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Comment by david-gpu | Hacker News Reader

Sleep apnea degrades your quality of life tremendously. Even when treated with CPAP you can still have pretty poor sleep due to the mask shifting around while you sleep and other side effects of the treatment, but it's generally much better than the torture of untreated apnea. It's so bad that even with moderate apnea you wake up more tired than when you went to bed.

Now allow me a preemptive reply: I suffered apnea with a BMI below 20. Plenty of people don't have apnea because they are overweight; instead, they are overweight because they suffer apnea.

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As an additional PSA, sleep apnea may not be the cause of exhaustion, even if diagnosed. I was diagnosed with apnea and CPAP did (still does) little if anything for my energy levels. I finally found a sleep doctor who checked my iron levels, and despite being within the normal range suggested I take an iron supplement (iron polypeptide) and within a week felt normal again.

It turns out that people with restless legs, which I’ve had since childhood, experience iron deficiency anemia with much higher blood iron content than the average population.[0]

My primary care didn’t consider this. A pulmonologist had no interest in checking this. An oral sleep doctor had no interest in checking this. I had people suggesting getting an implant to force my tongue to stick out when the issue was low iron.

Definitely get a sleep study (I’d recommend lab over home). I use a sleep tracker (cheap Garmin “smart” watch, but I’ve also tried an Apple Watch) as a reasonable proxy for REM and deep sleep. And if you think a practice is just trying to sell equipment, they probably are. Fortunately I found a good doctor from acquaintances that I would have never otherwise considered (not part of the local medical systems, though did take insurance).

Unfortunately, for many issues it’s not enough to trust the doctor. Do your own due diligence for your health.

0 - https://www.frontiersin.org/journals/neurology/articles/10.3...

I have occasional restless leg (once every two weeks or so) and low energy. How would one know if one has iron deficiency despite blood work being normal? Is it just a case of popping iron pills and seeing if you feel better?

Doesn't hurt to try does it? A bit of extra iron is harmless.

That was partly my question. Looking online, iron is definitely something that you don't want to have too much of.

My question is, basically, is having a non-anemic iron deficiency something that can be easily remedied by having low-dose over the counter vitamins, or is it something that requires a higher dose (to make up the difference in what you're missing) and so requires a doctor. And yet it sounds like this is difficult to diagnose.

Over the counter iron supplements are totally safe to take for the period indicated on them. They contain as much iron as a medium piece of chicken liver.

Most of the over the counter ones I see online are 65 mg iron, which is nearly twice the iron in a whole half kilo of chicken liver.

The medical sites say a safe value is no more than 45 mg per day.

There are also low iron pills (or "gentle iron") that are 28 mg.

So not only are many over the counter pills potentially over the safe levels, but it still doesn't even really answer the question, which is whether the low-dose pills that are under the RDA effective in countering an iron deficiency.

Anyway. I think I'll ask my doctor at a once-every-several-years checkup.

Do you live in America? Supplements tend to be much stronger there. Here in Germany at the local pharmacy you will mostly find in the 10mg-30mg range. I've bought and drank them before to no ill effect, which is why I even started this entire chain.

Same for here in the UK. My iron suppliments are 30mg, which seems pretty usual here.

It can indeed hurt[1], and getting medical advice from the Internet can be... fraught.

[1] https://www.ncbi.nlm.nih.gov/books/NBK557376/#:~:text=The%20....

What's "normal"? Your results are never just "normal", there is a range that is considered normal. If you're at the low end of normal, that could actually be just "low". Those teams can be a bit too wide.

How is your B12? If you're a vegan or vegetarian and aren't taking those supplements then I would start taking them. It's always safe to take extra B12.

Unless your iron is at the upper end of the band it should be safe to take a low dose. But it won't do anything if you're not really deficient.

I find that sitting at a desk all day makes me tired. I just push past it and go for a run. Always works, and it guarantees me a good night's sleep.

Just remembered, if you walk a lot, like over 25k steps a day, or do a lot of exercise (squats?) that can also cause restless legs.

Also, your diet? Most people are getting more than enough carbs these days, but are you on some weird diet?

Serum iron is a pretty useless test. What was your ferritin?

In August it was 66ng/mL prior to taking any supplement. So above the reference low, but below the adjustment for RLS.

Unfortunately, I just had it tested last week but had given power red a few weeks prior and came in below even the normal range (20ng/mL).

Do you have any additional resources you recommend on this topic? I've experienced life long restless legs alongside issues with sleep quality, daytime tiredness and low energy levels so this seems like an interesting avenue to explore.

I don’t, just my personal experience. A few years ago I started getting exhausted to the point I was napping every day and getting 10-12 hours asleep and still felt tired. I’ve never been overweight, don’t have any structural occlusions in my airways, though I do snore (so says my wife).

I did all of the normal things and got regular exercise. I finally went to a specialist, and got an at home sleep study which found moderate apnea (on the low side of moderate). I spent several months using a CPAP and bought a sleep tracking watch. Nothing improved and I was still tired. The pulmonologist suggested one of my medications affected REM. I was able to stop taking it without any significant issue and my REM improved, but I was still tired. I asked them for an in lab study and did that and it found the same as the home study.

I had convinced myself I had narcolepsy or some similar neurological issue.

My wife’s friend coincidentally mentioned he had sleep issues and they had found a sleep doctor they liked. He was the first to ask about restless legs and have any blood work done. He confirmed that I have apnea, but thought trying an iron supplement might help based on recent studies and my iron levels.

The iron helped almost immediately. Within a week I didn’t need to take a nap, which I had done daily for at least two years. I still use the CPAP because apnea can cause heart issues long term, but don’t “feel” like it does anything in the short term.

Usually, the most common thing is the most likely, but when it’s not, it can be really hard to find someone who both believes you and can do something about it. When I was exhausted all of the time, finding that person was even more challenging.

Isn't iron one of those things you don't want to overdo due to dangerous side effects?

You raise an interesting situation here though because I've also had restless leg forever and my iron tests came back normal. Still, I'm not sure how safe it is to take iron supplements under "normal" conditions.

EDIT: this is just one source, but it doesn't sound like a great idea to be taking iron supplements with normal iron levels, at least not on your own: https://ods.od.nih.gov/factsheets/Iron-Consumer/#h11

Did I suggest otherwise? I said I ended up seeing four doctors before one suggested what worked for me. YMMV. Consult a physician, etc., etc.

I need to have my iron levels checked semi regularly. I would imagine any doc suggesting iron supplements would suggest the same.

tbh. I generally I don't understand why some people are so insistant to point out "how dangerous supplements are".

For most nutrients there is quite a large area between what the body needs and when it starts to become a problem.

And while you can over a long time accumulate by not only only consume more then you need but also more then your body can disperse it's not really an issue either. Doing semi regular tests in case of knowing you have some nutrition issues is pretty common and stuff like fasting once a year can help you body to flush out accumulations.

And again for a lot of supplement choices people will often not run into this issue at all anyway.

I have seen a lot of people which live quality increased by taking supplements (including non water soluble ones) but yet have to see a single case of overdosing on supplements in my environment.

So interesting! Thanks for sharing. Do you still take iron every day, or is this the kind of thing one does for a period of time until the body is rebalanced?

H.Pylori is well known to impact iron absorption and serum iron/ferritin levels. Most of the world carries this unknowingly (esp. since childhood), and it has all sorts of silent consequences ranging from fatigue (due to iron impact, etc) to GI issues to stomach cancers.

[1] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8513126/

[2] https://pubmed.ncbi.nlm.nih.gov/11218379/

My wife had menorrhagia (extremely heavy periods that lasted a week) and extreme lethargy. And restless legs. Not only did her doctor not get her bloods checked, he didn't care about the heavy periods and said (about heavy periods), "go on the pill, and see a shrink" (because presumably he thought she was a hypochondriac or depressed, because she came back several times to see if he could do anything about it). He finally got her iron and B12 checked, and since they were both on the lowest end of the "Ok" range, he didn't do anything further.

It took 2 doctor changes and a lot of goggling to realise that her menorrhagia had a cause, but that she's need scans to prove she might have uterine fibroids. It took 2 procedures to correct them. Once all that was done and she got iron + B12 injections, and got her life back.

On a forum she talked to other women who were left to deal with fibroids for up to a decade because their doctors would just sigh and say, "Yes, women's problems. This is normal. Go on the pill". Unfortunately the fibroids grow so large that there is sometimes no option but a full hysterectomy. This is a common story.

I completely agree, you need to do your own due diligence these days.

> He finally got her iron and B12 checked, and since they were both on the lowest end of the "Ok" range, he didn't do anything further.

This type of mistake infuriates me to no end because there’s no reason it should happen. I was recently looking at blood tests from years back to figure out my usual resting glucose levels (just got a GCM) and stumbled on my testosterone results.

I was in the green, so my doctor (and nurse practitioner) didn’t notice a problem but I had the testosterone levels of a 50 or 60 year old in my late 20s. Since the acceptable range wasn’t adjusted for age by the Quest report, the range is ridiculously huge.

Similar for me, I thought I would start feeling better after my CPAP. Still had terrible sleep. Still experimenting with solutions (issues started after Covid vax, so I’m experimenting with long Covid protocols and have noticed much better sleep in the last month although I’m not getting my hopes up just yet)

If you don't mind sharing, what are some of these long-covid protocols that you're trying?

I just wanted to mention how I cope with occasional restless leg syndrome. I find that a wall sit for two minutes right before trying to fall asleep works every time. I have to do it long enough and push hard enough to make my legs really burn from the exertion. The more unpleasant it is, the better it works. Afterwards, I immediately get in bed and try to go to sleep (it doesn’t work unless I do it right before attempting to fall asleep). Usually by the time my heart rate returns to normal, I’m asleep.

I was sleeping 8.5-10h per day and still feeling extremely tired. Also had a lot of mental problems to the point I was thinking of going to a therapist (I thought it was work related).

My doctor sent me to do sleep apnea tests and blood work, but turns out I was vitamin B12 and B9 anemic AND seems like I have mild sleep apnea as well (I have more tests booked). But taking vitamin supplements cured most of my symptoms in less than a week. I had horrible headaches for the first couple of days of supplements though.

It's worth noting that in some cases it might be cheaper to outright purchase a CPAP machine online than to get a diagnosis via a sleep study.

I got a sleep study about a decade ago, having to go in first for diagnosis and then to evaluate the right settings. Even with insurance it cost about $2000 after all was said and done due to limited coverage and out of pocket fees. THen add the ongoing $35/month copay for renting the CPAP machine (they did not offer to sell it) and limited fee for having someone deliver it, which was a scam of an 'in-home medical visit' to set it up by handing me a box and saying where to plug in the hoses.

Meanwhile, the same machine sold for $400 online, wouldn't have required me to spend overnights in a lab or go through doctor visits every couple months for continued 'check-ups' where they read the card data to make sure I'm still using the machine to justify insurance coverage of everything beyond the $35/month fee. With automatic settings (now standard on machines, perhaps not at the time) or simply using materials online to do a few nights trial and error to figure out correct settings.

I felt like I (and my insurance carrier) was getting scammed at every point along the line. But the doctors claimed these were the hoops I had to go through to get tested and treated.

Hopefully it's a lot better today, but.. I doubt it. The CPAP did work when I finally got it, though.

I'm looking into this as of now. For your situation though, from what I've read about iron supplements. A week is too short of a time for anything. So your situation was placebo; in my opinion.

I wish CPAP manufacturers were a bit better. There has been little innovation, and if anything, there's been a downward trend in quality in recent years.

My wishlist:

1. Every CPAP device should be BiLevel.

2. All data they record should be accessible to the user (for tools like oscar).

3. Either more granular pressure controls, or better algorithms (or both). Some people do well on CPAP, others do better when iPAP > ePAP (BiLevel, or EPR), while others do better when ePAP > iPAP (vcom).

4. Better masks. Seriously. It's so hard to find a good mask, and so expensive to experiment with them. A new mask can set you back €150, and if turns you hate it, you're shit out of luck. I've toyed with the idea of personalized 3D printed masks to get a better seal for each unique nose/face shape.

5. Quieter machines. Without the Philips cancer foam.

6. Quieter masks. Some have excellent diffusers in the exhalation port (P10), while others blast out a concentrated jet of air that will wake you up when it hits the pillow, or will lead to divorce faster than your snoring ever did when it hits your bedpartner.

7. Bring back travel cpap devices. The market collapsed post covid. I'd love to keep a small device and super lightweight mask/hose in my bag for sleepover emergencies. I'd pay any price for that, because having to lug a full size cpap around ruins any chance of spontaneity in my bachelor sex life.

None of these are rocket science. But Philips Respironics are a bunch of evil cunts, ResMed are goofing off, and the other brands might as well not exist.

Agreed on all counts, down to having contemplated 3D printing molds to manufacture custom silicone masks. I also wish the tube had a sensor to detect whether you are sleeping on your back to preemptively raise the pressure. Or having better algorithms to detect hypopneas before the air stops flowing altogether.

I don't even understand why purchasing a CPAP machine requires a prescription. I'm scared of the possibility of a doctor denying me a new CPAP machine when the current one inevitably croaks. The device is a glorified fan, for goodness sake.

The prescription thing is probably location specific, but AFAIK you can just buy them online. I have a few spares I bought online from back when I frequently slept in different places.

Masks straps could probably be fitted with an accelerometer to detect positioning. If they can make heated tubing, this isn't such a stretch. Might also be useful in correctly flagging events: my machine often incorrectly marks position switches as periods of hypopnea.

> Plenty of people don't have apnea because they are overweight; instead, they are overweight because they suffer apnea.

A lack of sleep means a lack of energy. You're body compensates by getting food energy.

Too much stigma around what should just be understood as a biological mechanism.

This is stated as biological fact when it's simply not. Sleep apnea doesn't change the laws of thermodynamics - if you are gaining weight you need to eat less or move more. It's not stigma, it's simply the way it is for the vast majority of people (the rest being covered by rare hormonal conditions that require a doctor to treat).

Being tired may cause you to eat more but being tired isn't making you gain weight, it's the overeating that is.

Being tired changes how your body uses and stores energy. Your body might be permanently trying to save up for bad times (because the times are always bad) and so you're getting fat even if you eat very little.

can you point to examples of otherwise healthy individuals under moderate to high calorie restriction that gain weight due to chronic poor quality sleep?

it's not something I have ever been made aware of, and I don't understand how it could be the case.

A lot of things about your body changes when you're extremely tired.

I don't have anything specific to link - it's just my own personal experience and what the doctor said.

In my own case, I had to eat much more than I theoretically should because my body wasn't able to process the food as well as it should (less than 50% of usual efficiency). And yet I was fat - not obese, but definitely not thin. The body redirected some of my food to storage even though I didn't have enough energy (glucose etc) as measured by blood screening. And it didn't use the reserves properly when I stopped eating.

What is mentioned in a couple of these comments about your body's response to external stressors changing how it allocates calories is absolutely true, but it's at the margins. If you're at maintenance caloric intake and ± a couple hundred calories a day, over years this can have an effect. But it's not going to meaningfully impact a 500-1000 calorie/day deficit to the point where you're still gaining weight.

I believe there is a study where people ate at a 25% deficit but had high glucose and still gained weight.

Is this the study you were referring to?

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7898726/

> Effects of moderate sleep restriction during 8-week calorie restriction on lipoprotein particles and glucose metabolism

Because the conclusion starts with,

> In this study, 8 weeks of calorie restriction with and without sleep restriction of less than 90 minutes per day on 5 days with 2 days of ad libitum sleep per week, resulted in similar degrees of weight loss

Let me be clear that sleep deprivation doesn’t seem to be good for your circulating lipoprotien levels or insulin sensitivity based on that study, but they didn’t gain weight.

Not gonna try to find a specific example, but just from having listened so much to the Stronger by Science and Iron Culture podcasts for the past few years, there have at least been numerous studies and metas over the last decade examining the effects of sleep on weight loss and weight gain as it pertains to bodybuilding goals. I don't recall any having showed an impact on the rate of gain or loss but duration of sleep opportunity definitely has an impact on the quality of gain or loss. That is, you lose more muscle and less fat losing weight while sleeping poorly, and gain more fat and less muscle when gaining weight while sleeping poorly.

By this logic, one could run an army legion without food supplies simply by keeping them sleep deprived.

Uh, no? The whole point is that the entire system breaks down. So you get sleep deprived humans who can't process food properly and have no energy as a result. Sounds like a big failure.

The body is far more complex than simple thermodynamics however, and to pretend the dozens of biological feedback loops are fully under ones control betrays a lack of understanding.

Reducing getting fat to thermodynamics is like reducing computing to adding numbers. While that may be the basic building block, only a fool thinks that merely by comprehension of the add operator, one is also able to debug hugely complicated soft- and hardware stacks.

I actually like the computing and adding numbers analogy because "Sleep apnea makes people overweight" is the nutritional equivalent of saying "1 + 1 = hammer."

The root cause of weight gain is either overeating or lack of sufficient exertion in almost every case. Sleep apnea may absolutely cause someone to overeat in part because of those dozens of biological feedback loops you mention. But that doesn't mean that sleep apnea makes people gain weight. It's still too much food at the end of the day.

I'd like to contribute by saying that even when you are sleeping, body burns calories for various neurobiological processes. That automatically translates to bad sleep equals decreased calorie utilization (than a healthy baseline)

> It's still too much food at the end of the day.

It's all four fundamental physical forces actually, if you want to go that route. Which isn't helpful.

If overeating has causes, then it's not really a root cause.

By this logic, sleep apena doesn't make people gain weight either.

> But that doesn't mean that sleep apnea makes people gain weight

I gather that you are unaware of how sleep apnea causes poor sleep, which in turn causes insulin resistance, which in turn causes an elevated production of insulin, which in turn forces glucose into your adipose tissue, which in turn makes the rest of your tissues starved for energy, which in turn causes you to be hungrier, overeat and gain weight.

This is an oversimplification, of course, as there are hormones other than insulin and cortisol involved in the complex process of insulin resistance, but it is at least a starting point that goes beyond the useless truism that "people gain weight because they overeat". Of course they do, but the mechanisms why they are hungrier than they need to be are crucial if you want to address the problem, because in the long run every human being with free access to food will eat precisely until they are no longer hungry, whether or not they are metabolically healthy or not.

But that’s not what he’s saying. Being hungry does not cause you to eat. Regardless of hunger, a caloric deficit will result in weight loss.

There definitely is the issue of how to reliably maintain a caloric deficit when your body is screaming at you to eat more, but the underlying mechanism is much simpler.

At the most basic levels, food choice doesn’t even really matter (specifically for weight loss, not general health), but choosing satiating foods with low calories is going to help with implementation. Eating 2,000 calories of oranges (45) is going to be a lot harder than 2,000 calories of fast food hamburgers (2).

The problem isn't that CICO isn't true, it's that it's not useful. It can't even explain why fat people are still hungry when they have enough calories stored in their bodies to last them for months.

> Being hungry does not cause you to eat

Yes, it does. That's why people eat: to alleviate hunger. You may will power your way to a caloric deficit for some months, maybe a couple of years, but eventually hunger will win and you will eat until satiety.

Metabolically healthy people aren't slim by being hungry all the time. They eat to satiety, and they are lucky enough that their satiety signalling is still working well enough. If you make them chronically hyperinsulinemic, they will be hungrier and they will gain weight -- it happens in humans and in animal models when allowed to eat ad libitum.

> At the most basic levels, food choice doesn’t even really matter (specifically for weight loss, not general health), but choosing satiating foods with low calories is going to help with implementation

As long as you are hyperinsulinemic, you will store a portion of the energy you consume in your adipose tissue, because that is one of the major effects of insulin in the body. The remaining energy left in you will not be sufficient to supply the energy needs of your body, and as a result you will be cold, tired and hungry.*

> Yes, it does. That's why people eat: to alleviate hunger. You may will power your way to a caloric deficit for some months, maybe a couple of years, but eventually hunger will win and you will eat until satiety.

If this is the premise of your argument, it is flawed.

You have no idea if “eventually” happens to everyone. You’re making a wildly strange assumption.

>> You may will power your way to a caloric deficit for some months, maybe a couple of years, but eventually hunger will win and you will eat until satiety. > You have no idea if “eventually” happens to everyone

Have you tried? Are you willing to try? How many people do you know that intentionally remain hungry every day for more than a couple of years, while otherwise having free access to food?

Any weight loss advice that does not adequately address hunger and satiety is naive to the point of ridicule. And any person who advises others to address their weight by telling them to be hungry in perpetuity hasn't given much thought to what they are asking for.

Yeah. Turns out when you eat less your stomach shrinks and you need less food to feel satiated. What are you on about? You’re severely incorrect.

>> Being hungry does not cause you to eat

> Yes, it does.

Nearly 1:10 people in the world are chronically hungry. Being hungry has no impact on their ability to eat. Likewise, those with access to food eat when not hungry and (believe it or not) may not eat when hungry.

I really think you’re missing the point, though. We have a host of signals in our body that can misfire due to various conditions and people cope with them. Hunger is no different and many of us have spent months ignoring it to our own benefit (and some to their own peril).

Caloric intake in excess of expense causes weight gain. What factors lead to that excess do not.

There are certainly those with a variety of issues that make caloric deficit difficult. Fortunately, that’s not most people.

I know you’re being downvoted into oblivion, but I agree. I’m not overweight, but had put on nearly 40lbs more than my historic average. There’s all kinds of advice, but the best I found was: the only way to lose weight is to have a caloric deficit.

That meant measuring calories until I could generally estimate what I was taking in each day. 1000-1500 calories a day sucks at first, but seeing the scale drop is motivating. I dropped 30lbs in about 6 months.

You can’t gain weight if you are taking in less calories than you expend. That’s pretty simple. Not eating that cheesecake, on the other hand, not so easy.

>It's still too much food at the end of the day.

The problem with that is you can reach a point were trying to reduce calories further will only further sabotage your metabolism and makes you feel like shit. Which is why treating the symptom repeatedly fails to work long term.

I’m a 5’11” male who gained weight up to ~220 pounds on ~1800 calories eating a very consistent meal rotation. I now maintain ~190 pounds at ~2100 calories. My problem was likely a combination of my food acting as a chemical signal to gain weight (high in branch chain amino acids, polyunsaturated fats from fatty pork and chicken), work stress, bad sleep, and possibly even chronically elevated blood sugar or thyroid effects from essentially what was an almost carnivore one meal a day sort of diet. My body temperature was hitting lows of 96.3 degrees F. It’s now roughly two degrees higher, which seems small, but feels so much better.

I think one of the issues with this is that most people have pretty terrible diets, most people have pretty terrible diets that can be improved pretty easily, and when dietary improvements are suggested a lot of time the response is “this is just really complicated, it’s not that simple.” Not everything is simple, but, say, giving up soda is something that’s healthy and going to have a positive impact on people’s lives. People who are saying “don’t tell me to give up soda because I have sleep apnea” are looking for excuses for their bad habits.

If someone is eating healthy foods and making a genuine effort to get good exercise, then we can talk about other factors. But too many people use “this is so complex” to avoid the very basics of healthy living.

Lack of sleep and stress are associated with overeating, and not only that, they also trigger hormons that promote the body to prioritize building up fat reserves.

I'm on mobile and don't have time to link, but a quick google search should give medical studies on this.

The "energy" thing is a simplification, but as a description of how this feels, it is apt in my view.

This is not about thermodynamics.

> Being tired may cause you to eat more but being tired isn't making you gain weight, it's the overeating that is.

Potato pot-ah-to.

Maybe the end result is the same but it's an important distinction. It's too easy to say "oh yeah I'm gaining weight because I have sleep apnea" while you're snacking on donuts at your desk at all. The people who are tricked into believing it think that if they "cure" their apnea they'll be back to a healthy weight when a) they could be at a healthy weight despite their apnea with some effort, and b) they're building habits that even if their apnea disappears a year from now they will stay at the same weight.

You reference the laws of thermodynamics, but I'm not sure which laws you're applying to the human body? Is it the first which requires the measured system to be closed which a human body is not? Is it the second about entropy always increasing? Or is it the third defining perfect entropy at 0 Kelvin?

Bringing up thermodynamics as a generalization for biological systems is pseudo-intellectual. We aren't all equal machines that take in a fuel stock and output work. How do you account for differences in peoples' resting metabolic rates? How do you account for the difference in available energy in the foods you chose to eat, and in the differences in peoples' biological processes that extract that energy? Stress is a common hormonal modifier that impacts how the body stores fat; no where near a "rare" condition that many people experience nowadays, and yeah caused by things like sleep apnea. You betray your own argument anyway by adding an the "hormonal condition" exception (I don't see any exceptions referenced in the laws of thermodynamics, lol).

Biology has more dimensions than you are choosing to look at, and using thermodynamics as a "gotcha" when it comes to others' bodies reveals your lack of understanding and intuition.

Yes the first one. The energy contained in ingested food is far and away the dominant metabolic input.

There is no need to get into the weeds of various details of how that breaks down; the main problem is that calories are way too cheap in the modern day and age, and people's habits and instincts developed in far different eras lead to easily ingesting more than is expended. Yes the OP is not wrong, but it's not a very useful argument unless we're going to roll back the modern civilization.

He's not entirely wrong, but perhaps not for the stated reason. Sleep deprivation can skew the ghrelin/leptin hormonal balance, which can make appetite control difficult.

The body never processes 100% of calories from food the way a bomb calorimeter does https://en.wikipedia.org/wiki/Calorimeter#Bomb_calorimeters, but depending on how much energy it needs it processes more or less.

It's entirely possible to eat less food and have your body decide that food is more scarce and choose to strip more calories from your food than it was when you were eating more.

Thermodynamics is an asinine thing to bring up in a system that can reconfigure its efficiency on the fly to optimize for different environments.

All that does is change the lower limit. The system has a compensation limit, below that you lose weight.

Sure, but it's still unhelpful to say that overeating is what makes you gain weight when other people eating the same amount and with the same amount of activity are not gaining weight, especially when eating less could cause you to gain more weight until you hit a threshold.

I don't think many people disagree with "If you starve yourself enough your body will eventually start burning fat", they disagree that it's as simple as "anyone gaining weight is necessarily doing it to themselves by eating more than other people".

And starving yourself isn't easy. It's one of the top like five things your body is designed not to let you do. So how on earth is it helpful when people are talking about factors that can influence your appetite and can literally influence the number of calories your body chooses to extract from the exact same food to say "just eat less lol"?

I might add that overwhelming research suggests that social pressure on people's weight causes people to gain weight. So even if you were right, bringing it up would be counterproductive.

> when other people eating the same amount and with the same amount of activity are not gaining weight, especially when eating less could cause you to gain more weight until you hit a threshold

That's part of the "calories out" side of the equation, that few people put in the effort to find (if they even know how). And I've found online estimators aren't very useful here, you need to find it for yourself - they say mine is around 1600 when it's actually more like 2200.

Ignoring half of CICO just because people only like talking about CI doesn't make it false.

It's even harder to change CO than CI, that's why people talk about CI. You lose a bit over 100 calories per mile run, and then you have to not compensate by eating them when you're finished. Everyone has a different metabolic set point for how many calories they burn, true.

No one said not eating is easy, especially when there's a lot of food around! I struggle with it. The laws of physics are not kind.

What I will say though, is if I exercise moderate amounts, it makes appetite control easier, at least for me. YMMV. I believe this is because insulin is more level throughout the day.

> if you are gaining weight you need to eat less or move more

You could do a little experiment: set up an alarm to wake you up 15-30 times every hour while you try to sleep. That is what moderate sleep apnea does to you. Try this for, say, a year. See what happens to your overall health and your weight in particular. Don't forget to "eat less or move more".

People love to think of the body as a simple energy-in->energy-out equation, but it's definitely more complex than that, as the body can change what it's deciding to hold on to and what it's deciding to burn or expel.

I am one of those that stayed skinny as a rake throughout my childhood and mid-adulthood (in my mid-40s I'm starting to become more normal sized). I wasn't particularly active, and I ate voraciously -- third or fourth helpings of pasta bowls. But the food never stuck to my ribs. (And it wasn't a worm or anything -- the whole side of my mother's family is the same, while my dad's side is the opposite.)

No one should look at my body and say "clearly he is exercising more than he is eating" because it wouldn't have been true at all, and yet that's what the simplistic energy-in and energy-out conclusion would say.

I can second this. I get routinely mistaken for a runner because of my size. I do strive for 10k steps a day, but generally, my activity levels would not easily reflect my BMI.

>People love to think of the body as a simple energy-in->energy-out equation, but it's definitely more complex than that, as the body can change what it's deciding to hold on to and what it's deciding to burn or expel.

If calories-in/calories-out didn't work, then it would be impossible to starve to death.

Where people get confused is that the number of calories changes as your metabolism speeds up or slows down.

If you are ingesting fewer calories than your body requires, you will lose some combination of fat and muscle. There is no possible way for this to be false.

It's the flip side that is quite possible to be false. You can certainly eat more calories than your body requires and yet not gain weight. Your gut could absorb less, so you excrete otherwise-digestible carbs. You could have a parasite.

Further, you could be burning more calories without doing more exercise or otherwise doing anything "useful" with the energy -- i.e. having a higher basal metabolic rate. These calories can be burned doing all sorts of things that the person has no control over: you could have a higher core body temperature, you could be spending more energy on cellular repair and other cellular processes, you could be synthesizing more hormones, you could be spending more energy metabolizing foods, etc etc.

These latter causes are obviously on the "energy out" side of the equation, but they do not relate to things under our control. Further, they can change with age, stress, and (relevant to TFA) sleep.

So a body that has been coasting by eating 2200 calories per day and never gaining a pound could suddenly change and start putting on weight, even though the person's diet and activities haven't changed.

The point is that two people could eat the exact same calories, and do the exact same exercise, and one of them go up in weight and the other go down. The "calories in vs calories out" idea usually simplistically makes people think this couldn't be true, because "calories out" is simplistically taken as "exercise."

The reason I shared my story is that so many people just quote "calories in vs calories out" as if both sides of the equation were perfectly under control, and those people are also often like me: they find it easy to keep the pounds off (because of a high metabolic rate) and so they look down on people who have trouble shedding weight and figure that those people could live just like them. But those heavier people could well be eating less and doing more exercise than them.

> It's the flip side that is quite possible to be false. You can certainly eat more calories than your body requires and yet not gain weight. Your gut could absorb less, so you excrete otherwise-digestible carbs. You could have a parasite.

Is the flip-side really debated that much tho? I feel like when people talk about CICO they're primarily talking about reducing CI to lower than your CO. No?

The complexity in CICO of course is measuring your CO. Ie you could estimate your CO, reduce your CI to what you believe your CO is - and still not lose weight. But does that undermine CICO? Because as the other commenters mentioned, it's "impossible" for you to burn more than you take in without losing mass, so our issue in this example is incorrectly asserting the output (assuming of course we're not also underestimating the input).

Note my questions here are generally questions. I am not an expert here, so please correct me if i'm wrong.

> The reason I shared my story is that so many people just quote "calories in vs calories out" as if both sides of the equation were perfectly under control, and those people are also often like me: they find it easy to keep the pounds off (because of a high metabolic rate) and so they look down on people who have trouble shedding weight and figure that those people could live just like them. But those heavier people could well be eating less and doing more exercise than them.

Fwiw, i don't dispute that some people have the wrong ideas with CICO. Perhaps frequently even. But i thought it still stood as a foundational truth nonetheless; that you have to "simply" burn more than you take in. If you gain weight (ignoring water weight for simplicity), then you have ate more then you burned, always.

My takeaway with CICO is that the hardest question seems to be correctly figuring out how much you're burning. Which i feel like usually, especially for overweight people, it's much less than they think. You can't outrun a bad diet, as they say. Rarely do people actually want to exercise enough to truly compensate for the thing they want to eat. Hence why i like CICO, as to me it signals the only effective action is in restricting your CI, since increasing CO is so difficult.

In my Indian family, this sort of skinny phenotype with a voracious appetite had a simple folk explanation - you eat so much that the food doesn't have time to be absorbed.

And yet, if you want to lose weight, it’s almost always (outside of medical conditions) as simple as getting into a caloric deficit that matches the deficit necessary to induce weight loss.

If you have a 500cal deficit per day, you lose a pound of weight (fat) per week. It’s literally that simple.

There’s some auto regulation of caloric burn rate, but it’s not some impossible problem to solve.

If you knew your exact metabolic requirements as well as the exact calorie count of every food you ingested, then it would be that simple. But what if you take the elevator one day instead of the stairs and don't burn off the 30 or so calories it might take to go up them? What if someone went a little heavy on the dressing on a salad you ordered and added 100 calories or so?

I've manipulated my body weight a few times and the real world is vastly different from a simple model of CI/CO.

On average this doesn’t matter. Humans are a whole lot more predictable and pattern based than you seem to be implying.

Also, if you’re trying to aim to a specific deficit, you should be calorie counting your food. If you got fatty dressing, you should be counting that. Even estimating is relatively easy once you do it for awhile. And if you don’t get it quite right, being a little off shouldn’t impact your overall average too much. It keeps you honest, which I think is by and large the main reason people don’t think they can lose weight: dishonest assessments of food consumption.

As I've said, I can absolutley lose weight, but I cannot reliably lose one pound per week; I do not seem to have that resolution in the numbers.

Reliably losing one pound a week (beyond the initial 1-2 week period where your weight is going to go all over the place due to water weight fluctuations) is as simple as cutting calories until you see the weight (on average, ignore fluctuations) drop by 1 lb a week. You have to average extensively. Bodies are very temperamental at this, unfortunately. My scale weight swings 0.5-1 lb quite frequently mainly due to sodium changes in my diet. It’s all about trend weight, though.

I've been tracking my weight weekly and all calories (even with crude estimates in some cases) for a year and a half, and have been experimenting with exactly this: I made a scatter plot and linear regression of average calories per day on the X axis, and weight change for that week on the Y axis.

Week to week weight has extra fluctuations that make it difficult to tell what's going on, but after around 6 months of data it stabilizes, and has been consistent for any 6-month period over the last year and a half: I burn around 2200 - 2300 calories per day on average (way higher than the online estimator tools think I burn, 1600 - 1700).

Knowing this I've also been reliably able to control my weight up or down at the rate I want as long as I'm looking at it for over a month span - because as above, week to week there's too much fluctuation (fullness of stomach and bowels mostly).

That it takes that much data to see the result pretty much proves my point - maintaining a 500 calorie per day deficit is just very difficult for me and I suspect most people. I don’t mean the hunger - when I do lose weight the deficits are easily above 1000, but 500 is too marginal for me to resolve.

I believe you confuse an inequality of Energy(Fat) ≤ Energy(Food) - Energy(Activity) with an equation and are trying to disprove it with a counter-example. People saying "calories in, calories out" don't help with this confusion too. Another variant of your argument is "but different people extract different amounts of energy from the same food so there!". This being an equality, both arguments make no sense. I give you more - the "Energy(Food)" is calculated by burning the food in question and measuring the energy produced. It's guaranteed to be more than most humans could extract from the food as most humans excrete more complex chemicals than carbon dioxide and water, which burning food produces. But it does not matter because this is an inequality and not an equation. E.g. in your example the inequality still holds, you allegedly increased the Energy(Food) but the energy stored in fat did not increase, as asserted in the inequality.

A counter example to disprove this would be somebody gaining more weight in fat than the weight of fat needed to store energy from consumed food. Of course, this would have been broken pretty fundamental laws of nature and would have caused some kind of revolution in physics.

People do not live on a thermodynamic knife edge. There is a very wide leeway of excess intake that allows our body to burn energy “wastefully” or store it based on a hideously complex set of factors.

The idea that everyone is fat because we’re somehow more sinful (gluttonous, slothful) than in the past has repeatedly failed to resolve any problem except for the need for smug people to pat themselves on the back for using thermodynamics in a sentence.

This is the truth, even if people don't like it so you're receiving downvotes for it. Weight gain or loss is calories in vs calories out. Nobody's body is so special that you're defying thermodynamics and creating mass that you didn't intake as food. And that's definitely not changed by sleep apnea.

That said, there is the point that calories ingested doesn't necessarily equal calories absorbed, and sleep apnea could indeed affect that. But if you're relying on that thin margin for the difference between staying at a healthy weight or not, that's a fragile state of affairs, and you could fix your diet more to be more comfortably on the right side of it.

(My own, unscientific, hypothesis: far too many people are indeed unknowingly relying on that. I think a ton of people cram in 3k calories a day while absorbing 2k because there's just too much mass for the body to process, and then when they do cut ingestion to 2k, that doesn't change absorption and that's why they don't lose weight. (Numbers here are approximate.) It's actually pretty amazing how little food the human body actually needs and how little mass 1500 calories is.)

> and how little mass 1500 calories is

Or how much, depending on what you’re eating. It would be physically impossible for me to eat 1500 calories of lettuce in a day (10kg worth) but it definitely aids in “feeling full” when added to a meal.

Sidenote, i'm in your camp and agree with you - BUT, hypothetically there's a side to this i've not seen discussed here. That you can lose sleep and it causes a weight gain, with no other change to your CI or CO. Notably, you were previously not processing a portion of your potential CI and it was just passing through you.

In that case you didn't change how much you ate or how many calories passed your lips, but you did change your CI by way of changing your sleep.

Is this a real example or a contrived edge case from a software dev? No clue. I'll let better minds decide that hah.

I thought it was more complex than this, something like lack of sleep disrupting hormones that regulate feelings of hunger and fullness.

I'm sure it is. But the point should still stand.

>> A lack of sleep means a lack of energy. You're body compensates by getting food energy.

I saw this ironically during military basic training. Lots of exercise, but very little sleep. The body compensates by keeping blood sugar levels high. I was one of the many that actually gained weight during basic training. The eating routine of three solid meals eaten very quickly also was not healthy.

My doctor wore one of those continuous glucose monitors for a while and reports something similar. He considers himself an endurance athlete and his blood sugar levels were always a bit high when he was regularly exercising, but once he took some time off, his blood sugar levels dropped to "normal" levels once his body realized it wasn't under so much stress.

that concurs with my anecdotal sample size = 1 study, where I have gone for 3.5 days without sleep before, and just keep feeling hungry and snacking every hour or so.

(for those asking what happened after 3.5 days, I basically started getting hysterical - literally just laughing at nothing - and when I was finally able to get to a bed, it took about 2 hours of staring at the ceiling before my body finally decided I was no longer under stress, and allowed me to fall asleep).

Absolutely. When I was in the Navy, working 80-100hrs/wk, we were served four meals a day, every six hours, like clockwork. You can substitute sleep with calories for days or weeks at a time. It's terrible for you, I do not recommend it, but it can keep you going.

CPAP has been life changing for me. For my entire life I struggled getting up in the morning, and I never felt "refreshed". Getting up before 9-10AM was super difficult. I also was often in a sort of fugue state when I would first wake up, I'd often have no memory of any interactions, and apparently was often mean.

Now I can easily get up, even at hours that were previously unthinkable, and more often than not feel fully recharged.

I have no doubt that played a part in me being unhealthy - though by no means was it the sole reason.

As an aside, also getting on a dose of Semaglutide has been similarly life changing. The damn near elimination of "food noise" has been incredible.

I know there are a number of folks of the opinion that its somehow cheating. But for me I am left wondering "Is this just how normal people feel?".

It always bothers me when someone says it’s "cheating" to use a GLP-1 agonist.

It helps but the person losing weight still has to clean up their diet and start an exercise routine. There are still major changes they need to make to become successful. GLP-1 agonists help a lot of people make better decisions due to how they fight hunger. Less hunger means less chances to make bad choices when eating, and weight loss progress is a virtuous mental cycle where you keep doing what you’re doing because you see results.

None of that is cheating. There are still major changes one must make. Taking Ozempic but continuing to eat a trash-tier diet will yield little to no progress.

Definitely agree, but man, the sheer number of folks who leave just horrible comments on videos/posts people make about how they lost weight on a GLP-1 agonist is so disheartening.

In addition to saying that its cheating, they will actively wish harm to the person by saying "just wait til you get X" where X is some side effect (real or imagined). Or just the "well once you stop taking it you'll just get fat again".

The people who say "you'll get fat again once you stop taking it" also baffle me.

The most difficult part of losing weight for me personally is changing my routine and habits. Setting myself up with a kitchen that's ready to cook. Figuring out what kind of meals I'm happy to have on a weeknight that don't require a lot of cooking. Preparing parts of meals over an hour or two on the weekend to complete some of the more time consuming parts when I'm not so constrained on time. Learning to deal with the urge I (used to) have to "eat my feelings".

All of those things don't just magically go away when you stop taking a GLP-1 agonist. Losing a lot of weight isn't just about self-control like if you're just trying to lose five pounds to make your pants more comfortable for going to your 20th high school reunion; you have to rewire your habits and mind and make a life long commitment to those changes.

Rewiring your habits and rewiring your brain are things that persist if your intention going into the weight loss was to change your habits instead of just moving the number on the scale. If you are looking to do it only temporarily and are unwilling to lock in those behavioral changes then you're likely going to fail, and that has much more to do with mindset than medication.

Just to add to this, there's data to support the intuition there that there is long term good in taking GLP1s even after you stop:

https://glp1.guide/content/do-people-regain-all-the-weight-l...

Now, we need price to go down and availability to go up, but people who think all the weight bounces back as a sort of "gotcha" are silly. It's possible, but is a testament to the difficulty of dealing with obesity -- not some sort of gotcha of the drug.

> As an aside, also getting on a dose of Semaglutide has been similarly life changing. The damn near elimination of "food noise" has been incredible.

>. I know there are a number of folks of the opinion that its somehow cheating. But for me I am left wondering "Is this just how normal people feel?".

Heavily under-weighting (heh) the opinions of people on the internet (and honestly most people in real life) is the way to go.

We generally don't (and shouldn't) ridicule people for taking scientifically proven treatments that can help save/prolong their lives.

As a fairly thin guy in my 20s (I was about 130lbs and 5'6"), I had years of undiagnosed hypopnea. I would wake up with tears streaming down my face and choking, but couldn't figure out why. I was constantly exhausted and yet, couldn't sleep. I would spend more than 12 hours in bed every night, hoping to get as close to 8 hrs as I could.

Paid for a sleep study and the doctor walked in the room and said, "You don't have sleep apnea." I was like, " I knew that, but what can I do?" The doctor shrugged and said, "You have hypopnea. You could try a mouthguard...?" trailed off and left.

So, with this newfound wisdom I was back at square one.

Some things that dramatically helped me in recovering from years of sleep loss: - A chinstrap. - I found a study (n=1, literally) about a patient who didn't fit the typical sleep apnea profile as a thin older man. The doctors treating him wondered if it was "positional sleep apnea" and had him get a chinstrap. This held his mouth shut while sleeping and prevented his tongue from falling back and blocking his airway. I found a chinstrap on Amazon and immediately started sleeping better.

- A blood test - My doctor knew that I was dealing with adrenal issues due to not sleeping, Lyme disease, and other issues, so he ordered a blood test. This was fantastic. For me, addressing my underlying magnesium and B-12 deficiency made an enormous difference in sleep quality. I found that taking my B-12 right before bed helped my sleep be so much more restorative.

- Andrew Huberman - Andrew Huberman's podcast Huberman Labs is old news, now, but when I found him a few years ago, it was some of the more actionable advice I had ever gotten about sleep, falling asleep, and circadian rhythm.

Anyway, there were more things across the way, but these are some things I shared with others that they also found helpful. I now am in control of my sleep and feel decades younger. You can get there! It's worth experimenting and finding a doctor who is going to help you find your problem. The mental clarity, focus, and energy has definitely made up for all the the months of trying to find out what was wrong with me.

I hope you sleep well!

I had sleep apnea and got jaw surgery. But I also have a dysfunctional TMJ, so my mouth opens when I sleep. Every chin strap on the market pushes the chin down into the airway, it seems. Which one did you get?

I got some random generic one. I wouldn't recommend it as the quality could've been better. For you, I also tried tape over the mouth. I got a wide washi tape from a friend and experienced similarly helpful results to the chin-strap. However, I found that comfort-wise, I preferred the chinstrap.

But, if you can breath through your nose well enough, I think some kind of mouth tape can work? I haven't tried the Hostage brand anti-snore tape, but maybe someone here has had experience with that.

If you really want the chinstrap that I got, I got this one: https://www.amazon.com/gp/product/B08DR16XGV/

Based on the pictures, it obviously pushes the jaw backwards. That obviously wouldn't work for you. I wear mine in such a way that it is helping my jaw close and stay shut. I agree that you don't want something pulling your lower jaw backwards.

Yep I've tried mouth tape and it's pretty good, especially when combined with side sleeping.

Though I have this paranoia that mouth tape will increase my philtrum length, which I know is a vain worry. Another solution is one of those incline pillows - just a 20% gradient should allow me to back sleep, which I prefer.

Post-surgery I had my jaws wired shut and they had this chin strap that was like an ace bandage that around my head and chin. I could replicate that with one of those mouth guard combined with a chin strap, but I read somewhere that this would eventually pull the upper jaw down towards the airway as well (since maxillary plates are not fixed.)

Have you tried mouth taping instead? Seems to work better for some people than chin straps, but I don't really know.

Thank you for this comment which mirrors my experience. Unfortunately CPAP seems to be considered the be all and end all of treatment, although the mask, tubes and reliance on such a bedtime setup can be enormously disruptive of sleep on its own.

I think CPAP is just convenient and inexpensive compared to surgery. If I ever have sleep apnea, I'd want the surgery.

There is also the mouth guard for apena.

https://www.sleepapnea.org/treatment/sleep-apnea-mouth-guard...

I have heard horror stories about the surgery. Who knows, but I’m skeptical because surgery presumes the precise cause is known. The number of variables for sleep apnea is large to have certainty.

"The number of variables for sleep apnea is large to have certainty."

Clearly they have to know which part of your airway is restricted. Most of the variables for sleep apnea are not related to the surgey, just factors that make it more likely to experience that restricted airway (drinking, weight, etc).

I have sleep apnea and I use a CPAP. During the diagnosis, there were tests but nothing that would/could finger a physical culprit that could be fixed via surgery.

My question is, what tools are there to narrow, to a certainty, what would need to be done via surgery? In all my research I have found none. Maybe I missed them. If I did not, then it amounts to a guess by a surgeon. And that's what worries me and has fed a lot of the horror stories I've read about.

I talked to a bunch of dudes who had various surgeries to open up their airways. It seems the outcome of the surgeries is kind of hit and miss. Some people had multiple surgeries and still no success.

This is a really important comment. Whether for apnea or other sinus related issues, I've met far more people for whom the surgery did nothing than people I've talked to who had good outcomes.

I adapted to it really well but I am used to adapting to the needs of machines. My wife doesn't like it when it blows air on her but my cat is very curious about the mask. My doc told me that most people have a lot more trouble.

CPAP is by far the best option for very nearly everyone with obstructive sleep apnea (for now).

Unless you have a very specific, isolated problem (such as huge tonsils or a fucked up jaw), surgery is rarely a good option. Results are hit or miss, recovery is unpleasant, and the scar tissue created can result in more obstructions years down the line.

None of the current implants are as good as cpap and few peole qualify for them.

Mouth guards can work, but many don't tolerate them well and they can lead to TMJ issues.

Etc.

In case this helps anybody: I've been using those BreatheRight strips (extra strength) and they've been incredibly helpful. Not nearly as effective as CPAP, I'm sure, but a milder version of the same effect.

I could not handle the CPAP mask but instead I got a dental appliance (custom) that juts out my lower jaw a bit. Worked great.

I got a custom dental appliance for like $1000 out of pocket, and it broke within a few months, conveniently when I had moved out of state from my original dentist.

There are a few over-the-counter options that advertise themselves as just for snoring reduction - SnoreRX and ZQuiet are ones I've tried. I've found that wearing a BreatheRight-type strip along with one of these appliances works as well or better than the one I got from my dentist, and it's MUCH cheaper. I also take an anti-allergy nasal spray, as I have pretty bad allergies also interfere with sleep.

I got mine thru the city health service, so I only made a token payment. 1000$ ouch.

That's a little upstream of where in one's anatomy is the common choke point - usually the back of the throat/soft palate relaxes and obstructs all breathing.

But I have nose blockage issues and use nasal strips nowadays, too. It prevents mouth breathing which is nice to prevent dry mouth in the middle of the night (which even a humidifier on my nightstand can't completely solve in my climate)

Those never worked for me (mouth breather) but for some they do work wonders.

Tape didn't work for me. What did work were nasal dilators:

https://www.amazon.com/Rhinomed-Snoring-Solution-Reduction-C...

I don't understand why, but in my 30s, it's like my nostrils aren't big enough to get the airflow I need, especially when sleeping on my side where a pillow might compress one nostril.

Disclaimer: they are not very comfortable, but far more comfortable than a CPAP mask.

I feel the same way, I wish there was some kind of way to permanently expand my sinuses or something because I feel like I can't force air through them.

Sometimes just breathing hard through my nose starts to make my ears pressurize and threaten to pop

There’s a metallic device to insert inside your sinuses. It looks like a finger trap with one side going to a point. I remember it lasts a few years then needs to be replaced for $1000 or so.

My grandfather looked into it because the surgery doesn’t last very long and he had it done multiple times.

> Sometimes just breathing hard through my nose starts to make my ears pressurize and threaten to pop

I had something similar (ears permanently felt like they needed to be popped, for months). Was diagnosed with a deviated septum + allergic response causing my eustachian tubes to not regulate ear pressure properly. Flonase helped. But cluing in that it was partially due to an allergic response (deviated septum made my nasal passage narrow, allergies closed them all the way), I have found that Benadryl is extremely helpful with both nose breathing and preventing the issue with pressure in my ears. I only take it when I have difficultly nose breathing.

I actually had surgery done to fix a deviated septum about 10 years ago, now you mention it

You're probably right it's allergy related. Nothing ever shows up on scratch tests though

I use a nasal steroid I just wish there was a permanent fix

nasal dilators definitely help a lot. I've tried the mute brand you posted and another style that smells of lavender and the mute ones are better. my only problem is I subconsciously mid sleep pull it out because they are a bit uncomfortable like you mentioned, or it falls out at some point of the night and gets lost in the bed. it is amazing how much more air I can breathe through my nose with one in though, and I definitely feel much more rested using them when they stay in. I knew they worked the first time I fell asleep and woke up the next morning in the same position

Yeah exactly. I frequently wake up to realize I yanked the sucker out at some point, sometimes even with groggy recollection of it. (Though I do the same to a CPAP mask when I use one)

But it clearly works in the best case scenario. And sometimes it's the only way I can even breathe well enough to fall asleep.

I have severe apnea and have been skinny most of my life, as I get older (in my mid-40s now) I can gain _some_ weight, but I'm still slim. My apnea is caused by having a narrow airway entrance and thick tongue that just completely blocks the entrance during sleep when my tongue relaxes and falls back. Has nothing to do with my weight, just the genetics I inherited. I use a CPAP that helps. My AHI is really low with it on. Now I just need to make myself go to bed earlier, I definitely have that "revenge nighttime procrastination" thing where I stay up way too late.

I fixed apnea using MAD night guard (pulls jaw forward using a mouth guard device). Made by dentist. Cost about $2000. But it works.

You can also try "snore prevention" night guards like ZQuiet and SnoreRX - they're less than $100 and you can buy them online. I find they work just as well as the custom night guard I got from my dentist.

When you say fixed, do you mean you no longer need the device?

Do you think sleep apnea is a condition caused by civilization? I.e. did medieval people suffer from this? And is this a consequence of the American diet and a sedentary lifestyle, or something else?

If it's not weight, what's the common cause? Such a bad impediment on so many people should have a very clear signal. And apparently it's not weight? O never really looked into it

The most common cause of sleep apnea is anything that obstructs your airways. Being overweight does that and is far and away the most common cause of sleep apnea.

This is such an often repeated trope, but it's not at all as clear cut as that. Sleep apnea *causes* weight gain, the arrow of causality can go both ways.

One theory is poor facial structure that develops due to faulty breathing technique.

Reference https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4686746/

With obstructive apnea, it's mostly hereditary. You inherit the shape of nose from your parents, why not the structures in your airway? Weight gain can make it worse as those tissues also can expand, and any weight on your breathing can help turn a partial blockage into a full one. That weight can include muscle weight, and body builders often suffer from apnea.

But the thing to keep in mind is that obstructive sleep apnea isn't so much a condition as a description of what's happening. Apnea means you stop breathing, obstructive means something is blocking it. Maybe it's because your fat belly is weighing you down, maybe it's your tiny nostrils and deviated septum, or maybe the back of your tongue is thick because your dad also had a thick tongue.

That's not even including self-imposed factors like central nervous system depressants (alcohol) and smoking, both of which can make apnea worse. Ever notice how drunk people snore?

Beyond physical obstruction, sleep apnea can also be neurological which is the more annoying one since only air pressure seems to fix it. You simply stop breathing.

Obstructive apnea doesn't need to be caused by fat either. I always thought sleep apnea was a fat person's problem until I realized at age 30 that when I slept on my back, the tissue mass at the base of my tongue was dropping into my airway. And I'm fit/slim and also a nasal breather.

(I used to think I always woke up gasping for breath in my 20s because I had frequent nightmares. Ugh, wish I could go back and fix it sooner.)

It's not exactly common, but you can have central sleep apnoea instead of obstructive sleep apnoea. Essentially, rather than your airway being blocked, you just stop attempting to breath for a period of time. I was diagnosed with this a few years ago, and IIRC there are multiple possible causes of it.

One theory blames "modern life" as a supporting factor, that since modern people eat more processed and softer food, that jaw muscles are out of proportion to the bone structure and this contributes to apnea, as well as tooth problems like impacted wisdom teeth.

https://news.stanford.edu/2020/07/21/toll-shrinking-jaws-hum...

Sometimes I wonder if humans need more variability in sleeping positions. Animals sleep in all sorts of positions on all manners of not perfectly even terrain, probably trains nassal to be strong in different orientations. When I had bad heartburn/gerd I'd pass out propped up on the couch or setup a bunch of cushions in the corner of the room, or raise head of my bed up with a few books and getting great sleeps.

I’ve had sleep apnea and CPAP for years. The last several weeks have been grueling because of mask fit, movement, and other factors. My BMI is very high, but I am in minority that will have sleep apnea regardless due to anatomy. That doesn’t mean it won’t help to lose weight.

I'll throw this out based on the comments I'm reading, it seems like doctors don't personalize medical advice sufficiently.

Glad some people were able to find the good ones that did

How would one know if they had sleep apnea in any shape/form?

Get a sleep study for accuracy.

If your partner notices you snore or stop breathing when sleeping.

You can record yourself also. You wake with a headache and dry mouth almost daily.

Sleep apnea is not the reason people are overweight.

Nobody is overweight from one reason alone. But do you dispute the idea that it contributes?

If you are so confident, try setting up an alarm to wake yo up 15-30 times every hour of every night, for a year. See what happens to your overall health and to your weight in particular.

And that is moderate sleep apnea. Actually, apnea is worse because you wouldn't even be breathing normally while you are "asleep".

Sleep deficit drives metabolic changes that may result in obesity (e.g over feeding behavior).

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