My sleep specialist ran me through a list of symptoms: Do you sometimes wake up in the middle of the night? And then do you feel extremely thirsty? Do you often have the urge to pee, even when you don’t really need to? Do you have morning headaches, fatigue, or daytime sleepiness? Do you tend to forget small things like where you kept your phone or keys? Are you often irritable?
Yes! Yes! Yes! But how did he know?
It’s as if the sleep specialist lived with me. He was describing my life to me.
He conducted a sleep test, which had me sleeping with some wires and a machine around me, in the comfort of my home, on my own bed. A pulse oximeter, tightly wrapped around my index finger with tape, continuously measured my blood oxygen as I slept. A wire rested on my nostrils, recording my breathing pattern. The machine also recorded my heart rate. It was initially uncomfortable sleeping with all this paraphernalia around me, but I fell asleep anyway.
The next day, I went to the doctor to return the equipment. The data was downloaded on a computer, and in an instant, a printout diagnosed me with severe obstructive sleep apnea (OSA).
The ‘lifestylewallahs’
I should have seen a doctor long ago, but I was captive to what I call the ‘Lifestyle Advice Industry’. Friends, family, Google, and news media — all tell you to correct your “lifestyle” to address issues like obesity and poor sleep. The blame is always on you.
I remember starting to sleep poorly and putting on weight since the day I turned 18. With every passing year, both problems worsened.
The Lifestyle Advice Industry misguided me into believing the problem was with the choices I was making.
“Why don’t you join a gym?”
I had difficulty explaining I had no energy to workout, having often paid for gyms. It sounded like an excuse, a confirmation that I was lazy.
“Why don’t you sleep on time?”
Note to self: Tonight I’ll sleep early. Except nobody can summon sleep.
When it does come, I still find myself waking up too early or too late, still not feeling refreshed. “How much do you sleep (Kitna sote ho)?” I would be asked. Ironic, because no matter how much I slept, I didn’t feel fully rested.
Fatigue as a way of life
Over the years, the morning headaches, perpetual fatigue, and low energy became a part of my life. At some point, I stopped seeing it as a problem because I thought it was my obesity, my “lifestyle”, my genes, my mental health, or just me to be blamed. It was what it was.
My condition became so bad that it affected my work, health, relationships, everything.
For many hours after waking up, I would be struggling for energy. This meant that my day would meaningfully begin only by evening.
I’m not a morning person, I proudly declared to myself.
This is when your sleep cycle goes for a toss. The later you sleep, the later you wake up. Night becomes day, day becomes night.
I was Abhimanyu in a Chakravyuh, because one bad night led to a bad day, which led to another bad night.
There were nights when I couldn’t sleep at all. And by 5 am, I would be so ravenously hungry that I would empty the fridge and then go to a hotel for the early morning buffet breakfast.
There were times when I would travel out of town just to keep myself awake all day, and sleep only at night, thus correcting my sleep cycle.
I could not even predict when I would be awake and when I might fall asleep. I have missed professional meetings, cool parties, and doctor’s appointments because sleep got the better of me.
Sleeping aids that don’t work
Worry not, said the Lifestyle Industry. We can fix this. Why don’t you drink a little less coffee? Why don’t you try chamomile tea? Melatonin? An all-knowing friend even gave me Alprax.
I did not know it at the time, but these sleeping aids were all actually making my condition worse. They worked at cross purposes with my brain. They told my brain to switch off and go to sleep when it needed to prevent me from going to deep sleep.
Sleep apnea is the inability to breathe during sleep because your airway collapses. If that happens, you’ll die — like drowning in water. This is where your brain saves you by waking you up, so that you may make some effort to open your closed airway and breathe again. It happens in an instant without one realising it.
Sometimes, it can get so bad that the brain presses the emergency alarm and completely wakes you up. You are panting, gasping for breath, choking…just like when you can’t swim. You immediately want to drink water. Lots of it. This is why sleeping pills and aids won’t work on someone with apnea.
Almost everybody snores, so people don’t see snoring as a problem. But the sleep specialist explained to me that snoring was a sign of the airway getting narrowed in sleep.
If you have travelled overnight in Indian Railways, you have witnessed sleep apnea. There will always be at least one person in every compartment with a peculiar snoring pattern. His (and more likely his than her) snoring goes up like a crescendo — and then suddenly stops. It doesn’t come down. That’s when you hope he’s done snoring and now you can sleep in peace. Alas, he begins again. When he suddenly falls silent at the peak of a snore, it’s possibly the closing of the airway, called an apnea event.
To my surprise, the doctor told me that up to 5 apnea events per hour were considered normal in adults. More than 30 per hour amounts to severe sleep apnea. My test showed 32.
It also showed that at one point in the night, my blood oxygen fell to 73 mm Hg. My heart rate went as low as 48 bpm.
We know how terrible such low blood oxygen levels are because of Covid, when we were told to check in to a hospital if the blood oxygen falls below 93. It all made sense now — how was I expected to be cheerful, energetic, and productive when my body was fighting for oxygen?
The third stage of sleep is non-rapid eye movement (REM) sleep or delta sleep in which the brain consolidates information into memory. This is a deep, restorative period. Then comes the final stage — REM sleep, which is necessary for emotional processing. This is when we dream. Sleep apnea disrupts both these stages.
My amnesia was and is so bad that I regularly meet people who are offended I don’t remember them.
Leptin and Ghrelin
When we sleep, we secrete a satiety hormone called leptin, which assures the brain that the body has adequate energy and does not need food. If we don’t sleep well, we don’t have enough leptin, which makes us eat more than we need to. Another hormone ghrelin, which signals the brain about hunger, is secreted in excess if you don’t sleep well.
Leptin and ghrelin go for a toss in sleep apnea patients, and with the added lack of energy, they end up eating more, especially carbohydrates. This increases body fat and weight, which, in turn, worsens sleep apnea with fat deposits around the neck.
The doctor told me something I had always intuitively felt — my sleep and weight issues were closely interlinked.
He said that I could adopt any diet and exercise regimen, take any medication, and be as disciplined as possible, but without addressing sleep apnea, I can’t lose weight. I wish I could make him meet all the fat shamers I’ve had the misfortune of coming across. He could at least meet the person who used to tick me off for having beer in social gatherings. Like sleep, obesity is all on you — it’s your fault, it’s you who can’t go without a beer in a party.
I did nothing to get sleep apnea, the doctor said. It was like an anatomical defect that was always there and gets worse with time.
Nothing but CPAP
The good news, the sleep doctor said, was that my problem could be addressed overnight.
I knew for years what he was going to say: You need a sleep machine called continuous positive airway pressure (CPAP) machine, which pushes air down your nose at such high speed that your airway doesn’t collapse.
Despite Dr Google telling me for some years that I most likely had sleep apnea and needed a sleep test and a CPAP machine, I delayed going to a doctor because Google also gave me “lifestyle” type advice. Why don’t you try sleeping sideways? Why don’t you use a special pillow? Try a dental appliance? Or just lose weight?
None of these ever work, confirmed the doctor who must have seen thousands of people like me in his career. “How often have you slept sideways and woken up sideways too?” he asked. “There’s only one thing that works, and it’s CPAP.”
The doctor made me use a trial CPAP. I took to it like fish to water, easing into sleep around midnight. The water in the machine’s humidifier box made the air cool like mountain breeze. It felt good.
Eight hours later, I woke up and felt like I was coming out of a spaceship. I took off the mask and some divine force had me jumping out of my bed, going to the window, parting the curtains and taking in the morning light. I had a sense of deja vu — this is what it used to feel like waking up in the morning in my teenage years. I had forgotten this feeling.
It felt like I had landed in a new country. For the first time in almost 20 years, I actually slept.
A new lease of life
I immediately regretted not going to a sleep specialist much earlier. I had so become comfortably numb living with poor sleep that I couldn’t even imagine what light at the end of the tunnel might look like.
A year and half later, I look back at my pre-CPAP self and describe it as another person. I don’t work at night or miss my appointments anymore.
I no longer need to rush to the bathroom several times a night. The doctor said sleep apnea makes the heart produce a chemical that induces the need to pee even when you don’t need to. I can only hope CPAP therapy has also reversed some of the brain damage that sleep apnea causes.
I still forget where I’ve kept the keys but at least I don’t have those blackouts and daytime sleepiness.
I once had a blackout and fell from the stairs, which caused a painful ligament tear. I was too embarrassed to tell anyone that I had a blackout because how does someone in his 30s have blackouts and falls? Turns out, this is so common in OSA that people with an untreated condition are advised not to drive. Airline pilots have to take a compulsory sleep test once a year and can be grounded if they have severe apnea.
There were other changes I didn’t even expect. My eyes were a lot less dry than they used to be, I stopped feeling unncessarily depressed and unwell all the time, and probably stopped grinding my teeth in my sleep. Again, all of these are well-known effects of sleep apnea.
I write this piece because I realise that the awareness about sleep apnea is very low, even though millions of Indians are potentially suffering from it. Many of those who have heard of sleep apnea haven’t heard of CPAP.
While I am full of regret about the years I wasted on the Lifestyle Industry’s wrong advice, at least I went to the doctor before it was too late. Untreated sleep apnea is known to contribute to diabetes, heart disease, dementia, and Alzheimer’s.
Some of these cases we hear of people suddenly dying of heart attacks in their sleep could be cases of undiagnosed sleep apnea.
Next time someone tells you they’re regularly having trouble getting sleep, don’t ask them to correct their ‘lifestyle’. Ask them to see a doctor.
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