184. Dr. Sahil Chopra & Sagar Chopra: Why Your Sleep Apnea Machine Might Be Lying to You

Millions of people wear a CPAP machine every night, the standard breathing device prescribed for sleep apnea. They trust the number on the screen to tell them their sleep apnea is under control. I've had patients tell me they stopped using theirs because it felt pointless, and it turns out that feeling was often correct. We dive deeper into this in this episode of Extend with Dr. Sahil Chopra and Sagar Chopra, co-founders of Empower Sleep. We also chat about why palate shape and mouth breathing are driving more sleep apnea in kids, how GLP-1 medications are changing the CPAP conversation, and the truth about lip taping. Dr. Sahil Chopra is a pulmonary, critical care, and sleep medicine physician trained at UCLA and Loma Linda, with fellowship training in sleep medicine at Harvard. He is co-founder of Empower Sleep, a longitudinal home sleep testing platform used by physicians and patients nationwide. Sagar Chopra holds an MBA from the Wharton School, previously worked on product growth at Uber, and co-founded Empower Sleep alongside his brother, Dr. Sahil Chopra. What We Discuss: (8:04) The Landmark Study: 25,000 Nights of Data and the CPAP Discordance Problem (13:43) Inside the Empower Sleep Device and How It Differs From Wearables (25:27) Palate Shape, Mouth Breathing, and the Rise of Pediatric Sleep Apnea (30:31) Menopause, Andropause, and Why Sleep Apnea Shows Up Later in Life (41:53) Hypoglossal Nerve Stimulators and Central Sleep Apnea (47:27) How GLP-1 Medications Are Changing Sleep Apnea Treatment (51:13) The Truth About Lip Taping and Nasal Breathing Thank You to Our Sponsors: Next Health Longevity Summit: Head to next-health.com/summit https://www.next-health.com/summit to secure your spot at the first ever Next Health Longevity Summit in Nashville on 9/12. Momentous: Head to livemomentous.com/fiber http://livemomentous.com/fiber and use code DRSHAH for up to 35% off your first order. Learn more about Dr. Shah: Website: drshah.com/ https://www.drshah.com/ Clinic: next-health.com/ https://www.next-health.com/ Instagram: @darshanshahmd https://www.instagram.com/darshanshahmd/ Learn more about Dr. Sahil Chopra and Sagar Chopra: Empower Sleep: empowersleep.com/ https://empowersleep.com/ Sagar Chopra on LinkedIn: choprasagar/ https://www.linkedin.com/in/choprasagar/ Sagar Chopra on X: schopsss https://x.com/schopsss More Resources: Quality sleep is the most underestimated longevity accelerator. Download this sleep optimization workbook to transform sleep into a powerful longevity practice: drshah.com/sleep https://www.drshah.com/sleep

Speaker names marked ? are inferred from speaking time and the show’s known hosts — they are not voice-verified.

• 0:00Dr. Darshan Shah?

  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 12th, 2026. This is an all-day summit where you're going to be hearing from some of the best speakers in longevity's 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 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

• 0:39Dr. Darshan Shah?

  they're going quickly. That's next-health.com/summit. I look forward to seeing you all there.

• 0:48Dr. Darshan Shah?

  Welcome to Extend with me, Dr. Darshan Shah, a podcast dedicated to cutting-edge science, research, tools, and protocols designed to help you extend your health span. Having become 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.

• 1:34Dr. Darshan Shah?

  Welcome to Extend, 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

• 2:15Dr. Darshan Shah?

  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.

• 2:38Dr. Darshan Shah?

  Sahil and Sagar, thanks so much for joining me today on Extend. I'm so finally happy to have you guys here.

• 2:44Speaker 01

  So nice to be here. Thanks for having us.

• 2:45Dr. Darshan Shah?

  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 fashion, 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?

• 3:18Speaker 02

  And I'm thrilled to be here, man.

• 3:19Dr. Darshan Shah?

  Yeah, so good to have you guys. Okay, so anyone watching this on YouTube, we got to cover this first. They're probably looking at this like, are they related or something? So just tell us the story real quick. How did you guys get together on this?

• 3:30Speaker 01

  We've known each other for a long time. Sahil and I are brothers. So we've obviously known each other for a long, long time. And you want to go through the origin story?

• 3:39Speaker 02

  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, pulm care at Loma Linda. Loma Linda, by the way, is a blue zone. So like, I think that's where the seed of wellness and longevity was kind of planted. 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, right?

• 4:23Dr. Darshan Shah?

  Exactly.

• 4:25Speaker 02

  But when you're like at Stanford, or Harvard, or any of these big university centers, they look at sleep as a system. Like, 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.

• 5:00Dr. Darshan Shah?

  Right.

• 5:00Speaker 02

  And so I wheeled this guy in.

• 5:04Dr. Darshan Shah?

  Your brother.

• 5:06Speaker 02

  He was doing his MBA at Wharton, but I'll let you share your story.

• 5:11Speaker 01

  Yeah, yeah. I come from more of a tech background. So what's actually funny is, growing up, Sahil and I would always talk about entrepreneurship. And I remember, you know, these kids are like teenagers, be like, man, one day we're going to like start a hospital together. Just something like, we'd 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. I was pre-med for a few years in undergrad, but decided to eventually go down the tech path. And so I was at Uber, focused on product growth and expansion, launching new countries across the world, and also just had a very personal

• 5:56Speaker 01

  tie to healthcare. I mean, Sahil and I grew up, our father was chronically sick. He passed away when I was 18, Sahil 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. And so that was always, for me at least, it was always there. And after that, I 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, we'll hang out for like a weekend, come with me. And I was like, yeah, sure, let's do it. And I remember coming out of that weekend, just

• 6:37Speaker 01

  kind of thinking, like, wow, I can't believe more people are not talking about this. And I'd 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.

• 7:11Dr. Darshan Shah?

  I love it.

• 7:11Speaker 01

  And I jokingly said, I'm like, Sahil, you just roped me into this thing.

• 7:15Speaker 02

  First I told him, don't go into medicine, and then I looped him into like, everything that we're doing.

• 7:21Dr. Darshan Shah?

  Obviously 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 like 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

• 8:05Dr. Darshan Shah?

  just an anatomical problem created in your throat area as you age, or if you are overweight, or there's many, we'll 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 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.

• 8:29Speaker 02

  You know, there's been 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, 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 for that person as an N of one. And when you start to look at sleep and circadian science that way, it's like this massive unlock of like entering a new dimension. And you just see like, wow,

• 9:13Speaker 02

  there's like, there is so much work to be done here.

• 9:15Dr. Darshan Shah?

  Right, absolutely. Yeah, and I think expanding the definition of sleep to really be circadian science is also critical, right?

• 9:22Speaker 02

  Totally.

• 9:23Dr. Darshan Shah?

  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?

• 9:37Speaker 02

  A hundred percent.

• 9:38Dr. Darshan Shah?

  So, 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 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.

• 10:04Speaker 02

  Yeah, so let me, I'll take a step back 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.

• 10:46Speaker 02

  We use subjective symptoms and say, hey, Darshan, like, how do you feel? While you use your CPAP machine. So what we did was all of our patients.

• 10:55Speaker 01

  Which, can I just say, that's crazy that we do that. It's like, imagine you give someone metformin and then you never measure their glucose again. That's basically what's happening.

• 11:06Speaker 02

  Yeah, that's basically a hundred percent. And it's wild, right? Like, it's like you do an intervention and then you never measure, like, did this work or not?

• 11:14Dr. Darshan Shah?

  Right.

• 11:15Speaker 02

  And.

• 11:16Dr. Darshan Shah?

  And how many people are on CPAP machines in the United States, for example?

• 11:19Speaker 02

  Like, three to five million.

• 11:20Dr. Darshan Shah?

  Yeah, 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?

• 11:35Speaker 02

  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 10 pauses in breathing per hour and someone might say, no, you're fine.

• 12:20Speaker 02

  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, there's a lot of people out there who think that their sleep apnea is well controlled based on the data from the CPAP machine, but they still have significant, 88% of them have still significant disease.

• 12:41Dr. Darshan Shah?

  So these people are going, 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?

• 12:51Speaker 02

  They might be getting some.

• 12:52Dr. Darshan Shah?

  Yep.

• 12:53Speaker 02

  But there might be, and you know, we talk about optimization.

• 12:55Dr. Darshan Shah?

  Yeah.

• 12:56Speaker 02

  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, 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.

• 13:20Dr. Darshan Shah?

  Right.

• 13:21Speaker 02

  We're just asking, how do you feel?

• 13:23Dr. Darshan Shah?

  Exactly.

• 13:24Speaker 01

  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's 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?

• 13:53Dr. Darshan Shah?

  Yeah.

• 13:53Speaker 01

  Right? And 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.

• 14:00Dr. Darshan Shah?

  Yeah, I think, you know, a lot of my patients, and this explains it perfectly. They have, they get the CPAP when we discovered they have sleep apnea. And then they, I talked to them, maybe a couple of months later, they're like, I don't use it anymore. 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, 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. Correct. Because that is not the correct data.

• 14:38Speaker 02

  That's not the place of truth.

• 14:39Dr. Darshan Shah?

  Right.

• 14:40Speaker 02

  And, 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.

• 14:55Dr. Darshan Shah?

  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 to wear, right?

• 15:17Speaker 01

  The Darth Vader mask.

• 15:18Dr. Darshan Shah?

  Yeah, exactly. So, 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 a, about the size of a, of a football championship ring there.

• 15:34Speaker 02

  Yeah.

• 15:35Dr. Darshan Shah?

  And you just wear it on your index finger like that?

• 15:37Speaker 01

  Yeah, you wear it on any finger that's comfortable. And one thing that actually clarifies, you know, this, 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.

• 15:47Dr. Darshan Shah?

  Sure.

• 15:48Speaker 01

  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.

• 16:02Dr. Darshan Shah?

  Right.

• 16:02Speaker 01

  And they're caring.

• 16:03Dr. Darshan Shah?

  And how is this device different from like an Oura ring measuring your sleep?

• 16:07Speaker 01

  So there's a couple of things. It's sampling data at a much higher frequency.

• 16:12Dr. Darshan Shah?

  Right.

• 16:12Speaker 01

  Right? So because of that, if you wanted to look at the number of apnic events that are occurring every hour, it's going to be able to, to do that with a higher level, level of accuracy.

• 16:21Dr. Darshan Shah?

  Sure.

• 16:21Speaker 01

  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, you know, 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, right? So if you look at an Oura, 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, what's driving that? Is it the breathing? Is it circadian timing? Is it fragmentation at night?

• 17:04Speaker 01

  But with this, you kind of get about like 25 to 30 different biomarkers.

• 17:09Dr. Darshan Shah?

  That's amazing.

• 17:10Speaker 01

  Around sleep.

• 17:11Dr. Darshan Shah?

  And so when you say higher sampling frequency, what you're saying is that this is measuring your apnic events, meaning when your oxygen level drops more frequently throughout the night, right?

• 17:22Speaker 02

  Correct. And it's called the PPG sensor, the photoplethysmography sensor.

• 17:27Dr. Darshan Shah?

  Right.

• 17:27Speaker 02

  And like for any of us who have ever like 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.

• 17:39Dr. Darshan Shah?

  Right.

• 17:39Speaker 02

  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 apnic event that is a pause in breathing of 10 seconds or less, 10 seconds or more.

• 17:59Dr. Darshan Shah?

  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?

• 18:08Speaker 02

  Yeah, more frequently, like, so like, for example, if anyone uses a, like a wearable ring or a ultrium, and you'll see like when you're sleeping, the light that's on the inside, it goes from green to red.

• 18:20Dr. Darshan Shah?

  Ah, it does, okay.

• 18:21Speaker 02

  So like, yeah, so you'll, when it changes to red, it's using more battery and it's sampling data at a higher frequency.

• 18:27Dr. Darshan Shah?

  Ah, okay.

• 18:28Speaker 02

  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.

• 18:54Dr. Darshan Shah?

  Got it. And is the home wearable devices, is that not a PPG sensor? Is that a different sensor?

• 19:00Speaker 02

  It is a PPG sensor, it's a similar sensor, just like the sampling frequency is much lower. Sorry, much more spread apart.

• 19:06Dr. Darshan Shah?

  Right.

• 19:07Speaker 02

  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.

• 19:15Dr. Darshan Shah?

  Got it, got it.

• 19:16Speaker 01

  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.

• 19:26Dr. Darshan Shah?

  Oh, you do.

• 19:27Speaker 01

  So Oura, Garmin, Eight Sleep, Apple Watch, Whoop. 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, like 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? It's really powerful to know what's happening during the day.

• 19:57Dr. Darshan Shah?

  That makes total sense.

• 19:59Speaker 01

  Typically, it's not even like using one device over another, but combined is way more powerful than just using one of them.

• 20:06Dr. Darshan Shah?

  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 Next Health 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, 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.

• 20:50Dr. Darshan Shah?

  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.

• 20:56Speaker 01

  Yeah, and unfortunately they're called home sleep apnea tests, which is a pretty bad name. We need to change that.

• 21:02Speaker 02

  Yeah, no, totally. You can understand sleep health in a fundamentally different way. Is there 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 of days ago, referred from a colleague who's also a patient. There's been her, 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.

• 21:43Dr. Darshan Shah?

  Yeah.

• 21:43Speaker 02

  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 onto a lower dose of Lexapro.

• 22:05Dr. Darshan Shah?

  Yeah.

• 22:06Speaker 02

  Improve her sleep habits, like she can have a more physiologic sleep architecture. And that's what we talk about a lot, like, and you guys do this too, right? Like, the, the goal is not to give a drug or do a solution. The goal is to restore physiology as best as we can.

• 22:20Dr. Darshan Shah?

  Sure.

• 22:20Speaker 02

  And that's where this whole optimization idea comes in. And the same thing is true from like a sleep medicine standpoint. Like, how do we restore your housekeeping process?

• 22:31Dr. Darshan Shah?

  Yeah.

• 22:32Speaker 02

  To a more physiologic level with any kind of like data that we can understand about your sleep.

• 22:38Dr. Darshan Shah?

  Right, right. I think it's really important because I think one of the most misunderstood things about sleep is the seven, eight hour rule, right?

• 22:45Speaker 02

  Yeah.

• 22:46Dr. Darshan Shah?

  Yeah, and everyone thinks that as long as I'm getting seven, eight hours, that's probably good sleep. But it's, you don't know, right?

• 22:52Speaker 02

  You don't know.

• 22:52Dr. Darshan Shah?

  Right? So what else can be going on? Like this is, this is one example, just getting one session of REM sleep.

• 23:00Speaker 02

  Totally, 100%. And there could be a lot of circadian rhythm dysfunction. I mean, we do these things called, uh, office hours with physicians who are doing a trial and they're testing Empower 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, 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.

• 23:45Speaker 02

  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 micro arousals 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?

• 24:24Speaker 02

  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.

• 24:36Dr. Darshan Shah?

  Yeah.

• 24:36Speaker 02

  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.

• 24:44Dr. Darshan Shah?

  Wow.

• 24:45Speaker 02

  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.

• 24:57Dr. Darshan Shah?

  Like a knee jerk reaction.

• 24:58Speaker 02

  Knee jerk reaction.

• 24:59Dr. Darshan Shah?

  Yeah.

• 25:00Speaker 02

  And then, then they feel tired during the day. And then they're on a stimulant like methylphenidate, modafinil, something during, so it can be like this really vicious cycle and.

• 25:10Speaker 01

  Which is kind of crazy within the pediatric population as well. Where you think about like the underlying driver of, whether it's like ADD, ADHD.

• 25:17Dr. Darshan Shah?

  There's so many more kids being put on medication now for ADD, right?

• 25:21Speaker 01

  Like it's a sleep dysfunction at the end of the day that could be causing it.

• 25:24Speaker 02

  And there, and there's enough evidence to support that.

• 25:27Dr. Darshan Shah?

  Yeah.

• 25:27Speaker 02

  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 craniofacial like abnormalities. And they might 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.

• 25:52Dr. Darshan Shah?

  A lot of, a lot of my clients that I've, they talk 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 and 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.

• 26:14Speaker 01

  Check that 100%. And they're so easy to do now.

• 26:16Dr. Darshan Shah?

  Yeah, they're so easy to do. You just like order the ring and you can get a sleep study and a 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. Palate 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.

• 26:39Speaker 02

  Yeah, phenomenal.

• 26:40Dr. Darshan Shah?

  Yeah, phenomenal book. It goes over the history of our palate shrinking over the last few generations.

• 26:45Speaker 01

  All the societal changes and soft food diets and all that, it's fascinating.

• 26:49Dr. Darshan Shah?

  And now this palate expansion actually has a treatment that can 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. And especially for kids, right? Cause kids, kids, they don't do CPAP.

• 27:08Speaker 02

  No, my kids are in expanders. I'm like, I openly share.

• 27:11Dr. Darshan Shah?

  Oh, they are, yeah, yeah.

• 27:12Speaker 02

  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, uh, jetting of the mandibles in front of the, the upper teeth. And so they have underdeveloped jaws.

• 27:33Dr. Darshan Shah?

  Yeah.

• 27:33Speaker 02

  There's this maxillary mandibular complex is smaller than what it should be. And like expansion, like instead of like tooth extraction.

• 27:42Dr. Darshan Shah?

  Right.

• 27:43Speaker 02

  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.

• 27:54Dr. Darshan Shah?

  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.

• 28:29Speaker 02

  Growing into this.

• 28:30Dr. Darshan Shah?

  Growing into this, right?

• 28:31Speaker 02

  Yeah, and I think like for the audience who's, who's listening, like the way to, to, to think of this is, if you imagine like a triangle, like the roof of the mouth is the floor of the nasal cavity.

• 28:44Dr. Darshan Shah?

  Right.

• 28:44Speaker 02

  Right? So if the mouth is smaller, then guess what happens to the, the roof of the mouth? It becomes higher arched.

• 28:52Dr. Darshan Shah?

  Right.

• 28:52Speaker 02

  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.

• 29:31Speaker 02

  The nose nasal cavity is small, the back of the pharynx is constricted. So you have like this sort of uh 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're kind of stuck with these like narrow passages.

• 30:01Dr. Darshan Shah?

  Yeah.

• 30:01Speaker 01

  And then also with like thirty to forty percent of people who have any form of sleep apnea will then end up having some form of insomnia.

• 30:09Dr. Darshan Shah?

  Right.

• 30:09Speaker 01

  Because they create these like poor associations around.

• 30:11Dr. Darshan Shah?

  Right.

• 30:12Speaker 01

  Their sleep because they're just not breathing well during the night. And that becomes like a whole can of worms as well.

• 30:18Speaker 02

  Totally. And then and then if like that, if someone's housekeeping process is impaired.

• 30:24Dr. Darshan Shah?

  Yeah.

• 30:24Speaker 02

  One of my mentors used to use this metaphor, like you're, you can get like the newest iPhone.

• 30:28Dr. Darshan Shah?

  Uh huh.

• 30:29Speaker 02

  But if it's not charged properly, like dude, good luck, man. It's like, what's the, what's the point? Right? It's like, I'd rather have like an old iPhone that's properly charged than like a new iPhone. That's improperly charged and doesn't work, doesn't work well.

• 30:41Dr. Darshan Shah?

  Right.

• 30:42Speaker 02

  And so then if our physiology at night is impaired and broken, then hypertension, atrial fibrillation, cognitive decline, uh 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.

• 31:05Dr. Darshan Shah?

  Yeah, yeah, absolutely. It's makes it a lot harder to treat those. And actually, it might be that the poor sleep and the sleep apnea is 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 forties, mid forty age group. Why, why does that happen?

• 31:36Speaker 02

  There's a couple of things, um particularly in menopause for, for, for women. The, there's this thing called the uh arousal threshold.

• 31:47Dr. Darshan Shah?

  Uh huh.

• 31:48Speaker 02

  So, so if we, 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.

• 31:55Dr. Darshan Shah?

  Sure.

• 31:55Speaker 02

  Uh, heart failure comes in heart failure with reduced ejection fraction, heart failure with preserved. You have similarly like sleep apnea comes in a lot of flavors.

• 32:03Dr. Darshan Shah?

  Really? Okay.

• 32:04Speaker 02

  Yeah, in terms of like different pathologic mechanisms.

• 32:07Dr. Darshan Shah?

  Uh huh.

• 32:08Speaker 02

  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 have, 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.

• 32:38Dr. Darshan Shah?

  Yep.

• 32:38Speaker 02

  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.

• 32:52Dr. Darshan Shah?

  Okay.

• 32:53Speaker 02

  Okay. So if breathing is unstable, then the likelihood of developing some degree of sleep apnea or sleep disorder breathing is higher.

• 33:01Dr. Darshan Shah?

  Hmm.

• 33:02Speaker 02

  The other thing that happens is people gain weight. So one is like the physiology of sleep is changing.

• 33:07Dr. Darshan Shah?

  Uh huh.

• 33:07Speaker 02

  Second, our body composition is changing.

• 33:11Dr. Darshan Shah?

  Right.

• 33:11Speaker 02

  That results in more potential weight in the upper airway.

• 33:16Dr. Darshan Shah?

  Yep.

• 33:17Speaker 02

  The third reason is like the, 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.

• 33:28Dr. Darshan Shah?

  Okay.

• 33:28Speaker 02

  Like a weak muscle, like you've probably heard of this thing called myofunctional therapy.

• 33:32Dr. Darshan Shah?

  Yep.

• 33:33Speaker 02

  It's like physical therapy for your tongue.

• 33:34Dr. Darshan Shah?

  Yeah.

• 33:35Speaker 02

  Right? Uh, physical therapy for, for the upper airway.

• 33:37Dr. Darshan Shah?

  Uh huh.

• 33:38Speaker 02

  So like if the muscles are getting weaker, and that's why it's, it's useful because it's, it's targeting this idea of muscle responsiveness.

• 33:44Dr. Darshan Shah?

  Right.

• 33:45Speaker 02

  So if the muscles are weaker, the, the sleep is more fragile. And on top of that, um 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 uh many of these uh, 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.

• 34:13Dr. Darshan Shah?

  Yep.

• 34:14Speaker 02

  Of like a whole bunch of things happening and sleep apnea just happens to be one of them.

• 34:18Dr. Darshan Shah?

  Yeah, makes sense.

• 34:22Dr. Darshan Shah?

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• 35:05Dr. Darshan Shah?

  And you'll get up to thirty five percent off your first order using the code Dr. Shaw.

• 35:14Dr. Darshan Shah?

  Can you talk about the muscle therapy for your tongue? How, how does that work?

• 35:18Speaker 02

  So uh, it's called oral facial myofunctional therapy.

• 35:21Dr. Darshan Shah?

  Hmm.

• 35:22Speaker 02

  And you know, the tongue, I've heard this metaphor, uh, which makes a lot of sense. The, the tongue is like the natural retainer for the mouth.

• 35:32Dr. Darshan Shah?

  Okay.

• 35:33Speaker 02

  Okay. And, and uh, James talks about this, I, I think in, in the book too, where like where the teeth are placed is partially related to how much X, how much muscle, how much pressure is on the outside and how much muscle is on the, 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 up power, farther outside laterally and forward. There will be better growth versus if the cheeks are very strong and the tongue is weak.

• 36:04Dr. Darshan Shah?

  Oh.

• 36:05Speaker 02

  So, okay, and the tongue being the natural retainer of the mouth also then shapes the hard palate. So this idea of oral facial 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 oral facial myofunctional therapy, they also become better nose breathers.

• 36:50Speaker 02

  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 oral facial 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.

• 37:08Dr. Darshan Shah?

  Yeah. There's a whole trend on TikTok and on Instagram, you've probably seen it called looks maxing. Have you seen this trend?

• 37:14Speaker 02

  No, I haven't seen this.

• 37:15Dr. Darshan Shah?

  It's just kids um in early teen years doing oral functional therapy. And they're trying to expand their palate, just look better, you know?

• 37:24Speaker 01

  Chiseled jaws.

• 37:26Dr. Darshan Shah?

  Yeah, yeah, get chiseled jaws and um and expand their palates.

• 37:29Speaker 01

  Yeah.

• 37:29Dr. Darshan Shah?

  Right?

• 37:30Speaker 02

  Is that, that's different from mewing? I've heard of this idea of mewing.

• 37:33Dr. Darshan Shah?

  Yeah, exactly. Yeah, yeah, exactly.

• 37:35Speaker 01

  There's also, um, I'm forgetting the name of the instrument, but there's an instrument, there's been studies on this.

• 37:39Speaker 02

  Didgeridoo.

• 37:40Speaker 01

  Didgeridoo.

• 37:40Dr. Darshan Shah?

  The didgeridoo, yeah. What's the study on that?

• 37:43Speaker 02

  Yeah, so the didgeridoo, people who played the didgeridoo have a lower incidence of sleep apnea and people who 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.

• 38:06Dr. Darshan Shah?

  Oh, okay.

• 38:06Speaker 02

  Okay. And uh, there's actually a straw too.

• 38:10Dr. Darshan Shah?

  Yeah.

• 38:10Speaker 02

  Uh, I have no affiliation with them. We prescribe them to our, we, we give them to our patients, but it's, 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?

• 38:25Dr. Darshan Shah?

  Yeah.

• 38:25Speaker 02

  Doing these kinds of exercises, but in the process of drinking water.

• 38:28Dr. Darshan Shah?

  Oh, okay.

• 38:28Speaker 02

  So like, uh, 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.

• 38:46Dr. Darshan Shah?

  Yeah.

• 38:47Speaker 02

  And like strong upper airway. 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.

• 38:56Dr. Darshan Shah?

  Yeah. So you have to work out your upper airway muscles like you're working out at the gym, right? And uh, 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?

• 39:12Speaker 02

  Yeah. So it depends on the age. Again, I'm not an expert at this. See your local uh, ortho or dentist, you know, who, who does these things. But the sort of in, in, in, in the pediatric population. The bones are much more like malleable.

• 39:27Dr. Darshan Shah?

  Malleable, yeah.

• 39:28Speaker 02

  There's this 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, 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 eighteen, twenty, twenty one.

• 40:00Dr. Darshan Shah?

  And my sutures, 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.

• 40:12Speaker 02

  Yeah.

• 40:12Dr. Darshan Shah?

  When you're an embryo, that, well, they develop throughout embryo and then they, when you grow up, they fuse in the middle, right?

• 40:18Speaker 02

  Yeah, thank you for clarifying that.

• 40:20Dr. Darshan Shah?

  Yeah, yeah. And so, and you know, 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?

• 40:29Speaker 02

  Yeah.

• 40:29Dr. Darshan Shah?

  And so we would actually bring those together and fuse them for the kid. And I'm thinking adults, you can actually do a little surgery, open up that fusion. So you can expand the palate, right?

• 40:40Speaker 02

  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 like forms, that 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 are a couple of screws that go into the heart palate, so you have some anchor. And then you can expand with like, turning a screw.

• 41:02Dr. Darshan Shah?

  Turning a screw, right.

• 41:03Speaker 02

  To, for lateral expansion. And then there are also very relatively minimally invasive double jaw surgeries that can bring the maxilla, the upper cheek bone, the upper jawbone and the lower jawbone forward. So there's a lot of different solutions available now. And then 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.

• 41:28Dr. Darshan Shah?

  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.

• 41:47Speaker 02

  Yeah.

• 41:47Dr. Darshan Shah?

  Prominent now because of these other more minimally invasive procedures that you can do.

• 41:53Speaker 02

  Yeah. You think of it as changing the, the structural architecture versus changing the soft tissue.

• 42:01Dr. Darshan Shah?

  Right.

• 42:01Speaker 02

  Right? The soft tissue, if it's like, it'll come back to some extent.

• 42:05Dr. Darshan Shah?

  Yeah.

• 42:06Speaker 02

  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 these, it's very nuanced. I, I'm not an expert at this by any means, but, but like these surgical options are becoming more and more promising, less and less invasive.

• 42:29Dr. Darshan Shah?

  Right.

• 42:30Speaker 02

  And in the right solution and the right person is what this like precision medicine really comes down to.

• 42:35Dr. Darshan Shah?

  Yeah, I think in, in surgery, everything is getting more and more precise. I mean, before, all they did was just remove all the tissues.

• 42:41Speaker 02

  Yeah.

• 42:42Dr. Darshan Shah?

  And then they, 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, 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? Could you talk about those a little bit?

• 43:13Speaker 02

  Yeah, there's a, so there's, you know, there's two kinds of sleep apneas, obstructive and central. There's a hypoglossal nerve stimulator.

• 43:20Dr. Darshan Shah?

  Right.

• 43:21Speaker 02

  It's like a pacemaker that sits inside your chest. It, it 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.

• 43:39Dr. Darshan Shah?

  Uh huh.

• 43:39Speaker 02

  So it's like, it's sensing when you, when you breathe, it'll push your tongue out of the way.

• 43:47Dr. Darshan Shah?

  Right.

• 43:47Speaker 02

  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 frontic nerve is what talks to the diaphragm. And it can stimulate the diaphragm to breathe if you forget to breathe. So there, there's a whole bunch of unique solutions available and, but again, these are not like first line, you know?

• 44:12Dr. Darshan Shah?

  Out of all of the sleep apneas, what percent are central sleep apnea? What percent of people have central sleep apnea?

• 44:18Speaker 02

  If you're at altitude.

• 44:20Dr. Darshan Shah?

  Yep.

• 44:20Speaker 02

  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 five to 10%.

• 44:30Dr. Darshan Shah?

  Oh, so it's actually not, not as low as I thought, right?

• 44:33Speaker 02

  No, it's actually, but if you think of it as like a spectrum.

• 44:36Dr. Darshan Shah?

  Right.

• 44:36Speaker 02

  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%.

• 44:49Dr. Darshan Shah?

  Hmm, interesting. And for the audience, central sleep apnea, like you said, is, is coming more from the brain. It's your brain does this automatically normally, it tells your body to breathe when you're sleeping. But sometimes there's disorders that occur that system is broken and 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, there's a lot. And how can you differentiate between central sleep apnea and obstructive and anatomical sleep apnea using a device like this? Or do you need additional tests?

• 45:19Speaker 02

  No, it can be super helpful. There's a very unique signature of central sleep apnea. And so central sleep apnea is, 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.

• 45:42Dr. Darshan Shah?

  Hmm.

• 45:42Speaker 02

  Uh, because our autonomic nervous system behaves a very particular way. So that signature is like embedded and then most sleep physicians should be able to pick that up.

• 45:51Dr. Darshan Shah?

  I love that.

• 45:52Speaker 02

  Um, 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.

• 46:06Dr. Darshan Shah?

  Okay.

• 46:06Speaker 02

  It's like a head and neck CT scan that is looking at the sort of volumetric size of the upper airway.

• 46:14Dr. Darshan Shah?

  Hmm.

• 46:14Speaker 02

  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.

• 46:22Dr. Darshan Shah?

  Thank you.

• 46:25Speaker 02

  You know, good arches and on the surface, everything looks beautiful.

• 46:27Speaker 01

  Thershen's been looked maxed.

• 46:28Speaker 02

  Yeah. But you, you don't know until you.

• 46:32Dr. Darshan Shah?

  No one's called me beautiful in a very long time. I appreciate that.

• 46:36Speaker 02

  But you don't know until you look, you know?

• 46:38Dr. Darshan Shah?

  Absolutely.

• 46:39Speaker 02

  So it's, when you look, then you can see the anatomy in a whole, in a fundamentally different way.

• 46:44Dr. Darshan Shah?

  I, I, 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, should, if you're getting evaluated for sleep apnea, should you be asking for this?

• 46:59Speaker 02

  I think it's, it's reasonable. So there, there are some nuances to this, particularly around, it's an awake exam.

• 47:07Dr. Darshan Shah?

  Yeah.

• 47:08Speaker 02

  While you are upright.

• 47:10Dr. Darshan Shah?

  Oh, so you have to go into a special CT scan?

• 47:12Speaker 02

  Yeah, so it's like an upright CT. A lot of dental offices may have it.

• 47:16Dr. Darshan Shah?

  Yeah.

• 47:17Speaker 02

  And so it's like, it's, it, 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.

• 47:27Dr. Darshan Shah?

  Yeah.

• 47:28Speaker 02

  You know, it's not, it's not a diagnostic tool because it's just like, it's not a diagnosis, it's not a tool to diagnose sleep apnea. It's a tool to assess like the anatomical risk of having sleep apnea.

• 47:38Speaker 01

  It's still probably helpful if you're putting someone through appliances.

• 47:40Speaker 02

  Yeah.

• 47:40Speaker 01

  To measure like.

• 47:41Dr. Darshan Shah?

  Yeah.

• 47:42Speaker 01

  As.

• 47:42Speaker 02

  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 hydrop, like, how bad is a septum in between the two nasal cavities?

• 47:56Dr. Darshan Shah?

  Uh huh.

• 47:57Speaker 02

  Or these turbinate that live in the nose? And so there's, there's a lot of like anatomical information that can be gathered. And I think it's, it's extremely formative.

• 48:06Dr. Darshan Shah?

  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 GLP-1s, right? And so talk about that a little bit. How is GLP-1s like Ozempic and Terzepatide, how's that changed sleep apnea?

• 48:26Speaker 02

  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 Terzepatide in a very large patient population. And there was a massive reduction. And they took people who were obese.

• 49:07Speaker 02

  So like, you know, the obese, over, like someone who is extremely overweight on GLP-1s, a massive reduction in the overall burden of apnea. And I personally have had patients who no longer have sleep apnea.

• 49:22Speaker 02

  And have been liberated from CPAP.

• 49:24Dr. Darshan Shah?

  Wow.

• 49:25Speaker 02

  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 GLP ones can be a game changer.

• 49:41Speaker 01

  And also change 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 GLP one and your sleep is under control, that treatment will be much more efficacious. Compared to you just going through GLP ones alone without having your sleep apnea managed.

• 50:12Dr. Darshan Shah?

  Right.

• 50:13Speaker 01

  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.

• 50:24Dr. Darshan Shah?

  Yeah.

• 50:25Speaker 02

  And and if it's not a complete liberation saga, it's a as we think of it as a bridge, maybe it's a bridge to like a dental appliance.

• 50:33Dr. Darshan Shah?

  Yeah.

• 50:34Speaker 02

  Right?

• 50:34Speaker 01

  Or lip taping.

• 50:35Speaker 02

  Or it's a bridge to myofunctional therapy. It's a bridge to maybe expansion. Like before, they weren't a candidate.

• 50:40Dr. Darshan Shah?

  Yeah.

• 50:40Speaker 02

  For like, like expansion.

• 50:42Dr. Darshan Shah?

  Right.

• 50:42Speaker 02

  And now it's a bridge to like, now I have, I went from severe hypoxic obstructive sleep apnea to now mild apnea. 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.

• 51:03Dr. Darshan Shah?

  Right.

• 51:03Speaker 02

  Then through this like sort of acute, here's a CPAP lifelong solution and and you know, good luck.

• 51:11Dr. Darshan Shah?

  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.

• 51:17Speaker 02

  Yeah.

• 51:18Dr. Darshan Shah?

  And it does not have to be, right? Especially if, you know, the physician's prescribing CPAP also at the same time. If the person's overweight significantly, talk about GLP ones and and reducing the weight, right? And when you're sleeping better, it's much easier to lose weight.

• 51:33Speaker 02

  Totally, totally.

• 51:34Dr. Darshan Shah?

  Exponentially.

• 51:35Speaker 01

  It'll be more motivated, like it's more energy, 100%.

• 51:39Dr. Darshan Shah?

  Exactly. More energy to exercise, more energy to, yeah, and you're big better food choices when you're sleep well, too.

• 51:45Speaker 01

  Yeah.

• 51:45Dr. Darshan Shah?

  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.

• 51:51Speaker 02

  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, right? Like, I think that's worth noting. Like, if I create the sound of snoring.

• 52:19Dr. Darshan Shah?

  Yeah.

• 52:19Speaker 02

  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.

• 52:29Dr. Darshan Shah?

  Your nose, right?

• 52:30Speaker 02

  With my mouth closed, it's it's it's it's there's much more active effort that goes into this, right?

• 52:35Dr. Darshan Shah?

  It's hard, yeah.

• 52:36Speaker 02

  It's much harder. So it's it's a similar idea. And when when the mouth is closed, the tongue is like 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 to just breathe through your nose.

• 53:03Dr. Darshan Shah?

  Breathe through your nose.

• 53:03Speaker 02

  Okay. And like, whether it's a chin strap or lip tape, like they're all like achieving the same physiologic like mechanism, like, you know, the the mechanism is, I think, where it's worth like.

• 53:14Dr. Darshan Shah?

  Do people need to be careful lip taping? Like, is there some dangers to it?

• 53:17Speaker 02

  So what I was gonna say is like, if someone has like severe obstructive sleep apnea, lip taping should not be done in isolation.

• 53:23Dr. Darshan Shah?

  Right.

• 53:23Speaker 02

  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 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.

• 53:51Dr. Darshan Shah?

  Oh, what's in it?

• 53:52Speaker 02

  That has a this nasal strips.

• 53:54Dr. Darshan Shah?

  Nasal strips, right?

• 53:55Speaker 02

  You've probably seen these things on TikTok, like the intake ones and then.

• 53:58Dr. Darshan Shah?

  Oh, yeah, like Hormozzi wears one all the time.

• 54:00Speaker 02

  Yeah, exactly.

• 54:01Dr. Darshan Shah?

  Same one, same idea.

• 54:03Speaker 02

  Like it has nasal strips, external, an internal one called mute. It has this straw that helps them do myofunctional therapy.

• 54:11Dr. Darshan Shah?

  Right.

• 54:11Speaker 02

  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.

• 54:17Dr. Darshan Shah?

  Yeah.

• 54:17Speaker 02

  Because I think that can be dangerous in someone who is not.

• 54:21Dr. Darshan Shah?

  Right.

• 54:22Speaker 02

  Is not a primary nasal breather.

• 54:25Dr. Darshan Shah?

  Right.

• 54:26Speaker 02

  Uh, we use one called, uh, it's just like European company called Myo. Myo Tape, yeah.

• 54:31Dr. Darshan Shah?

  Yeah.

• 54:32Speaker 02

  And it has a, it it 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.

• 54:41Dr. Darshan Shah?

  Right.

• 54:41Speaker 02

  It like cinches everything from the side.

• 54:43Dr. Darshan Shah?

  Got it.

• 54:44Speaker 02

  And it just makes it that opening the mouth is now an active effort.

• 54:48Dr. Darshan Shah?

  Right.

• 54:48Speaker 02

  Versus like a, like this passively sort of chin dropping with atonia.

• 54:52Dr. Darshan Shah?

  Sure, sure. I've also seen a mouth tape that is just like a small square that you put just in between.

• 54:57Speaker 02

  Yeah.

• 54:57Dr. Darshan Shah?

  Because that way you can still open your mouth if you need to.

• 55:00Speaker 02

  You need, you need like some safety.

• 55:02Dr. Darshan Shah?

  Escape valve, right, exactly.

• 55:04Speaker 01

  But I think this is where having this like longitudinal data is so important.

• 55:07Dr. Darshan Shah?

  Yes.

• 55:07Speaker 01

  Because if you're just experimenting in the blind, it's not, it's not going to be helpful.

• 55:10Dr. Darshan Shah?

  Not helpful, right?

• 55:11Speaker 01

  And there's been so many situations actually where like someone has sleep apnea, mild, moderate. They 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.

• 55:37Dr. Darshan Shah?

  Exactly. And that's where Empower Sleep really makes a huge difference, is a huge leap forward, is you're not just stopping with the diagnosis. You're continuing the monitoring, trying different things. I'm a big fan of N of one, you know, it's like it's very analogous to continuous glucose monitor, right?

• 55:52Speaker 02

  Yeah.

• 55:52Dr. Darshan Shah?

  You don't just measure your glucose one time, say it's high, and then start throwing, you know, different techniques up against the wall.

• 55:58Speaker 02

  Yeah.

• 55:58Dr. Darshan Shah?

  If you wear a continuous glucose monitor, you can see what foods are calling your, 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.

• 56:21Speaker 01

  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.

• 56:42Dr. Darshan Shah?

  Right, right.

• 56:43Speaker 01

  Because right now what happens is like the the the industry of sleep, it's like, okay, I have my wearable. And then there's like a thousand different things I can do.

• 56:51Dr. Darshan Shah?

  Yeah.

• 56:51Speaker 01

  Right? Everything from vitamins to medications to medical devices to lip taping. And people are just lost.

• 56:57Dr. Darshan Shah?

  Yeah.

• 56:58Speaker 01

  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 with with a much higher level of confidence.

• 57:07Dr. Darshan Shah?

  Yeah, that's so critical. So you're taking all the data from different people, seeing what works for different types of sleep architecture.

• 57:14Speaker 02

  Yeah.

• 57:14Dr. Darshan Shah?

  And then saying, for your data set.

• 57:16Speaker 01

  Yeah.

• 57:17Dr. Darshan Shah?

  This is what's worked for most people and go right to that. So people can reduce the time to finding the right solution.

• 57:24Speaker 01

  Exactly.

• 57:24Dr. Darshan Shah?

  Right?

• 57:25Speaker 01

  Yeah.

• 57:25Dr. Darshan Shah?

  Oh, that's that's a huge, that's a huge advancement, I think, in the in the field.

• 57:30Speaker 02

  It's redefining the endotypes is what they're called.

• 57:33Dr. Darshan Shah?

  Right. The endotypes of sleep.

• 57:35Speaker 02

  Endotypes of like the different sleep disorders that exist.

• 57:37Dr. Darshan Shah?

  So what are the different endotypes of sleep?

• 57:40Speaker 02

  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 and I have a couple of drinks. That's a very different, and it's mild, right? That that 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 have, they're traveling. Twice, thrice a month between LA and New York. So even though like the label might be the same and 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 like looking

• 58:25Speaker 02

  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 in 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.

• 58:52Dr. Darshan Shah?

  Yeah, let's let the data kind of cluster, right? And create the endotypes.

• 58:55Speaker 01

  Exactly. And what's interesting too is I think with the technology that's available today is you could almost run these like many, 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 so like, I remember like Sahil would say this, he's like, you know, it'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

• 59:40Speaker 01

  apnea who has very fragmented sleep to begin with. 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.

• 59:56Dr. Darshan Shah?

  Yeah, that'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 just changing so rapidly.

• 1:00:41Dr. Darshan Shah?

  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.

• 1:00:50Speaker 02

  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 love working there. 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.

• 1:01:34Speaker 02

  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.

• 1:02:01Dr. Darshan Shah?

  Right. To get him outside.

• 1:02:03Speaker 02

  To get him outside that weekend. But do we made it happen? We made it happen. He wanted a Modelo. 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 Sagar, 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.

• 1:02:31Dr. Darshan Shah?

  Yeah.

• 1:02:31Speaker 02

  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?

• 1:02:37Dr. Darshan Shah?

  Right.

• 1:02:38Speaker 02

  Like, what is like the reason that he can't go outside?

• 1:02:41Dr. Darshan Shah?

  Yeah.

• 1:02:42Speaker 02

  Oh, because like there's no oxygen. Okay. Like let's get a freaking, let's get an oxygen tank. 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 completely different.

• 1:02:53Dr. Darshan Shah?

  You're solution oriented. Right.

• 1:02:54Speaker 02

  It's totally solution oriented. And, and I think, and 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?

• 1:03:10Speaker 01

  And it's kind of been a principle for us, right? It's like, let's think about this from a physiology first approach.

• 1:03:16Dr. Darshan Shah?

  Yes.

• 1:03:16Speaker 01

  And remove any sort of administrative constraints, right? So who cares about like what insurance will pay for? They're not going to pay for multi-night testing. Like it doesn't matter, but what physiologically makes sense to do? Let's think about it from the ground up. And I think that this allows you to think very differently about healthcare.

• 1:03:35Dr. Darshan Shah?

  It really does. Yeah. It's a, it's fantastic job you guys are doing. I really appreciate you joining us on the podcast today. And I know people want to 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?

• 1:03:54Speaker 01

  Yeah, you can 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.

• 1:04:03Dr. Darshan Shah?

  Yeah, we can refer you as well.

• 1:04:04Speaker 02

  Yeah, go to Next. You'll get better for your game. You'll get better pricing.

• 1:04:09Dr. Darshan Shah?

  That's true.

• 1:04:09Speaker 02

  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 bidirectional relationship with health and sleep. And you probably have seen this either personally or with patients, like when, 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.

• 1:04:46Dr. Darshan Shah?

  Absolutely.

• 1:04:47Speaker 02

  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.

• 1:05:05Dr. Darshan Shah?

  Absolutely. Yeah. We love working with you guys and look forward to a long relationship. And thank you guys so much.

• 1:05:12Speaker 02

  Thank you, man. Thanks.

• 1:05:16Dr. Darshan Shah?

  Thank you so much for listening to the podcast today. Please remember to subscribe if you liked 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.