November 27, 2003
Q & A With Dr. Peretz Lavie
Dr. Peretz Lavie has spent his career studying sleep and sleep disorders. The fifth-generation Israeli is head of the Technion Sleep Laboratory, which has hosted more sleep patients than any other laboratory in the world.
"We've had about 60,000 patients who have slept with us," he joked.
Lavie's most recent book, "Restless Nights: Understanding Snoring and Sleep Apnea" (Yale University Press), examines the history of sleep apnea and provides advice for people suffering from this potentially life-threatening sleep disorder.
Sleep apnea is characterized by brief interruptions in breathing during sleep. Each apnea, Greek for "want of breath," can last a minute or longer and can occur as often as 20 to 30 times per hour. According the National Institutes of Health, as many as 18 million Americans suffer from sleep apnea. Risk factors include being male, overweight and over 40, snoring loudly and genetic predisposition. Untreated, the disorder can lead to cardiovascular disease.
The Journal sat down with professor Lavie during the Los Angeles stop of his American Society for Technion-sponsored tour of the United States to talk about sleep apnea and how the intifada has impacted people's sleep.
Jewish Journal: What have you seen in the way of sleep problems since the situation began in Israel?
Peretz Lavie: If you ask people in Israel now if they sleep better or worse, probably people will say worse. But when you measure it or study it, it's not so bad.
We studied sleep during the Gulf War when Scuds hit Israel almost nightly with objective recordings at patients' homes and we didn't find any effect on sleep. When we do a survey and ask people how they sleep, there was an increase in the complaints about insomnia of about three or fourfold.
JJ: What about the quality of sleep?
PL: The quality of sleep wasn't so bad. This is true for many, many studies of what we call post-traumatic stress disorder. There is a vast disparity between how they perceive their sleep and what we find in the laboratory when you measure it objectively.
We studied people during the worst night of the Scud missile attacks on Israel. There were three missiles that fell during that night, so you could see in our recordings the time that the missile fell, the patient woke up and 10 minutes later the patient was asleep like nothing happened. That's it.
What led me to this were studies done in London during the Blitzkrieg, how people slept in underground subway stations. No problem whatsoever. It was so easy to sleep under these conditions, but nobody believes it's possible.
JJ: What led you to study sleep apnea?
PL: Sleep apnea is both fascinating and a very prevalent phenomenon. One in 10 men have a little bit of apnea, which is clinically significant. Sleep apnea is turning out to be one of the major risk factors for a variety of cardiovascular diseases -- hypertension, myocardial infarction, arterial sclerosis, strokes. Ninety percent of the patients we see are sleep apneic.
JJ: What are the primary causes and what are the cures?
PL: Sleep apnea is a very widespread phenomenon. We do not really know what is the specific cause of sleep apnea. We know that there are several risk factors that predispose an individual to sleep apnea, and I talk about most of them in the book. Upper-body obesity, for instance, is one of the big risk factors.
The patients, when they come to us, they are not aware that they stop breathing. They are only aware of the consequences -- fatigue, tiredness, etc.
It has to do with the control of the muscles of the upper airway, with the distribution of fatty tissue around the neck and it is more prevalent in men than women.
One treatment for sleep apnea is CPAP -- continuous positive air pressure. It is [a device] that pushes air through the nostrils in order to keep the airway open. The problem is that compliance is 50 percent.
The other treatments are surgery -- uvula-palatal pharyngoplasty, a laser removal of the uvula -- and a dental device that pushes the lower jaw forward leaving a space at the back of the throat for air.
JJ: What are the warning symptoms to look for?
PL: One high-risk population is children. The second high-risk population is the obese. So the obese, as young as possible, must be studied and treated. The third group is people who develop hypertension at 23-35 for no particular reason.
JJ: Is snoring always an indication?
PL: If you are continuously snoring, you don't have sleep apnea. Snoring of a sleep apnea patient is intermittent. The wife usually describes that her husband stops snoring for 30 seconds and she kicks him to see if he's still alive. This is sleep apnea.
JJ: What's next for you?
PL: We are working now on mortality. One of the findings is if you're past the age of 60 and you have sleep apnea, you don't have any risk of dying. I'm following patients who are 89 years old with 60 apneas per hour who don't have any risk of dying [from sleep apnea].
JJ: What's the difference?
PL: This is what we're studying. What is the mechanism that allows certain individuals to live with this? We believe there are mechanisms that allow some individuals to overcome the cardiovascular results of sleep apnea.
The other issue is what happens when you start treatment at the age of 30, not with CPAP but with lipid-lowering drugs, antioxidants and vitamins.
We're trying to understand the molecular mechanism that translates the change in oxygen to arteriosclerosis. We started working on it seven years ago and we've made huge progress.
JJ: Can you foresee a drug treatment?
PL: Oh, yes. I would recommend to any sleep apnea patient to be on a lipid-lowering drug even if his lipid profile is within normal levels. We've found lipid peroxidation in sleep apnea patients free of any cardiovascular disease, which is the backbone of the arteriosclerotic process. Free radicals attack the lipids, so if there are more lipids, there's more substance to attack. It's an inflammatory process. These molecules form clots, and when a clot comes to the coronary artery [and blocks blood flow] you have a heart attack.
Once you understand the process, you know how to intervene. So one of the conclusions we've come to is lower your lipids as much as possible.