Do you feel chronically tired, or get up in the morning and still feel not rested? Assuming that you’re trying to get your needed 8 hours of sleep, perhaps you have what doctors call obstructive sleep apnea. This is a relatively common issue especially in very overweight people, where a part of your throat gets closed off while sleeping, which can cause you to not breathe for a few seconds, followed by sudden awakening as your body reacts to the lack of oxygen. If your partner is telling you that you snore a lot and that you also seem to stop breathing and suddenly catch your breath, perhaps you have apnea and may need evaluation.

I saw an excellent review article in the Wall Street Journal’s Health section (Relief of Sleep Apnea can be found using CPAP devices, but compliance is low), which details the latest research and treatments. The diagnosis is best made with a sleep study, where you sleep overnight in a medical lab which hooks you up to a lot of monitors and measures your breathing patterns. If you clearly have apnea, the usual choice of treatment is some type of mask which delivers a small amount of oxygen into your throat, hopefully enough to keep the airway open and give you perfect sleep. Many patients find this treatment immediate and almost miraculous in giving them a normal life again, full of energy. But the masks themselves can be uncomfortable — and you always need to wear it each night. Fortunately, the technology is constantly improving.

What also helps? Surgery is a last-resort option, but there are easier methods:

Simple lifestyle changes can add to the benefits of other treatments. Sleeping while lying on the side, instead of the back, can prevent the airway from closing, some studies show. Losing weight can help, and so can stopping smoking, since smoking leads to inflammation and fluid retention in the airway. Sufferers also should avoid alcohol and sedatives, which can further relax the airway during sleep.

One interesting footnote was research showing how the aboriginal instrument, the didgeridoo, can actually help strengthen your vocal cords and throat muscles enough to really improve your apnea:

If all else fails, there is always the didgeridoo, an indigenous Australian musical instrument. In a study published in the British Medical Journal, 25 patients with sleep apnea who practiced playing it for about 30 minutes a day, six days a week for four months, significantly reduced the number of apneas they had during sleep; daytime sleepiness also decreased. Scientist believe the breathing technique required to play the didgeridoo strengthens the upper airway and makes it less likely to collapse.

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Using ear drops to remove impacted ear wax is better than no treatment, but no particular sort of drops can be recommended over any other. Impacted ear wax is one of the most common reasons that people visit their general practitioners (family doctors) with ear problems, as it can cause reduced hearing, discomfort, and sometimes pain and dizziness. Ear drops (either oil- or water-based) are often prescribed to clear the wax or to aid subsequent ear syringing if necessary. The review of trials found that ear drops (of any sort) can help to remove ear wax, but that water and saline drops appear to be as good as more costly commercial products. The quality of the trials was generally low, however, and more research is needed.

The Bottom Line?

You should certainly try some type of wax softener before coming to the doctor, who would probably prescribe something just as effective as an OTC product. For more information, you can read this patient handout from American Family Physician.

By the way, you should never routinely use cotton swabs to clean your ears! There’s no need at all to routinely clean your ear canal, as mother nature does it just fine. I see many patients who have outer ear infections, and most have a story of routinely cleaning their ears with something, usually Q-tips. Remember that earwax is normal and protective; daily messing around in your ear canal sets you up for infections as well as risks of puncturing your eardrum.

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A study in the current Otolaryngology, discussed in the New York Times (Vital Signs), had post-surgery children fill out a quality-of-life questionnaire; this group experienced “quality of life similar to that of normal-hearing peers”. That’s a wonderful result!

You can read more about this exciting technology from the U.S. National Instititute on Deafness and Other Communication Disorders.

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1. Asian Fruits & Vegetables: Which Are Healthier? - includes one of the most useful-to-daily-life PDFs I’ve ever seen from any government. Memorize it!
2. How To Prevent Heart Attacks & Strokes – even in China, heart disease is still the #1 killer. This slide show shows some basic lifestyle choices that can reduce your risks up to 80% — without medicine
3. Chinese Medicine and the Flu: I Say Tomato, You Say 西红柿 – part of a series of articles revolving around flu basics, but triggering insights on TCM and Western medicine
4. Fruits & Veggies: How Many Servings Do You Need? (And How Much Is A “Serving”, Anyway?) – again, more basics but how many actually know how much servings to eat? Now, you can find out in 20 seconds…
5. My Air Quality Journal: 太可怕！ - one of my many pollution posts; this one highlighted my really fun experiments with a handheld pollution monitor — and the many surprising conclusions…
6. Top Things Your Ayi Should Know - This one was very popular as well; it provides bilingual PDFs on food safety, hand washing, first aid…
7. Air Pollution: How Bad Is It, Really? – This article goes into detail about air pollution in China, as well as what we can all do about it
8. Do You Know Your Cardiovascular Age? – Again, heart disease is the #1 killer; with a bit of your medical records you can create a wonderfully informative graph of your 10-year risk of having a heart attack — as well as tips on what you can do to reduce that risk
9. Do You Know Your BMI? – obesity is a worldwide issue. One basic is your body mass index; do you know yours? Now you can find out…
10. Organics Quiz: Do You Know Your Labels? - There are a lot of round green stickers on Chinese foodstuff, and many do not mean organic; now you can navigate with knowledge.

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Well, this hasn’t been the most fun winter here, has it? Most snow in 50 years; coldest temperatures in 60 years; Avatar sold out again. Shall I go on? Yes, you have every reason to get the winter blues; many people are very prone to this. The western world even has a name for it: Seasonal Affective Disorder (SAD). Most people just feel blah, but others can get seriously depressed and need some help. Fortunately, there are many ways to fight this off.

The Wall Street Journal has a nice review of the latest and best treatments for the winter blues (Treatments for the Winter Blues or Seasonal Affective Disorder Now Exist). Some major approaches for mild symptoms are:

• Light therapy
• Dawn stimulation
• Vitamin D supplements
• Morning exercise/walk

I personally feel the morning walk, or at least morning exposure to sunlight via windows, helps a lot. Light therapy does have some evidence, but I’m not familiar with that treatment being offered in Beijing. And a good dose of vitamin D may help many other things besides your mood, including protecting your bones as well as possible benefits against cancer and heart disease.

What About Serious Depression?

I definitely see a lot more acute depression in the winter. Some people do need antidepression medicines, but there’s also an effective non-Rx method called cognitive behavioral therapy (CBT, for short). This is performed by a trained psychologist/psychiatrist, and with a few sessions of analyzing behavior and working on weeding out maladaptive thoughts and behavior, many people’s depression symptoms can be well controlled. This CBT treatment  is useful all-year round for all types of depression. Here at International Medical Clinic, our Dr Mike Mehrvarz is trained in CBT; other clinics usually also have trained staff.

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Those of you with high cholesterol will be happy to learn that there are some legitimate options to your statin pills. Many people cannot tolerate the extremely popular statin pills, especially from side effects of muscle aches. But there’s now some very strong evidence that herbal medicines, including red yeast rice, can be at least as effective as a statin, and without the side effects. Too good to be true? Maybe not…

Red yeast rice is a bright reddish purple fermented rice, which acquires its colour from being cultivated with the mold Monascus purpureus. Red yeast rice is known as Zhi Tai when in powdered form but is called Xue Zhi Kang in alcohol extract form. This has been used in China for many centuries for many reasons, but researchers have been very interested in its effectiveness in lowering cholesterol and preventing heart disease (similar benefits from statins). It seems that the main active ingredient is indeed the natural form of a common statin, lovastatin — but researchers feel that other ingredients inside may add more protective effects. There is an official patented Chinese TCM formulation, called Xue Zhi Kang (xue2 zhi1 kang2 jiao nang 血脂康 胶囊), which has the equivalent of 10mg of lovastatin. The ScienceDaily website has a nice 2008 review of a well-designed study, printed in American Journal of Cardiology, which followed 5,000 persons after their first heart attack, and divided them into two groups taking either xuezhikang or placebo. After 5 years:

Frequencies of the primary end point were 10.4% in the placebo group and 5.7% in the XZK-treated group, with absolute and relative decreases of 4.7% and 45%, respectively. Treatment with XZK also significantly decreased CV and total mortality by 30% and 33%, the need for coronary revascularization by 1/3, and lowered total and low-density lipoprotein cholesterol and triglycerides, but raised high-density lipoprotein cholesterol levels. In conclusion, long-term therapy with XZK significantly decreased the recurrence of coronary events and the occurrence of new CV events and deaths, improved lipoprotein regulation, and was safe and well tolerated.

This is impressive data, and the study design is very well done, which means the evidence is quite strong. One co-author, Dr Capuzzi, has a nice summary:

“It’s very exciting because this is a natural product and had very few adverse side effects including no abnormal blood changes,” said Capuzzi. “People in the Far East have been taking Chinese red yeast rice as food for thousands of years, but no one has ever studied it clinically in a double-blind manner with a purified product against a placebo group until now and we are pleased with the results. However, people in the United States should know that the commercially available over-the-counter supplement found in your average health food store is not what was studied here. Those over-the-counter supplements are not regulated, so exact amounts of active ingredient are unknown and their efficacy has not been studied yet.”

In another randomized trial study, printed last year in the Annals of Internal Medicine, patients who had previously failed treatment of statins due to side effects were given 1800mg of red yeast rice twice a day versus placebo. The red yeast rice group had a significant improvement in cholesterol numbers — with no major reports of severe muscle aches they previously had on the statins.

There are other studies that also show similar benefits. In fact, the evidence is so strong that it is classified as Grade A evidence: “Strong scientific evidence for use”. This is the highest grade that any therapy can get. There are a number of good reviews of red yeast rice in Western literature, including from Medscape; the Mayo Clinic; WebMD; MedlinePlus; and NCCAM. There’s also more informal information from the TCM blog Qi Spot. You can find more scholarly information in the 2008 review from Chinese Medical Journal.

The Bottom Line

I’m impressed enough by all this to start stocking it in my clinic’s pharmacy, and I will start to discuss this option with patients as well. The evidence for this herbal medicine is unusually strong, and this could become one of China’s more popular medicines around the world, as it seems to have similar cholesterol reducing properties as the statins — without those liver and muscle side effects. Please note that people already on statins and very happy with them should not add this medicine, as the active ingredient is about the same. But for those who couldn’t tolerate the statin side effects, or even those newly diagnosed with just slightly elevated cholesterol who want to avoid “prescription” medicines, you may want to consider discussing red yeast rice with your doctor.

But it’s also important to buy the proper Chinese version of xuezhikang, since there are reports of pills being doctored with actual statin medicines. The photo above shows the official patented Chinese version. There seem to be other patents in other countries, including Lipascor. In America, the pills Cholestin are pure red yeast rice.

What Else Works For Cholesterol?

There’s a nice summary of herbal medicines, including red yeast rice, from Natural Medicines Database. There’s also pretty good evidence for the omega-3 in fish oil; at least 1 gram a day of the supplement may help, independently of statin’s benefits. And the mineral niacin can also be extremely effective for certain people, although the flushing side effects can be severe when using the immediate release tablet, and dosing is tricky.

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The Wall Street Journal has a good article (Seeking Coffee’s Benefits to Health) from last week which reviews the latest medical literature on this. Coffee was in the news last year due to a couple large studies which showed a decrease in developing diabetes with increasing amounts of coffee drinking. Another study showed a long-term decrease in developing prostate cancer. These are interesting findings, but the amount of coffee needed per day was very high, from 2 to 6 cups a day. However, it seems that decaf had the same benefits! Which means that there must be some unknown molecules in the coffee bean, apart from the caffeine, which create the benefits.

But it’s not all good news; too much coffee can raise blood sugars in people already diabetic, and it can raise blood pressure and cause insomnia, among other common effects. I certainly wouldn’t recommend that people who don’t already drink coffee start drinking it based on these newer studies. I love to start my day with home-brewed coffee; maybe now I will be more inclined to have another cup later in the day – decaf, this time.

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We all sense that China’s current economic frenzy has led to many people — expats as well as locals — to work extremely long hours and face huge amounts of stress in their jobs. Well, it’s no secret that stress, poor sleep and poor diets can adversely affect your health, but a disturbing new report shows just how serious this is in China. The excellent website China Corporate Social Responsibility discusses a new report on this issue:

The survey report “The Health White Book of Chinese Urban White-collar Workers” — which was jointly published by the Chinese Medical Doctors Association, the Chinese Hospital Association, Beijing Health Insurance Association, and Ciming Checkup — shows that 80% of the white-collar workers surveyed have irregular sleeping or dining schedules and they feel fatigued during the day; 23.7% of them do not take the time to eat breakfast; over 20% of them often eat fast food; 54.4% of them lack sufficient sleep; and 32.4% of them do not get quality sleep; only 46% of them take even occasional exercise. In addition, over half of the white-collar workers often feel irritated, 20% feel lonely, and over 70% feel a lack of happiness and satisfaction.

Yikes! This doesn’t sound too healthy, long-term both for individuals as well as society. Hopefully, surveys such as this can foster a good societal debate as to just what we are sacrificing here, or at least motivate individuals to take their own initiatives. I personally feel that a big portion of the disease and mental health problems I see in my clinic is related to work-related stressors and lifestyle decisions. You can read the full ChinaCSR article here (New Survey: 76% Chinese Office Workers Sub-par – ChinaCSR.com – Corporate Social Responsibility (CSR) and Sustainability News for China.). This website also has a nice weekly free email newsletter that highlights the top stories of the week.

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The Data, Please

One of my favorite websites to review natural medicines is the U.S. National Institute of Health’s National Center for Complementary and Alternative Medicine. They have excellent, readable reviews of many herbs and therapies, as well as good referencing of relevant studies. They have one page dedicated to bladder infections and commonly used cranberry, as well as saw palmetto’s effectiveness in the male-centered problem of enlarged prostate.

The best studies to date show that regular intake of cranberry juice does have some effect on decreasing the recurrence of bladder infections in women that get them often, but a 2009 review by the Cochrane group found no great evidence that it helps decrease an acute infection. It’s possible that it does; it just didn’t find enough high-quality studies to prove either side.

As for saw palmetto helping men with prostate symptoms, Cochrane and other reviews do show some improvement in men’s symptoms, and the medicine is considered safe as well. But the overall endorsement still recommends further studies.

Bottom Line?

I think cranberry juice does little harm, and women who suffer from frequent bladder infections may benefit from a daily intake of cranberry after discussing with their doctor. As for men, I think there’s enough data to support saw palmetto as a safe alternative for those with minor symptoms, again as long as they’ve discussed it with their doctor and ruled out more serious causes of their symptoms.

Other Websites?

There is a lot of misinformation out there regarding alternative medicines, and it’s crucial to stick to the most honest sources. Besides the links above, another of my favorite websites for evidence-based natural medicine is the Natural Medicines Database. They have one page dedicated to bladder infections and another for prostate problems.

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…The human mind can store huge amounts of knowledge. Intuition is not simply belief; it springs from this knowledge. A doctor making an intuitive diagnosis is doing so on the basis of thousands of hours spent treating patients. The problem, however, is that the mind is not particularly good at sorting through this knowledge and weighing different parts appropriately. We give too much weight to information that confirms our suspicions or that is highly memorable…

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