]
A
Right.
- [33:46]
C
So if the muscles are weaker, the sleep is more fragile, and on top of that, that our physiology is changing. It's kind of like a setup to possibly develop something like sleep apnea. And if we look at sort of many of these, and the other thing that also happens at this time is the prevalence of restless leg almost doubles. Insomnia symptomatology jumps up. So it's kind of like this perfect storm of like a whole bunch of things happening and sleep apnea just happens to be one of them.
- [34:18]
A
Yeah, makes sense. Creatine isn't just the most researched supplements. It's actually proven to deliver results. So whether you want stronger muscles or you want a sharper mind, creatine is the energy source you're going to need to get there. Momentous just introduced signature Spec creatine. It's their highest quality creatine to date. It has 10 times fewer impurities and 2 to 5 times stricter heavy metal limits than even other premium creatines. And it's all backed by six stages of testing and certification. Not to mention the ultra fine micronized powder makes it so easy to mix into your favorite drink or smoothie. Try it yourself@livemomentous.com Dr. Shaw, and you'll get up to 35% off your first order using the code. Drshaw, can you talk about the muscle therapy for your tongue? How does that work?
- [35:18]
C
So it's called orofacial myofunctional therapy. And you know the tongue, I've heard this metaphor, which makes a lot of sense. The tongue is like the natural retainer for the mouth. Okay, okay. And James talks about this, I think in the book too, where, like where the teeth are placed is partially related to how much, how much muscle, how much pressure is on the outside and how much muscle is on the inside. How much pressure is on the inside. So the tongue, if it is, if the tongue is stronger than the cheek muscles, the teeth will be farther apart, farther outside, laterally and forward. There will be better growth versus if the cheeks are very strong and the tongue is weak. Okay. And the tongue being the natural retainer of the mouth, also then shapes the hard palate. So this idea of orofacial myofunctional therapy is all around doing physical therapy for the tongue. Series of exercises that help strengthen the tongue. And if the tongue is stronger, there is less backward collapse during sleep. And if there's less backward collapse during sleep. There's less upper airway blockages, less sleep apnea. And people who end up becoming. Who tend to have, like. Who go through this program of orofacial myofunctional therapy, they also become better nose breathers because it's, like, helping them. It's forcing them to breathe better, breathe more through their nose. So there's a variety of mechanisms through which orofacial myofunctional therapy helps people, especially children, change the anatomy. But then older individuals like you and I become better nasal breathers and mitigate the burden of sleep apnea.
- [37:08]
A
Yeah. There's a whole trend on TikTok and on Instagram, you've probably seen it called looks maxing. Have you seen this trend?
- [37:15]
C
No, I haven't seen this.
- [37:16]
A
It's just kids in early teen years doing orofunctional therapy, and they're trying to expand their palette, just look better, you know, Chiseled jaws. Yeah, yeah. Get chiseled jaws and expand their palates.
- [37:29]
B
Yeah, right.
- [37:30]
C
Is that. That's different from mewing. I've heard of this idea of mewing.
- [37:33]
A
Yeah, exactly. Yeah. Yeah, exactly.
- [37:35]
C
There's also.
- [37:36]
B
I'm forgetting the name of the instrument, but there's an instrument. There's been studies.
- [37:39]
C
Didgeridoo.
- [37:40]
B
Didgeridoo.
- [37:41]
A
The didgeridoo. Yeah. What's the study on that?
- [37:44]
C
Yeah. So the didgeridoo. People who played the didgeridoo have a lower incidence of sleep apnea, and people who've played the didgeridoo have actually reversed and reduced the burden of sleep apnea. Okay. And then again, it kind of makes sense because, like, the upper airway, you know, you have to work the upper airway in such a way that your muscles become stronger.
- [38:06]
A
Oh, okay.
- [38:07]
C
Okay. And there's actually a straw, too. Yeah. I have no affiliation with them. We prescribe them to her. We give them to our patients. But it's inspired from this idea of, like, strengthening the. The tongue and upper airway through, like, this, like, suctioning of, like, making these, you know.
- [38:25]
A
Yeah.
- [38:25]
C
Doing these kinds of exercises, but in the process of drinking water.
- [38:28]
A
Oh, okay.
- [38:29]
C
So, like, we've had. You know, it's so funny. I had a patient maybe a year and a half ago, famous singer, very overweight. And I was like, this guy has sleep apnea, and, man, he had, like, the healthiest breathing I could imagine. And I think, like, this is my hypothesis, that it's probably because he's just, like, a singer.
- [38:47]
A
Yeah.
- [38:47]
C
And, like, strong upper airways. So I Think there's. There's enough compelling evidence. And I've had some unique anecdotal cases where this makes a lot of sense.
- [38:56]
A
Yeah. So you have to work out your upper airway muscles like you're working out at the gym. Right. And expanding the palate is also another great way of treating this. And so palate expansion, those are. Talk about those a little bit, those devices, how does those work? Your kids are on them.
- [39:12]
C
Yeah. So it depends on the age. Again, I'm not an expert at this. See your local ortho or dentist, you know, who does these things. But they sort of. In the pediatric population, the bones are much more like malleable.
- [39:28]
A
Malleable.
- [39:29]
C
There's just a suture, interpalatine suture that has not fused yet. So, like, expanding laterally to the side is much easier. And then expanding forward through what's called reverse headgear is much easier. So there's a variety of different, like, dental solutions in kids that are based around expansion. In the adult population, it's a little bit different. Like, these sutures can. And this is kind of like debatable, but these sutures can fuse after the age of like, 18, 20. 20.
- [40:01]
A
And my suture is just for the audience. You're meaning the. It's a line between bones inside your palate, like on the top of your mouth. There's a line there that is actually a fusion of the bones from either side when you're an embryo that. Well, they develop throughout embryo, and then when you grow up, they fuse in the middle. Right?
- [40:19]
C
Yeah. Thank you for clarifying that.
- [40:20]
A
Yeah, yeah. And so I did a lot of cleft palate surgery in my time as a reconstructive surgeon. And cleft palate is basically when those don't fuse. Right. And so we would actually bring those together and fuse them for the kid. And I think in adults, you can actually do a little surgery, open up that fusion. So you can expand the palate, right?
- [40:40]
C
Yeah, yeah. And there's a procedure called marpi. You may have heard of it. It's like it comes in sort of two different forms. You either have bone anchored expansion where there are these, like, screws that. Again, this is like an outpatient. It sounds morbid, but it's an outpatient procedure. These couple of screws that go into the hard palate so you have some anchor and then you can expand with like turning a screw. Turning a screw for lateral expansion. And then they're also very relatively minimally invasive double jaw surgeries that can bring the maxilla the upper cheekbone, the upper jawbone, and the lower jawbone forward. So there's a lot of different solutions available now. And weight loss, I mean, I mean, from like a dental and surgical standpoint, like, those are sort of the, the more efficacious ones in the sense of trying to address the root cause of the anatomy.
- [41:29]
A
Yeah. And, you know, I think the bigger surgeries, like the UPPP surgery, where they actually would remove all the tissues, that's kind of like the last ditch effort. Right. To remove the tissues in the throat surgically. I think ear, nose, and throat surgeons do a lot of those for sleep apnea in the past. But it seems like from the surgeons I talk to, that's getting less and less prominent now because of these other more minimally invasive procedures that you can do.
- [41:53]
C
Yeah. Think of it as changing the structural architecture versus changing the soft tissue. Right, right. The soft tissue, if it's like, it'll come back to some extent.
- [42:06]
B
Yeah.
- [42:06]
C
But if you change the anatomy and soft tissue sits on top of the anatomy, you're. It's a better, longer term solution for an individual. Again, like, you know, patient selection and all of these, it's very nuanced. I'm not an expert at this by any means, but these surgical options are becoming more and more promising, less and less invasive. And in the right solution, in the right person, is what this precision medicine really comes at.
- [42:35]
A
Exactly. Yeah. I think in surgery everything is getting more and more precise. I mean, before all they did was just remove all the tissues and then like you said, they would grow back a lot of the times. And now that we understand the anatomy better, we can just adjust the anatomy a little bit. And that does a much better long term job with less surgery, actually. So it's a really great age to even revisit surgery with a surgeon that specializes in this type of stuff, because things have changed so dramatically. Right. And just to like, you know, finish up on the surgical side of things, there are now devices that are kind of like pacemakers for your throat. Right. Can you talk about those a little bit?
- [43:13]
C
Yeah, there's a. So there's, you know, there's two kinds of sleep apnea, obstructive and central. There's a hypoglossal nerve stimulator. It's like a pacemaker that sits inside your chest, connects to the hypoglossal nerve, that regulates and controls the tongue. And there's also like a separate lead that, that goes into like one of the intercostal muscles, the muscles between your Ribs to sense when you're breathing. So it's like it's sensing when you. When you breathe, it'll push your tongue out, out of the way.
- [43:47]
A
Right.
- [43:48]
C
And that could be a potential solution. And then if someone has what's called central sleep apnea, where their sort of brain forgets to remind their brain sort of forgets them to breathe. Forgets to remind them to breathe. There's a. The phrenic nerve is what talks to the diaphragm, and it can stimulate the diaphragm to breathe if you forget to read. So there. There's a whole bunch of unique solutions available. And. But again, these are not like, first line, you know, out of all of
- [44:13]
A
the sleep apnea is, what percent are central sleep apnea? What percent of people have central sleep apnea?
- [44:19]
C
If you're at altitude, there's a much larger proportion of people who have central sleep apnea. But in, like, the general population, like pure central sleep apnea is maybe somewhere between 5 to 10%.
- [44:31]
A
Oh, so it's actually not. Not as low.
- [44:33]
C
No, it's actually. But if you think of it as like a spectrum, right, where there's a lot of like, mixed components, like, where it's like obstructive on top, but there are flavors of like, this, like, central nature that's much higher, maybe like 20, 30%.
- [44:50]
A
Interesting. And for the audience, central sleep apnea, like you said, it's coming more from the brain. It's your brain does this automatically. Normally it tells your brain body to breathe when you're sleeping. But sometimes there's disorders that occur. That system is broken. It has to do with the receptors in the brain, et cetera. It's too deep to go into right now, but there's a lot of. And how can you differentiate between central sleep apnea and obstructive anatomical sleep apnea using a device like this, or do you need additional tests?
- [45:20]
C
No, it can be super helpful. There's a very unique signature of central sleep apnea. So central sleep apnea has to do a lot with, like, carbon dioxide regulation. And there's a very rhythmical nature to this central sleep apnea phenomena. And you can detect it with these kinds of sensors because our autonomic nervous system behaves a very particular way. So that signature is, like, embedded. And most sleep physicians should be able to pick that up.
- [45:52]
A
I love that.
- [45:53]
C
How to pick up anatomical sleep apnea, that is a little bit challenging. That is like a mix of a good history, an exam, and then what can be really helpful is what's called a cone beam CT scan.
- [46:06]
A
Okay.
- [46:07]
C
It's like a head and neck CT scan that is looking at the sort of volumetric size of the upper airway. And that can be very formative because what. Like if I do a cone beam for you, for example, you have a very well developed jaw. Good.
- [46:23]
A
Thank you.
- [46:25]
C
You know, good arches. And on the surface, everything looks beautiful.
- [46:28]
B
Their shin's been looked maxed.
- [46:31]
C
But you don't know until you.
- [46:32]
A
No one's calling me beautiful. I appreciate that.
- [46:36]
C
But you don't know until you look. You know.
- [46:38]
A
Absolutely.
- [46:40]
C
So it's when you look, then you can see the anatomy in the whole. In a fundamentally different way.
- [46:45]
A
Even I did not know that you can measure the volume of your sleep, of your airway using a cone beam ct. That's fantastic. Is this something that you can ask your doctor for if you have sleep apnea? If you're getting evaluated for sleep apnea, should you be asking for this?
- [47:00]
C
I think it's reasonable. So there are some nuances to this, particularly around. It's an awake exam while you are upright.
- [47:11]
A
Oh, so you have to go into a special CT scan. Yeah.
- [47:13]
C
So it's like an upright ct. A lot of dental offices may have it.
- [47:17]
A
Yeah.
- [47:17]
C
And so it's like, it's. It's where I think, like, the problem comes is like, when people will try to diagnose sleep apnea based off of this. But it's really like a risk profiler.
- [47:28]
A
Yeah.
- [47:28]
C
You know, it's not, it's not a diagnostic tool because it's just like, it's not a diagnostic. It's not a tool to diagnose sleep apnea. It's a tool to assess, like, the anatomical risk of having sleep apnea.
- [47:38]
B
So probably helpful if you're putting someone through appliances. Yeah.
- [47:41]
A
Like, yeah.
- [47:42]
C
As you. You can get a sense of, like. Yeah. You can sense, like, what's the TMJ health Before they get a mandibular advancement device. You can get a sense of, like, how bad is like a deviated nasal septum or turbinate hydrophy? Like, how bad is the septum in between the two nasal cavities or these turbinates that live in the nose. So there's, there's a lot of, like, anatomical information that, that can be gathered. And I think it's. It's extremely formative.
- [48:06]
A
Right. No, that's. That's a really good tool to have and just, you know, to touch upon. The last thing I want to talk about with sleep apnea is I've seen a Massive improvement in sleep apnea on patients on GLP1s. Right. And so talk about that a little bit. How has GLP1s, like Ozempic and tirzepatide, how has that changed sleep apnea?
- [48:26]
C
It's changing the landscape in a very positive way. Like, we've known from, like, weight loss surgeries, whether it's gastric sleeve or bypass, that sleep apnea can go away. Okay. Like that. So it's, it's the weight loss that drives the change in, like, adipose tissue, fat tissue in the upper airway. Total body is what changed. Like our changes our respiratory physiology and really powerful study. New England Journal of Medicine, I think, like three years ago, two. Three years ago, looked at tirzepatide in a very large patient population and there was a massive reduction and they took people who were obese. So, like, you know, the obese over, like someone who is extremely overweight on GLP1s, a massive reduction in the overall burden of apnea. And I personally have had patients who no longer have sleep apnea and have been liberated from cpap.
- [49:25]
A
Wow.
- [49:25]
C
Which is, like, amazing. It took about, you know, a good year and a half or so. But it's, it's totally doable if, like, if. If weight is the primary driver of this, like, upper airway collapsibility, like, weight loss should be done. And GLP1s can be a game changer.
- [49:42]
B
It's also changed the perspective on cpap. Right. Like, whereas before, when you think of cpap, a lot of patients thought of it as this lifelong therapy, but now you could frame it as just a very temporary tool to get you to sleep better while you're going through weight loss therapy. Right. So if you're on a GLP1 and your sleep is under control, that treatment will be much more efficacious compared to you just going through GLP1s alone without having your sleep apnea managed.
- [50:13]
A
Right.
- [50:13]
B
So I think it's a. It's an interesting framing for someone where it's like, okay, I'll just. I'll do this for the next year while I'm going through this treatment. And then with this hopes of eventually. The hope of eventually being liberated from it.
- [50:25]
A
Yeah.
- [50:26]
C
And if it's not a complete liberation saga, it's as we think of it, as a bridge. Maybe it's a bridge to, like a dental appliance. Yeah, right. Or lip taping. Or it's a bridge to myofunctional therapy. It's a bridge to maybe expansion. Like before, they weren't a candidate.
- [50:40]
A
Yeah.
- [50:41]
C
For like. Like expansion.
- [50:42]
A
Right.
- [50:43]
C
And now it's a bridge to like. Now I have. I went from severe hypoxic obstructive sleep apnea to now mild apnea.
- [50:51]
A
Right.
- [50:51]
C
Minimally symptomatic. And now I want to just a little tweak to the anatomy can, like, cure them for the rest of their life. So it's like, if we think of it, like, through a. Through the chronic disease lens, we start to think about these things very differently.
- [51:03]
A
Right.
- [51:04]
C
Than through this, like, sort of acute. Here's a CPAP lifelong solution and good luck.
- [51:11]
A
Yeah, exactly. I mean, and that's why a lot of people don't want to do cpap, because they think of it as a lifelong commitment and it does not have to be. Right. Especially if the physician's prescribing cpap. Also, at the same time, if the person's overweight Significantly, talk about GLP1s and reducing the weight. Right. And when you're sleeping better, it's much easier to lose weight.
- [51:34]
C
Totally.
- [51:34]
B
Totally.
- [51:35]
A
Exponentially.
- [51:36]
B
You'll be more motivated. It's more energy.
- [51:39]
A
Exactly. More energy to exercise, more energy to. Yeah. And you make better food choices when you sleep well, too.
- [51:45]
B
Yeah.
- [51:46]
A
You know, you had mentioned a little earlier lip taping. Can you talk about that? Because that's something I get asked about all the time, too.
- [51:52]
C
Yeah. I feel confidently sharing this because we have, like, objective data and we track people across time in this situation of when someone has, like, mild obstructive sleep apnea and they have. And they are primarily a mouth breather, improving nasal breathing and helping them. So if we take a step back and we think about, like, why does lip tape work?
- [52:14]
B
Right.
- [52:15]
C
Like, I think that's worth noting. Like, if I create the sound of snoring.
- [52:19]
A
Yeah.
- [52:20]
C
Like, I. It's much easier to do when I push my tongue back and I breathe through my mouth. But if I try to recreate the sound of snoring with my mouth, with my mouth closed, there's much more active effort that goes into this.
- [52:35]
B
Right.
- [52:36]
A
That's hard.
- [52:36]
C
Yeah, it's much harder. So it's a similar idea. And when the mouth is closed, the tongue is sandwiched between the jawbone, the lower jaw and the upper jaw, the mandible and the maxilla. So when it's sandwiched between the mandible and the maxilla, the propensity for posterior collapse or falling backwards is much lower. So, like, the idea of lip taping is not really lip taping. It's about, dude, just Breathe through your nose. Okay. And like whether it's a chin strap or lip tape, like they're all like achieving the same physiologic like mechanism. You know, the mechanism is I think where it's worth, like do people need
- [53:15]
A
to be careful lip taping? Like, is there some dangers to it?
- [53:18]
C
So what I was going to say is like, if someone has like severe obstructive sleep apnea, lip taping should not be done in isolation.
- [53:23]
A
Right.
- [53:24]
C
But if you have mild sleep apnea, we have in our anecdotal experience about a third of people who have mild non hypoxic where like their oxygen levels don't drop that much, their sleep apnea goes away objectively, like it's, it, it, it, it just by changing how they breathe, you cure them of a problem. So I'm. We actually have what's called like a mild sleep apnea kit that we give to our patients.
- [53:52]
A
Oh, what's in it?
- [53:52]
C
That has this nasal strip.
- [53:55]
A
Nasal strips. Right.
- [53:55]
C
You probably have seen these things on tick tock intake ones and then.
- [53:59]
A
Oh yeah, like Hormozi wears one all the time.
- [54:02]
C
Same idea. Like it has nasal strips external, an internal one called mute. It has this straw that helps them do myofunctional therapy and it has mouth tape. And the mouth tape that we're giving to patients is not like this like hostage tape that you see online. Because I think that can be dangerous in someone who is not. Right. Is not a primary nasal breather. We use one called, it's just like European company called Myotape. Yeah, yeah. And it has a, it works by having tape around the lips. Not over the lips, but around the lips. So it's kind of like a purse string suture.
- [54:41]
A
Right.
- [54:42]
C
It like cinches everything from the side.
- [54:44]
A
Got it.
- [54:44]
C
And it just makes it that opening the mouth is now an active effort.
- [54:48]
A
Right.
- [54:48]
C
Versus like a, like this passively sort of chin dropping with atonia.
- [54:53]
A
Sure, sure. I've also seen a mouth tape that is just like a small square that you put.
- [54:57]
C
Yeah, that works too. Yeah.
- [54:58]
A
Because that way you can still open your mouth if you need to.
- [55:01]
C
You need, you need like some safety valve.
- [55:03]
A
Right, exactly.
- [55:04]
B
But I think this is where having this like longitudinal data is so important.
- [55:07]
A
Yeah.
- [55:08]
B
Because if you're just experimenting in the blind, it's not, it's not going to be helpful.
- [55:11]
A
Not helpful. Right.
- [55:11]
B
And there's been so many situations actually where like someone has sleep apnea, mild, moderate. And then we'll run a series of experimentations. Right. So instead of going to something directly like cpap. It's like, hey, let's try lip tape and nasal dilators, and let's see how that changes your breathing. And then you can then look at that and say, whether it's under control or not, or hey, let's actually try CPAP for a few weeks and see how that changes your breathing. And I think that's where the data piece is so critical.
- [55:37]
A
Exactly. And that's where Empower sleep really makes a huge difference. It's a huge leap forward, is you're not just stopping with a diagnosis, you're continuing the monitoring, trying different things. I'm a big fan of N of 1. You know, it's like, it's very analogous to continuous glucose monitor. Right. You don't just measure your glucose one time, say it's high, and then start throwing different techniques up against the wall. If you wear a continuous glucose monitor, you could see what foods are causing your glucose to rise, what activities you do help your glucose to stay low. It's the same with sleep monitoring as you do these different experiments. Lip taping, mewing, you know, all these exercises, maybe dental appliance. With a device like this, you can measure over time to see what's working and what's not.
- [56:21]
B
Exactly. And I think what's what we're really excited about too, is eventually you could get to a point where with a pretty high level of confidence, very early on in the patient journey, you could tell them, we think that this stack of therapies is going to work for you based off of millions of hours of sleep data that we've collected. And people who have had a very similar type of sleep architecture have come to us.
- [56:43]
A
Right, right.
- [56:43]
B
Because right now what happens is like, the industry of sleep, it's like, okay, I have my wearable, and then there's like a thousand different things I can do. Right. Everything from vitamins to medications to medical devices to lip taping. And people are just lost. Like, what am I? What's the right stack for me? But I think having these longitudinal data sets just allows you to build those personalized stacks, which with a much higher level of confidence.
- [57:08]
A
Yeah, that's so critical. So you're taking all the data from different people, seeing what works for different types of sleep architecture, and then saying, for your data set, this is what's worked for most people, and go right to that. So people can reduce the time to finding the right solution.
- [57:24]
B
Exactly.
- [57:25]
A
Right.
- [57:25]
B
Yeah.
- [57:28]
A
That's a huge advancement, I think, in the field.
- [57:30]
C
It's redefining the endotypes is what they're called, right?
- [57:34]
A
The endotypes of sleep.
- [57:35]
C
Endotypes of like the different sleep disorders that exist.
- [57:38]
A
So what are the different endotypes of sleep?
- [57:40]
C
So we're discovering them. I mean, there are like these predefined four endotypes of sleep apnea. But what we're trying to do is like redefine these different sort of cohorts of individuals like someone might have. And I'll just use this as an example where I have sleep apnea when I have a couple of drinks. That's a very different. And it's mild, right? That label of mild is very different in me than someone else who might have mild sleep apnea. And they have a ton of circadian variability. They're traveling twice, thrice a month between LA and New York. So even though the label might be the same, but the sleep architecture is fundamentally different, the circadian system is fundamentally different. So we're trying to. So what we've been doing recently is looking at what are all the different clusters that exist within the database and see who did well with what kind of solution. And we're letting the data drive the endotyping and the clusters rather than like in a traditional. It's like very hypothesis driven of like, oh, I think this might be a mechanism or this might be a category of a subset of a disease. And instead of doing it that way, it's like, let's let the data decide and see what happens.
- [58:53]
A
I think let the data kind of cluster. Right, and create the endotypes.
- [58:56]
B
Exactly. And what's interesting too is I think with the technology that's available today is you could almost run these like mini, I'll say the word loosely, but like clinical trials or just research experiments within your own clinic. Because I think every physician has some level of intuition around like you see so many patients and you're like, oh, that's weird. Like when I see these types of patients, they react very positively to this therapy. And I think every physician has had that as they go down their specific specialty. And now what you could do is pretty easily run a query, right? And since so like I remember, like Saha would say this, he's like, you know what's so strange is when I see patients with sleep apnea who have well preserved sleep architecture, they kind of tend to do better on CPAP versus someone with sleep apnea who has very fragmented sleep to begin with, right? And that's a very easy query to now run right. Where you can kind of look at like the database and leverage some form of AI and basically run these little experiments and get some really good insights from it.
- [59:56]
A
Yeah, no, it's fantastic. I think you guys have really changed the game with sleep and especially sleep apnea and monitoring. And we didn't even get to the device and the app, it doesn't just focus just on sleep apnea, it's also insomnia. And you incorporate cognitive behavioral therapy for insomnia. We've talked about all these topics in previous podcast episodes, but I think it's really super important to highlight what you guys are doing because this idea of longitudinal data, meaning measuring yourself over time, it's so critical. And the value of the data that you're collecting on people leading to better therapies and quicker therapies and more options is also so critical. So, you know, it's all. This field is changing so rapidly and to have the latest knowledge from both of you and you guys developing the tools to get that knowledge is a game changer. So I really thank you guys for doing this.
- [60:50]
C
No, I'm really grateful to like my mentors across the different fellowships. I'm inspired by folks like you, you know, like physicians who are trying to solve a problem, right. Rather than like just being comfortable with receiving a paycheck from Kaiser. You know, like, no disrespect to Kaiser or the VA or any of these like, you know, Goliath Health Systems, but they don't really like. I'll give you an example, man, I, I was working in the, I still sometimes spend time in the ICU because I, I love work. I. Working there, Sure, I love working there. And I was working in the unit a month and a half ago and I had this patient who, end stage interstitial lung disease, had a vats, had a thoracic surgery while he was in the hospital. We tried to get him transferred to Stanford, ucla, Cedars, ucsd. Nobody would accept him, just given the nature of the end stage disease. And he was not a transplant candidate. And man, he just wanted to go outside. He's on a mix of like high flow oxygen and a BiPAP machine. No pressure, no like medications to support his blood pressure. And he just wanted to get outside of the icu. And man, I had to jump through so many hoops, right, to get him outside, to get him outside that weekend. But dude, we made it happen. We made it happen. He wanted a Modelo. Yeah, I told his family, like, we got him a Modelo, he took off. The BiPAP would have a little Sip of beer. But it's like the healthcare system and I think I was telling like the team and soccer, I was like, dude, the only one of the reasons I had like the confidence and like even like I will think outside the box and figure out a way to make this happen is because I like, I live in a startup.
- [62:31]
A
Yeah.
- [62:32]
C
When you live in a startup and as a physician, when you're operating in the startup, you can be like, why can't we do this?
- [62:37]
A
Right?
- [62:38]
C
Like, right. Like what is like the reason that he can't go outside?
- [62:41]
A
Yeah.
- [62:42]
C
Oh, because like there's no oxygen. Okay. Like let's get a freaking, let's get an oxygen tank.
- [62:46]
A
Exactly.
- [62:47]
C
And what if it runs out? Then you get two of them. Right. Like you. Because from when you're thinking, when you're operating a startup, you're like in a
- [62:53]
A
completely different, you're solution oriented. Right?
- [62:55]
C
It's totally solution oriented. And, and I think I'm grateful to Empower Sleep that I can like, it's changed how I think. And when I go back to the hospital and I have residents and fellows, it's like, dude, that was like cool, man. I'm glad that we like, we made that happen, you know?
- [63:11]
A
Exactly.
- [63:11]
B
It's kind of been a principle for us. Right. It's like, let's think about this from a physiology first approach.
- [63:16]
A
Yes.
- [63:17]
B
And remove any sort of administrative constraints. Right. So who cares about like what insurance will pay for? They're not gonna pay for multi night testing. Like it doesn't matter. But what physiologically makes sense to you. Let's think about it from the ground up. And I think that this allows you to think very differently about healthcare.
- [63:35]
A
It really does. Yeah. It's a fantastic job you guys are doing. I really appreciate you joining us on the podcast today and I know people wanna learn more, especially if they think they have sleep apnea or they've already been diagnosed and are in cpap. How can they find out about Empower Sleep and what you guys are doing?
- [63:54]
B
Yeah, you come to the website www.empowersleep.com. you can sign up for a consultation there with a sleep coach or if you're at next, yeah.
- [64:04]
A
We can refer you as well.
- [64:05]
C
Yeah, go to Next. You'll get better. You'll get, you'll get better pricing.
- [64:09]
B
That's true.
- [64:10]
C
Yeah, go to Next. You'll get better pricing. And sleep is a component. Right. And sleep is like a component of like a much larger system. And if you go to next, that much larger system can also be addressed because it's really interesting. There's a bi directional relationship with health and sleep, and you probably have seen this either personally or with patients. When sleep gets better, other components of health get better. And when health gets better, exercising, you're doing the right things for your nutrition, you're doing the right things for your mental health, then your sleep also gets better.
- [64:46]
A
Absolutely.
- [64:47]
C
So, like, we're just, we have a very small part to play in a much grander, you know, ecosystem that you guys have built and all of these other clinics are doing. So thanks for letting us be a part of it. But yeah, if you just have an isolated sleep issue, we're happy to take care of you, but most of the time, you. There are usually other things that need to be addressed.
- [65:06]
A
Absolutely. Yeah. We love working with you guys and look forward to a long relationship. Thank you, guys.
- [65:12]
C
Thank you so much. Thank you, Matt.
- [65:13]
A
Thanks. Thank you so much for listening to the podcast today. Please remember to subscribe if you like this episode and give us a good review and share a link with your friends. It really helps to support all of our efforts. I also want to remind you that the information shared on this podcast is for educational purposes only and is not intended to replace professional medical advice, diagnosis or treatment. Please consult with your healthcare provider or physician before making any decisions or taking any action based on what you hear today, especially if you have any underlying health conditions or on any medications. Your doctor knows your personal health situation the best, and it's always important to seek their guidance.