An Integrative Approach to Sleep Disorders and Cardiovascular Health—Dr. Sherif Hassan—International Physician and Keynote Speaker

Richard Jacobs: This is Richard Jacobs with the Finding Genius podcast. My goal here is to find the exceptional people in their fields, not just to run in the middle of people that have been licensed, but the ones that really go above and beyond and what I call the geniuses of their field. So I have Dr. Sharif Hassan, I think he definitely qualifies. He’s an international physician from Washington DC with a focus on precision medicine means he incorporates integrative medicine with genomic mapping, a traditional as well as nutritional and lifestyle management. It’s geared to the individual patient. So he’s also a keynote speaker and we’re going to go into his approach to sleep medicine. So Sharif, thanks for coming.

Dr. Sherif Hassan: Thank you. Thank you for inviting me. Jacob.

Richard Jacobs: Yeah. Tell me about your work in sleep. What first got you interested in it?

Dr. Sherif Hassan: Well, actually I’m trained as a critical care physician from the UK. I used to work in a transplant unit up in Newcastle upon Tyne before I moved over to the US so I have been working in the intensive care unit managing patients pre and post-transplant, on ventilators. So I’m quite familiar with assisted respiration and once I came here to the US because of that I had an interest in working with sleep medicine as a sleep disorder.

Richard Jacobs: Okay. Well, what kind of sleep disorders particularly fascinates you?

Dr. Sherif Hassan: Actually the most common one is obstructive sleep apnea. So I go out of the studies in my office. But my interest goes beyond that. I meant I don’t stop at treating the patient with sleep apnea. And that’s it. It’s very important to follow up because sleep apnea and in specific and in general, sleep disorders affect the whole body. Especially when it comes to the cardiovascular system and the interest here and that cardiovascular disease is the most prevalent and yet the most preventable non-communicable disorders. So there is a lot of interaction here between the sleep or the brain and mind and the heart. So that is the main focus on my work and my interest in sleep medicine.

Richard Jacobs: So within the world of obstructive sleep apnea, some people are doing like airway evaluations to see in the shape and you know, the airway. I mean, you know, there are of course CPAP oral appliances. I mean, where are you finding your niche? What’re some of the new or unusual things you’re investigating within the world of sleep apnea?

Dr. Sherif Hassan: I’m very interested in following up of patients after they have the corrective measures with CPAP or BiPAP machines and dental appliance because so far it’s very poorly understood the outcomes after they get treated in the sense that if they regain the weight, what is going to be their morbidity or mortality ratio. It’s very poorly understood how much of hypertension are disorders of the blood pressure they would regain after treating sleep apnea. It has been established by studies that metanephrines and the metabolic products of adrenaline are still there in the urine after getting the patients the CPAP and BiPAP machine, especially if they get told, Oh, everything is fine. You have no problems now. And they ignore or this regard the symptoms coming on or peeping going again very slowly, especially with the snoring because what happens usually with very mild sleep disorders and the form of the wants that do not need sleep assisted the device like a C-PAP or so they get told all they got to open up their airway. They got to use some sort of expanders on the nose to open up. They’re near so that the grease properly, but indeed that snoring can progress to AHI if not properly diagnosed early on. They can think of the snoring as this being snore via snoring without other elements of sleep apnea while having the lower AHI.

Richard Jacobs: Oh, AHI is the apnea-hypopnea okay. So is snoring itself a hypopnea or snoring is just snoring? And what does a hypopnea versus an apnea?

Dr. Sherif Hassan: Hypopnea is just basically a lower threshold of breath which results in hypoxia and a drop of the oxygen passage to the blood.

Richard Jacobs: Okay. So hypopnea is just I guess restricted breathing and snoring. Is snoring a low-grade hypopnea does it cause that, you know, what’s the interface there?

Dr. Sherif Hassan: It can’t be associated with lower hypopnea and again it can’t be positional or non-positional.

Richard Jacobs: Oh, meaning if you sleep on your back, you snore, but on your side, you don’t.

Dr. Sherif Hassan: Yeah. Exactly.

Richard Jacobs: Well I have definitely positional apnea and snoring too, but yeah. Okay. So I know what you mean. Like for me, if I’m on my back, it’s bad if I’m on my side and sometimes, okay. Gotcha. So, all right. What are you trying to figure out then? Has anyone studied the progression of snoring? Like do you characterize the volume of the snore, the frequency of the snore, the roughness of the snore? Has anyone looked at that?

Dr. Sherif Hassan: To the best of my knowledge, no. What is being done recently is actually correlating sleep disorders, particularly sleep apnea for the harp and what happens there, especially now with the evolution of genomic medicine and how that is linked all together. It’s fascinating actually to have a deeper look into that.

Richard Jacobs: Okay. Well, let’s focus there. So what have you discovered so far? I mean, when you have apnea, obviously the heart is affected. What does the heart do? Does it accelerate, beat faster, trying to circulate blood to get oxygen? I mean, what does it do?

Dr. Sherif Hassan: Well, the very interesting thing is that it has been noted that there is a Kagan oscillation and the heart cells are like thin about 10% of the heart sheets oscillate and a time of day defendant pattern or a manner or depending on the week sleep cycle. And that affects the heart contractility. It’s, in turn, affects the blood pressure and the variability of the heart rate, especially during sleep, whereby people who’ve got the disturbed sleeping pattern, they tend to have a lesser dip and the blood pressure on the heart during sleep, which affects their mortality actually in the long term.

Richard Jacobs: Well, okay. So what happens to the heart? Does it contract harder during the apnea or after you’ve had apnea for a period of time? Does the heart change and does it contract harder normally or not as hard?

Dr. Sherif Hassan: Its contracts hard initially as a normal compensatory mechanism. But then the longer term, the hearth muscle hypertrophy, it’s becomes thickened and eventually, it results in the weakening of the heart muscle and heart failure.

Richard Jacobs: Oh, okay. So apnea at first will cause the heart to contract harder and that will pump up the heart muscle, will build it up and make hypertrophy and then hypertrophy why does that weaken the muscle? Isn’t hypertrophy a sign that the muscle has gotten stronger or just bigger. Does it change the morphology, the hardware, it’s harder to pump the blood for some reason because you have this fatter muscle.

Dr. Sherif Hassan: Yes, exactly. Here’s what happens. I meant that the muscles increase and the heart muscles increase in size and the number, but it outgrows the blood supply to it. That’s why it becomes weaker so you have an excess of non-functioning or properly functioning muscle cells.

Richard Jacobs: It’s interesting. I wonder how preferential the heart is to itself. You know, if it feels like it’s not getting enough blood, does the heart say, well, I’m number one, I wanted this blood. So maybe it pumps harder to try to get more blood to itself or does it seem to have any allegiance to itself or you know, is it just worked in concert with the rest of the body or is that like a, you know, a heart researcher question?

Dr. Sherif Hassan: Yeah, it has a preference to itself because remember when we’re sleeping, the whole body is resting except relatively for the heart muscle. I meant when you’re awake, your heart free to 70, but when you go to sleep it’s 55. But the skeletal muscles as an example hardly work there. So definitely the heart has a preference to bring blood supply and oxygen to itself. And it’s interesting that the heart muscle region array by a ratio or a percentage of about 0.5 to 5% for the year. And this is good news because it shows that to a large extent the pathological changes or the negative changes that happen there are reversible if we follow the proper treatment and lifestyle as well.

Richard Jacobs: What about the interplay between fat around the heart or through the heart and hypertrophy like people that have fat deposits in their hearts, does that increase hypertrophy? How does it interact with it and how does it interact with the heart function as well? Do you look at that?

Dr. Sherif Hassan: When we say hypertrophy, we mean the lean heart muscle itself, but the fat around that can be affected by other diseases among them as hypothyroidism as an example or amyloid disease, If you mean fatty degeneration of the muscle, that happens in very, very, very late stages of heart failure.

Richard Jacobs: Oh, so the people for the most part do not have fat deposits around their hearts. Their hearts are pretty lean or no?

Dr. Sherif Hassan: Yes. It doesn’t happen except in the very late stages of heart failure. For it to be observed macroscopically or on looking on it with the naked eye.

Richard Jacobs: Well the reason I was asking is if it could be observed, then maybe there would be an interplay, you know, people with apnea that I’ve fatty hearts or as people that have apnea that doesn’t have fatty hearts, but it sounds like it doesn’t correlate right now. So that’s fine.

Dr. Sherif Hassan: Yeah. The impressive correlation is actually about the weight changes that happen. Oh, in correlation with sleep apnea and cardiovascular changes is I’m in the incidence or prevalence of heart disease. Then the high blood pressure, coronary artery disease and peripheral vascular disease too. This is much more well established.

Richard Jacobs: So the heart regenerates a little bit each year, which is good. Again, apnea appears it causes hypertrophy and then the heart essentially starves itself in some part so it can’t contract as hard. So what happens then? What is the progression due to people?

Dr. Sherif Hassan: One, it doesn’t contract as hard and not able to supply the body systems. And that leads to upsetting the whole body systems. I meant there is an increase in sympathetic nervous activity. There is increase inflammation in the body. There is increased oxidative stress. There is metabolic dysfunction with more insulin resistance that is more hypercoagulability of the blog, more industrial damage, more atherosclerosis, more heart arrhythmias, and also the Southern or unexplained deaths.

Richard Jacobs: All right, so are you looking at it from an intervention standpoint or just an observational? Like this is what happens standpoint. What’s your end goal here?

Dr. Sherif Hassan: No, I’m looking at that from an observational point of view.

Richard Jacobs: Okay. But how would this inform you? I mean it’s one thing to say, all right, apnea is worse than we thought, let’s say, or here’s what it really does. But then what do you do with that? How do you make an intervention to help people more than they’re being helped right now?

Dr. Sherif Hassan: It is to influence the lifestyle in addition to treating the sleep disorder, whether it’s by dental device or a C-PAP or BiPAP machine and how the body form more nitric oxide. Because this is what gets the Vestus devices ILA to helps more with the oxygen delivery to all parts of the body system, especially that it is not a specific organ dependent chemical. It’s produced by all sorts of the body.

Richard Jacobs: Okay. So yeah, I mean to keep going. So what was the implication of that?

Dr. Sherif Hassan: The implications of that when you’re able to make the body for more nitric oxide, there is more vasodilation, more delivery of oxygen to every cell on the body, which helps to reverse a lot of the changes that happen with the apnea.

Richard Jacobs: So how about in training a little bit of nitrous oxide in the air supply of a C-PAP? Would that be beneficial, you think?

Dr. Sherif Hassan: I’m not aware of this being implemented or even possible. What I meant is to increase nitric oxide production by the sense of the body. well, I know

Richard Jacobs: Well, I know that. That’s been looked at quite a bit for athletes and for a lot of things are high blood pressure, but how would you do that or how does science already come? You know, there are supplements people take, but I don’t know if they’re effective. I mean, I know the nasal passages, it is a bit of nitrous oxide versus the mouth. So if you’re a nose breather, you may be better off than a mouth breather. But how would you get the body to produce more nitrous oxide

Dr. Sherif Hassan: By giving actually the essential substrate in the form of vegetables, things like celery, spinach, lettuce, there are antioxidants also that health like using vitamin C, E as well as glutathione and exercise itself. And the interesting thing is the role that the oral bacteria and the microbiome lay in because giving antibiotics or even using mouth wash on a regular basis affect nitric oxide production because you’re affecting the assimilation of nitric oxide in the cells from this basic nutrients.

Richard Jacobs: So, yeah. What kind of correlation has been observed with frequent mouthwash users or people that have a disease like a periodontal disease? I’m sure that changes the oral microbiome.

Dr. Sherif Hassan: Yeah, it has been shown actually that the people who have got dental disorders or use antibiotics or antimicrobials or repeated mouth wash or poor oral hygiene, that the nitric oxide production is less, especially that when they have sleep apnea or they’re using the CPAP machine, they mouth breathe already, so they are affecting their microbiome. They look like the nasal breathers whereby this is avoided altogether.

Richard Jacobs: So, and there have been studies on mouth breathers versus nose breathers. And how does their microbiome, their oral microbiome differ?

Dr. Sherif Hassan: The oral microbiome is different definitely between both groups in the sense that the oral microbiome and mouth breathers are unfavorable for the production of optimal amounts of nitric oxide.

Richard Jacobs: I see. That’s interesting. I wonder what happens to the nasal microbiome if you’re a mouth breather for a period of time, I mean, I guess you’re not a nasal breather because the nose is clogged, so I don’t know, maybe it goes from aerobic to anaerobic bacteria preferentially because you know, there’s no air going through there. I just wonder what happens. Have you seen any studies that look at the nasal microbiome?

Dr. Sherif Hassan: Actually there are some studies, but the data are not solid there exactly into what type of a relationship. But what is clear that there is a difference in that between nasal breathers and mouth breathers.

Richard Jacobs: Huh. So is your research, again, solely focused on the heart or it sounds like you’re of a lot of things going on, but what specific things are you trying to figure out right now through your work?

Dr. Sherif Hassan: Actually what I’m trying to do is come up with a program to optimize sleep and cardiovascular health in the sense that if we can make the regular individual sleep between seven and eight hours a day, that’s the proper amount of sleep to optimize not only their cardiovascular health but the hormones and the basic function of the body. Because when we sleep, there are certain hormones and certain chemicals that go out in our body as specific at specific times. So if we apply the principle of going early to sleep and waking up early, combining that with proper lifestyle changes, nutrition and exercise, I think we’re going to positively impact the individual patient’s health. Not only the sleep disorder, the patients but actually the regular apparently this is a free page.

Richard Jacobs: Okay. I mean for people that you know, they may be in the bed seven, eight hours, but there again, because of apnea, they’re, you know, the 7,8 hours or I mean completely fragmented. What can they do? I guess just get the typical treatments, right, the C-PAP or oral appliance and then try to get that seven or eight hour that they need and go from there. Or is there an order of things that you would suggest to people?

Dr. Sherif Hassan: Yeah, definitely. We’ve got to address the sleep disorder, whether it’s sleep apnea, whether it’s interrupted sleep disorders. If it is hypersomnia, if it’s idiopathic hypersomnia or because of something else, like finally being syndrome or what, but after you manage that with the proper follow-up, of course you would really need to address these other ancillary approaches.

Richard Jacobs: Okay, good. So what do you think is in store for the future of sleep science in the near term in the next few years? Any big changes coming or just a better understanding characterization?

Dr. Sherif Hassan: Yeah, I’m actually pretty interested in the overvaluation of home sleep studies and now you have the newer versions of the machine that turns sleep detail wildly, so it can be used for monitoring as well. Gathering up this data and incorporating it with machine learning protocols be the way of optimizing one’s health in the sense that you’re going to reuse the incidence of cardiovascular disease and other diseases as well. And using digital health applications like a chatbox. And so you’re able to educate the patient on demand.

Richard Jacobs: Okay. Educate him on demand. I mean, as they’re using a C-PAP for instance, or just in the beginning before they get into any intervention or when do you think would be the best time?

Dr. Sherif Hassan: The best time to use it of course during the day whereby you can deliver to the information about the disease, the sleep disorders, how it interacts with the different body systems and organs. Approaches just for them to improve their sleep hygiene, that eating habits control of other associated illnesses as well as the high blood pressure, cardiovascular disease, diabetes that happens there. In addition to associated illness, I meant something like as an example GERD or acid reflux. It’s not as straight forward in sleep order, but definitely, if they have that food denial is going to affect their sleep, resulting in an interrupted sleep pattern, which throws off their sleep cycle in the sense that they don’t have enough of deep sleep. Their sleep becomes interrupted. It’s more of a REM sleep, which is not sufficient for revitalize and rest the body. So it helps us to understand the patient as a whole, not only being restricted to sleep apnea or sleep disorders.

Richard Jacobs: Okay. Right. Well, very good. So Sherif what’s the best way for people to find out more and to observe your research and ask questions about it or at least learn, where should they go?

Dr. Sherif Hassan: Actually I’m working on a product that’s a digital health product under the name of Luana. The website’s name is Luanna.health. They can get in touch with me over there. What we’re doing regarding addressing the whole body health through looking at it through an integrative approach, especially when it comes to sleep because this is a chatbot application that is going to integrate with several sleep monitoring methods like the aura ring. And we’re going to gather the data there and provide the patient with an application that they can use not only to manage their sleep but their overall health and prevent the most prevalent and preventable disease, which was cardiovascular.

Richard Jacobs: Well, very good. Well, thank you for coming on the podcast. I appreciate it. And it’s just amazing all the factors that go into what apnea does and all the things to consider. So it’s good that you’re looking at these aspects of it. So thank you.

Dr. Sherif Hassan: You’re welcome. Thank you so much for inviting me. I appreciate it.