She is highly active, enjoys eatin g a healthy
diet, doesn’t smoke, and rarely drinks alcohol. She has a sedent ary job with
an 8- to 10-hour  day, but she walks between four and five kilom eters, works
out every day, and sleeps well for seven or eight hours every night. Despite
the care she gives to her health , Emma found herself struggling with PMS
symptoms that gradually became more and more dif ficult to cope with. Emma had been  taking an oral contraceptive since her late teens. In her
late twenties, she took a break  from her pill. After three years with no
hormonal contraceptives, she began to take a combined contraceptive pill. This was when her “hormonal rollercoaster” began. At first, Emma chalked
her PMS  symptoms of mood swings, fatigue, bloating, and brain fog down
to the particular pill she was prescribed. Her doctor switche d her to a
different combin ed pill. For the next three months, Emma’ s symptoms were
constant. She was bloated all the time, her mood was low, she had problems
with her digesti on, and her energy levels were “on the floor .” Despite her
regular exercise regime and healthy diet, she gained two kilos in body
weight. She was in a constant state of stress. After much research, Emma switched to a more localized contra ceptive,
opting to have an IUD inserted. The IUD is different from an oral
contraceptive in that the release of hormones is much more direct so that the
hormones are not constantly circulating in the bloodstream. Next, she
prioritized her well-being to combat the debilitating PMS symptoms she
had been experiencing. Synthetic hormones were still being released into
her body , even with the IUD, so she wanted to do everything she could to
support her health while her system adapted to the new contraceptive.In the following months, she did several things that significantly
improved her condition:
• She began taking daily supplements of diindolylmethane (DIM), magnesium, and a
vitamin B complex. DIM is a natural supplement found in vegetables including kale,
broccoli, and cabbage. It helps the body metabolize estrogen. Emma learned that
hormonal contraceptives deplete the body of key nutrients such as B vitamins10—
something she wished her doctor had told her . • She made the switch to nasal breathing. While Emma was not a habitual mouth
breather , she did always breathe through her mouth during exercise. She worked to
ensure that she breathed only through her nose, even on a 100-km cycle. This left
her feeling much calmer during exercise and throughout the rest of the day . • She began practicing breath holds and long, slow breaths. Emma never considered
herself a fast breather , but each month, around the same time she experienced PMS
symptoms, she noticed that her breath felt shallow . She would struggle to take a full,
deep inhalation, almost as though her body was not capable of getting the oxygen it
required. By becoming aware of her breath, she felt better able to control it. She now
uses breath holds to reset her system to get suf ficient oxygen into her body . • Emma began practicing meditation. She found that stopping for 15 to 20 minutes a
day to “reset and reenter” had a profound ef fect on her PMS symptoms and on her
daily life. Her PMS lows became much easier to deal with, and she felt better able to
pull herself out of the “PMS hole” she found herself in on a monthly basis. Her
concentration became sharper , and she began experiencing the best sleep she had
ever had. Emma had always been told that PMS is normal, that symptoms
including fatigue , brain fog, bloating, and low moods are par for the course,
and that she should “deal with it and take a painkiller .” She was shocked to
realize that nobody had ever explained why she experienced these
symptoms, what was happening  in her body to make her feel this way. Now
she understands that her feelings of breathlessness are largely caused by the
drop in CO 2 during the premenstrual phase of her cycle. Emma’ s PMS has not completely disappeared, but every month her
symptoms are less severe and more manageable. She has lost the extra two
kilos she was carrying, she no longer has dramatic mood swings or brain
fog, and her bloating is much less extreme. Her quality of life has improved
because, in her words, she has much less of a battle to fight each month. For wom en who suffer from PMS, the connection to hyperventilation is
big news. It means that many symptoms previously believed to be hormonal
and unavoidable are actually the result of a hormone-driven change inbreathing pattern s. That is something that can be addressed with breathing
exercises and by moderating blood sensitivity to CO 2. If you suffer from PMS, keep an eye on your breathing. If your BOL T
score decreases,  your breathing gets faster , or you experience air hunger ,
then practice breath holds, begin  light, slow, and deep breathin g, and work
to restore full-time nasal breathing. That should help relieve your
symptoms. HOW PREGNANCY AFFECTS BREA THING
It makes sense that breathing would change during pregnancy . After all, you
are now breathing for two. Oxygen demand is higher due to a 15% increase
in metabolic rate and a 20% increase in oxygen consumption.11 The space
within the abdominal cavity , where the diaphragm rises and falls, becomes
incrementally smaller as pregnancy progresses. The increase in sex
hormones in the system leads to a significantly higher incidence of
hyperventilation,12 Early on, there is a rise in minute ventilation of around
40% to 50%,11 levels of blood CO2 drop, and the ventilatory responses to
hypoxia and hypercapnia increase13. The changes in pregnancy that lead to hyperventilation are believed to
be caused by a heightened response to blood CO2. There is a close
relationship between blood sensitivity to CO2 and the relative ratio of the
hormones, progesterone, and estrogen. As well as maintaining pregnancy ,14
progesterone acts as a respiratory stimulant in men and women . Levels of
the hormone increase around 100-fold during pregnancy .15
Sex hormones are instrumental in respiratory changes during pregnancy . Even back in 1979, researchers reported that the respiratory response to
pregnancy was “largely mediated by the action of proges terone and,
perhaps to a lesser extent, estrogens, at least in the first and second
trimesters.”16 Estrogen, which increases around 80-fold during pregnancy ,
is known to improve the functioning of progesterone receptors.13 The 1979
paper stated that breathlessness during pregnancy is likely to be caused by
hormones, but at that time, the relationship between hormones , functionalrespiratory change, and the development of symptoms was not clearly
defined.16
More recent work has demonst rated that hyperventilation at rest, even
during the first trimester of pregnancy , is linked to an increase in ventilation
with no change in respiratory rate.17,18 It is now understood that
hyperventilation during pregnancy is caused by alterations to the blood
acid-base balance, cerebral blood flow, metabolism, variations in sleep
patterns, and changes in the central chemoreflex drive to breathe, triggered
by the increased concentration of sex hormones.12
There are, of course, mechanical factors to consider too. For instance, as
the size of the fetus and therefore the uterus increases, there is progressively
less room for the breathing muscles. During the second half of the
pregnancy , residual lung volume decreases by as much as 22% and
respiratory resistance becomes greater . The diaphragm is displaced upward
by abou t five centimeters, increasing its ability to generate tension as
muscle fibers lengthen.19 The diaphragm may have to work harder as load
increases, but widening of the chest prevents further loss of lung volume.20
The gradual extension of the abdominal muscles causes their fibers to
lengthen by up to 115%, their thickness reduces, and their angle of function
changes. This inhibits their ability to stabilize the pelvis—which may be a
factor in back pain during pregnancy .19. Around 70% of healthy pregnant women report breathlessness during
their daily activities. This often begins during the first trimester , suggesting
that mechanical changes to the diaphragm and lungs are not to blame. It is
more likely that breathlessness is caused either by hyperventilation
associated with pregnancy or by a heightened perception of respiratory
discomfort as the result of increased ventilation. Not surprisingly , the incidence of sleep-disordered breathing increases
among pregnant women. The physiological and anatomic al changes
intrinsic to gestation can unma sk or exacerbate obstructive sleep apnea
(OSA).21 If this is left untreated, the limitations in upper airway flow can
lead to serious consequences for both maternal and fetal health. While not
the focus here, it should be noted that, generally in the realm of respiratory
disorders, uncontrolled maternal asthma has been found to be associated
with an increased risk of spontaneous abortion.22Healthcare providers should screen expectant mothers for OSA to
ensure the well-being of both mother and baby . This is especiall y important
in preeclampsia, a primary cause of maternal and fetal illness and mortality ,
which sleep-diso rdered breathing has been proven to increase the risk and
severity of. It is believed that the repetitive limitations to airflow that occur
during sleep-disordered breathing are linked to surges in nocturnal blood
pressure and poor health in both mother and baby—and may be just as
damaging as full apneas.21
One 2016 paper about OSA during pregnancy describes sleep apnea as a
modern epidemic.23 It is now accepted that the condition is widespread in
women, particu larly during pregnancy . According to curren t evidence,
sleep-disordered breathing is present in 50% of high-risk pregnancies and in
15% of otherwise healthy , obese  pregnant women. It should be no surprise
that pregnancy contributes to sleep disorders. By its nature, it causes
anatomical, physiological, and hormonal changes, including narrowing of
the uppe r respir atory tract, which can increase the risk of OSA or worsen
existing apneas.24
During pregnancy , OSA contributes to a five-fold increase in maternal
mortality due to complications including pulmonary embolism23 (a
blockage of an artery in the lungs). A 15-year study of matern al deaths in
Michigan found a connection with OSA and sleep-disordered breathing and
demonstrated that, even after the birth, OSA presents a risk for women.25
Maternal OSA has also been linked to poor fetal outcomes, fetal growth
restriction,23 low birth weight,26 preterm delivery ,23 cesarea n sectio n, and
preeclampsia.27,28 It has been connected to a low Apgar score in babies in
the five minutes after delivery .24 The Apgar score is a generalized measure
of health  that assesses appearance (skin color), pulse (heart rate), grimace
response (reflexes), activity (muscle tone), and respiration (breathing rate
and effort).29 A 2012 study set out to determine whether poor pregnancy
outcomes were related to OSA. It concluded that babies are at an increased
risk of complications in the areas previously listed when the mother has
sleep apnea. This can impact the health of the child long term.24
Children born significantly preterm commonly suffer from medical
problems and growth restrictions in early childhood.30 They frequently have
lower weight, height, and head circumference than their classmates. Thepreterm children were much more likely than normal term children to have
serious dental malocclusions, and deep bite and overjet were also
prevalent.30 According to pediatric dentist Dr. Kevin Boyd, restricted fetal
growth can cause problems that will result in suboptimal airway  health once
the baby is born. In Chapter Eight , we discussed how dental problems and
compromised airways in children can lead to childhood mouth breathing,
and subsequent cognitive, developmental, and behavioral issues. When fetal development is poor due to frequent drops in blood oxygen,
as can be the case for mothers with OSA, the baby may have cognitive
problems that progress into child hood and may not receive appro priate care. A 2020 review confirmed that children with restricted inter-uterine growth
and small birth weight had significantly lower cognitive scores than those
born at an average gestational age.31 While these children had similar
cognitive scores to those born preterm, they were unlikely to receive the
follow-on care or to be included in the rehabilitation programs that are
available to preterm babies.31
Another review explored the role of placenta health in chronic  disease
later in adulthood.32 Much research has demonstrated how low birth weight
contributes to the onset of certai n diseases, including obesity , heart disease,
stroke, and diabetes. Chronic hypoxia and elevated stress levels, both
symptomatic of sleep apnea, cause changes to the organs of the unborn
baby . The review cites a study of 187 men and 47 women that found that
sudden cardiac death was linked  to a thin placenta at birth. Fetal  growth and
lifelong health can be strongly  influenced by the health of the placenta,
which requires continual adequate oxygenation through healthy breathing
during pregnancy . ANXIETY DURING PREGNANCY AND AFTER
Anxiety in new mothers is common. As a woman takes on a new role and
new responsibilities, it could be considered an appropriate adaptive
response.33 However , some mothers suf fer with severe, invalidating anxiety ,
depression, and other mood disorders in the period shortly before and after
the birth of their child. Hormone fluctuations can play a part, as can
psychological issues—perceived  or real challenges and fear— which mayincrease in the case of an unexpected or unwanted pregnancy ,33 or when
assisted reproductive technology has been used.34
It is now genera lly acknowledg ed that new mothers are vulnerable to
postpartum depression, but the prevalence of anxiety disorders during
pregnancy has not been as wide ly studied. Many women experience new or
worsening anxie ty symptoms in the months before and after birth: 21% of
women have clinically significa nt anxiety during pregnancy , and 64% of
these women continue to suffer with anxiety after giving birth.33 Research
suggests that prenatal anxiety is a major factor in susceptibility to postnatal
depression. Untreated anxiety and depression, which often exist
comorbidly , can have a serious impact on the mother and baby .33 Anxiety
during pregnancy can contri bute to numerous problems , including
preeclampsia, more time off work, nausea, increased visits to healthcare
providers, spontaneous early labor and delivery , low birth weight, difficulty
breastfeeding, and a more difficult birth with an increased likelihood of
PTSD. Pregnancy-related or postpartum anxiety can produce feelings of
constant worry , fatigue, nervousness, insomnia, mood swings, poor focus or
memory , hot flashes, nausea , and sleep disturbance. At its worst,
postpartum anxiety inhibits the mother ’s ability to care for her child,
causing conside rable distress and resulting in a sickly infant or even
infanticide. There isn’t much information about generalized anxiety in pregnant
women and new mothers, although it is believed that anxiety is more
prevalent in postpartum women than in the general population. In one study ,
between 10% and 50% of new mothers with anxiety also displayed
symptoms of depression.35 In another , 65% with generalized anxiety also
reported depres sion, panic disorder , or agoraphobia. It is believed that
generalized anxiety lasting more than six months may be more common in
postnatal women33 and that anxiety in new mothers is actually more
common than depression.35 It can be challenging to achieve a clear
diagnosis of anxiety during pregnancy because it is normal for women to
experience a certain level of worry at this time.36 Also, there is no data
about preexisting anxiety disord ers in women before becoming pregnant, so
it is impossible to ascertain to what extent anxiety is pregnancy related.Generalized anxiety disorder during pregnancy can present as
nervousness, fatigue, difficulty concentrating, persistent “worry” thoughts,
muscle tension, and sleep distur bance. Due to the physiological changes of
pregnancy , especially hormone-induced hyperventilation, pregnant women
may be at greater risk for panic disorder . While there is research suggesting
that pregnancy may provide some kind of protection against panic
symptoms, the role of premenstrual hormone changes in panic disorder
suggests that fluctuations in sex hormones make new mothers more
vulnerable to anxiety and panic disorder .36 One review has confirmed this
increased susceptibility ,37 and some researchers hypothesize that this may
be due to the sharp drop in progesterone after delivery .37
During pregnancy , progesterone levels are high. This supports the
pregnancy , but it also causes hyperventilation and a reduction in blood CO2. After the baby is born, progesterone drops and CO2 rises, triggering panic
symptoms. Too much blood CO2 can cause panic attacks in patients who
have a high sensitivity to blood CO2, as the increase  in air hunger triggers
feelings of fear.38 Conversely , panic symptoms  can be triggered by
hyperventilation when blood CO2 drops to levels that are too low. The
important thing to understand is that by improving functional breathing
patterns, it is possible to normalize levels of blood CO2 so that they are
neither too high nor too low. It is also possible to reduce the body’ s
sensitivity to CO2 so that normal fluctuations do not cause panic-inducing
air hunger . Panic symptoms include breathlessness, hyperventilation, chest pain, a
sense of choking or nausea, dizziness, and paresthesia (numbness and
sensations like pins-and-needles). All of these are also symptoms of
breathing pattern disorders. The symptoms of panic attacks point to a correlation with poor
oxygenation and sympathetic activation. Cognitive function abruptly
declines, feelings of exhaustion occur , the patient becomes increasingly
anxious to prevent further attacks, and quality of life suffers. In pregnant
women and new mothers, the anxiety around future attacks can become
severe enough to cause agoraphobia and social isolation.33 There is also
evidence that anxiety in the mother during pregnancy impac ts on infanttemperament, producing babies who are more “difficult,” exacerbating
maternal anxiety and stress.34
During and immediately after pregnancy , women are also more
vulnerable to experiencing other mental disorders such as OCD and PTSD. Left untreated, these problems can have a significant impact on the physical
and mental health of mother and child and other family members.33 For the
most successful results, resear chers recommend an integrate d treatment
approach in which medicines are prescribed alongside psycho educational
options, such as relaxation exercises and cognitive behavioral therapy . There is no research into the therapeutic benefit of breathing exercises for
postpartum anxiety and depression, but a considerable body of research
does clearly indicate the link between blood CO2, sensitiv ity to CO2, and
these psychological disorders. While a few studies discuss the hormonal implications of abortion and
miscarriage, there is nothing  in the literature to connect hormonal
fluctuations in abortive pregna ncy to respiratory health. In women who
suffer very early pregnancy loss, the luteal phase is shorter for the next few
cycles.39 Early pregnancy loss is also associated with lower levels of luteal
estrogen and progesterone. Heightened anxiety , depression, and insomnia
are, not surprisin gly, common after miscarriage. This is partly due to stress
and to fluctuati ons in sex hormones. A breathing practice would help
moderate hormone-induced hyperventilation during this difficult time,40
regulating important factors that influence sleep and mood. Important: The breathing exercises in this book should not be
practiced if you are in your first trimester of pregnanc y. Practice
relaxation and work to gently  restore nose breathing. In your second
trimester , you may practice gentle relaxation, nasal breathing, and slow
breathing. Throu ghout your pregnancy , it is very important to approach any
exercises very gently . You should not practice any breath holds while
pregnant. HORMONAL CONTRACEPTIVES AND THE BREA TH
Progestogens and estrogens combined in oral contraceptive pills have been
in widespread use since the 1960s. While much publicity has been given tothe potential side effects in terms of cardiovascular health, little research
has been done into the ef fects on breathing and the respiratory system.41
One 1979 study did find that women taking a progesterone-o nly oral
contraceptive pill had a significa ntly greater minute ventilation than women
ovulating normally , except when the control subjects were in the late luteal
phase of their cycle.16 This added weight to the idea that progesterone acts
as a respiratory stimulant, a theory that has since been confirmed. In terms  of respiratory symptom s, a 1999 paper found no indication that
hormonal contraceptives influenced asthma severity in women with mild
asthma.42 In a 2001 cross-sectional study of the general population in
Copenhagen, no marked increase in asthma, asthma medication, wheezing,
or coughing on exertion was found in women using oral contr aceptives,43
although some studies showed that asthma symptoms were slightly
worsened by hormone replace ment therapy (HRT) in postmenopausal
women. In a 1995 study , researc hers found that women who had previously
taken oral contraceptives had a higher risk of developing asthma,44 in
contrast to a 2006 Australian study that reported a 7% decrease in adult-
onset asthma for every year of oral contraceptive use.45 A study of women
in North ern Europe again found the opposite—that oral contraceptive users
displayed a higher risk of developing asthma—but when examined
alongside body mass index data, it was unclear whether the hormone pill or
body weight was the primary factor in the asthma symptoms .41 A 2015
paper reported  that hormonal contraceptive use reduced asthma
exacerbations in nonobese women,46 while they increased the risk of
asthma in obese women.47
An investigation of bronchia l hyperactivity (BHR) show ed less
variability in symptoms over the course of the menstrual cycle in women
using hormonal contraceptives, but the study did not describe how levels of
BHR were affected by contrac eptive use.41 It makes sense  that women
whose asthma symptoms vary a lot through their menstrual cycle may
experience more  stability by using a hormonal contraceptive,  but studies
have returned contradictory results as to the relationship between overall
asthma susceptibility and contraceptive use. Clearly , observational research examining the connection between oral
contraceptives and respiratory health often produces results that are difficultto analyze. Studies are subject to the problem of “confounding by
indication.” This is the scientifi c term for the difficulty in assessing a risk
factor or treatment in relation to an outcome when there are “confounding”
variables that could also be affecting the outcome. This is one reason why a
study may draw inaccurate conclusions. For example, in studies into the
side effects of a medication, patients who are prescribed the medication
may be inherent ly different from people who do not take it—they are, after
all, taking the drug for a reason. This very fact can distort the findings of
research. For example, oral contraceptives are often used to treat polycystic
ovary syndrome  (PCOS). PCOS is linked with asthma, lower lung function,
diabetes, and cardiovascular disease. Therefore, PCOS may be a significant
factor confoun ding (complic ating) the relationship between oral
contraception and respiratory disorders. This, however , has not been
considered in any of the studies described. The relationship is further
complicated by the fact that hormone contraceptives can sometimes cause
irregular menstruation.41
In gene ral, the scientific literature on this topic is inconsistent and
problematic. The makeup of oral contraceptives has changed over time—
modern pills have a higher progesterone content and lower estrogen
compared with those that were used some years ago. Each pill used in the
early 1960s was roughly equivalent in terms of dosage to seven of today’ s
pills.48
The 2012 review concludes that it is “likely and biologically plausible”
that oral contraceptives affect the airways in diverse ways. While some
studies indicate that asthma can be caused by contraceptives in some
women, others demonstrate the opposite. It is important, therefore, for
healthcare professionals to be aware of the possibility that hormonal
contraceptives might affect respiratory health in different ways and to listen
to their patients and assess them on an individual basis. The likelihood that
these medication s impact the airway is sufficient for researchers to advocate
that respiratory symptoms and disorders be included in trials of new oral
contraceptive pills. I recentl y talked  to Geor gie, a healthy 25-year -old woman who is very
fit with a high level of endurance. In the weeks before we spoke, Geor gie
had stopped taking her combine d oral contraceptive pill and returned to hernatural 28-day cycle. She tracks her cycle daily , logging her temperature via
a fertility and ovulation app called “Natural Cycles.” She also takes her
BOL T score every day. Geor gie’s average BOL T score is around 30 or 31
seconds at rest, but during the midluteal/luteal phase of her cycle, there is a
marked decreas e of between 6 and 10 seconds. At the same time, she
experiences increased anxiety , lower motivation and a lack of focus. Since coming off the combined  contraceptive pill, she has noticed the
drop in her BOL T score is not so severe. Geor gie told me:
I know it usually takes around  three months for the hormone s to
fully adjust back into their natural rhythm when you come off the
pill, but for me an awareness of how my hormones fluctuate,
especially in terms of respiratory function, is comforting. It
improves my understanding about how to train in an athletic sense,
and it helps me to know when  I need to look after myself a little
more. Besides oral contraceptives, other methods of contraception are also in
common use. Nonoral options include inter-uterine devices (IUDs) and
implants, both of which release a synthetic progesterone hormone called
levonor gestrel. There are also injectable medications. Most list depression
and anxiety as side effects,9 though no direct link has yet been made to
breathing pattern disorders or respiratory health. It is possible, though the link has not been investigated, that the
recognized psychological side effects of hormonal contraceptives are linked
to low levels of blood CO2 triggere d by the hormone changes, just as
hyperventilation is a common factor in the luteal phase of the menstrual
cycle. The low levels of blood CO2 intrinsic to hyperventilation are
associated with panic attacks, and panic symptoms lessen when levels of
CO2 are normalized. Breathing exercises that normalize blood biochemistry
and decrease the ventilatory response to CO2 should help alleviate cyclic
depressive symp toms and create a positive feedback loop in which panic
symptoms are better controlled. In very rare cases, contraceptive  devices have been known to negatively
affect the health  of the respirato ry system in a directly physical  manner . Inone case, a young woman who was experiencing shortness of breath and
severe chest pain attended the emer gency department, where an X-ray
revealed that her IUD had become displaced and was in her abdominal
cavity . The device was removed , resolving her symptoms. IUDs should be
regularly checked that they are still correctly positioned. A misplaced IUD
should be considered by doctors where the cause of symptoms is not
clear .49 In another case, a single-rod subdermal contraceptive implant
migrated into the lung of a 37-year -old woman.50 Only those with the
relevant training should ever undertake the insertion and removal of these
implants. INFERTILITY AND BREA THING
In 2007, Austrian scientists examined changes in end-tidal CO2 pressure
during the menstrual cycle.51 End-tidal CO2 provide s a measure of how
much CO 2 is in the blood. Researchers examined 160 women with a histor y
of regular menstrual cycles, measuring levels of blood CO2 every day. The
women’ s menstrual cycles were monitored using ultrasound and by
recording levels  of hormones, including estrogen and progeste rone, in the
blood and urine. The change in end-tidal CO2 during the menstrual cycle
was found to follow a regular pattern. They concluded that this could
provide a promising method of natural family planning, and that it should
be possible to identify the fertile phase of the menstrual cycle by measuring
end-tidal CO 2.51
While CO 2 levels can help identify what’ s going on with the hormones,
there are clear aspects of health  that can cause complications for fertility . One such factor , described in a 2018 study , is psychological stress.52 The
connection betw een stress and infertility has been debated for years. Women who experience infertility report heightened feelings of depression
and anxiety , and it is clear that infertility causes stress. What is less certain
is whether stress can cause or contribute to infertility . According to the 2018 review , recent research has documented the
effectiveness of psychological interventions in reducing mental distress and
significantly increasing rates of conception. The review concludes thattherapeutic approaches to reliev e stress may be the most effective way to
achieve both goals for women struggling to conceive. Cognitive behavioral
therapy (CBT) is suggested, but it is worth remembering that research has
found slow, diaphragm breathi ng to be as effective as CBT in treating
patients with panic attacks.53 Slow , deep breathing works via different
mechanisms, addressing the biochemical trigger for stress as well as the
psychological factors. It would therefore make sense that breathing
reeducation could be useful in supporting women with infertility-related
stress. At the very least, it will certainly do no harm! Citing stress as a factor , a 2015  study examined the influence of sleep
on fertility . Stress certainly contributes to poor sleep, and the review set out
to exam ine by which mechanisms sleep disorders might affect fertility . In
the United States, infertility affects 15.5% of all women and 24.3% of
women who have never had a child.54 According to the review , many more
women than men have insomnia. Menstrual transitions, pregnancy , and
menopause all create a vulnerability to sleep continuity disturbance, and so
women are more at risk for sleep problems throughout their lives. Traditionally , it was believed that mood swings, lifestyle changes, or
hormonal fluctuations create a susceptibility to insomnia. However , the
study suggests that the opposite  may be true—a disturbance in sleep may
influence fertilit y. If, for example, insomnia is caused by hyper arousal, the
body is reacting to a real or perceived threat. In this instance, insomnia may
be the evolutionary response to less-than-optimal circumstances for
reproduction. Sleep disorders  and disturbances are increasingly recogn ized as
pertinent to women’ s health and well-being, particularly in relation to the
menstrual cycle, pregnancy , and menopause.54 Little is currently known
about how and to what extent fertility is affected by sleep quality and
quantity , but sleep problems are frequently comorbid with infertility . The
review conclude s that, at the very least, treatment of sleep disorders would
enhance the quality of life for women with fertility problems. At best, one
or more sleep disorders represent “moderating factors for infertility or
response to treatment.” If this is indeed the case, treatment for sleep
disorders may increase the chance of natural conception, improve theresponse to fertility treatment , and boost the potential for successful
carriage to term.54
Again, as we discovered in Chapter Seven  on sleep disorders, correct
breathing plays a vital role in sleep quality . This is yet another  therapeutic
reason to address breathing in sleep disorders, whether it impacts fertility
directly or indirectly . A study reported in Reuters Health  in 2018 further examined the link
between infertility and sleep disorders,55 suggesting that women who have
trouble sleeping may be more than three times as likely to experience
infertility and that women with insomnia are four times more likely to
struggle to conceive. The study  specifically examined women with sleep
disorders other than OSA. Difficulty conceiving is often caused by a
hormone imbalance called polycystic ovarian syndrome, though blocked
fallopian tubes, anatomical problems with the uterus, sexually transmitted
infections, smok ing, diet, age, and excessive alcohol consumpti on can also
play a role. The 2018 study examined data from 16,718 women, all newly
diagnosed with sleep disorder s over a 10-year period, 2000 to 2010,
alongside a control group of 33,436 women with no sleep problems. At the
start of the study , the women ranged in age from 20 to 45. Results, before
age and other health issues were taken into account, showed that women
with sleep disorders were around 2.7 times more likely to experience
infertility . With age and other medical conditions factored in, women with
sleep problems were 3.7 times more likely to be infertile. Sleep disorders
are frequently related to chronic  health problems such as high cholesterol,
hypertension, and lung disease. Women who sleep badly are also more
susceptible to irregular menstrual cycles, depression, anxiety , and thyroid
disorders. While the study did not examine whether a direct causal link exists
between sleep disorders and infertility , and researchers lacked data on
certain things that impact fertility , the results indicated that poor sleep may
be a factor for women strugglin g with infertility . CBT is the standard first-
line approach for treating insom nia, but breathing exercises can be effective
in addressing sleep disorders and the underlying stress that may be at theirroot. If you are trying for a baby , a gentle practice of slow breathing, sleep,
and relaxation will boost your physical and mental resilience and health. MANAGING MENOP AUSE
At a certain point in every wom an’s life, menstruation will spontaneously
and perm anently cease, and menopause will begin. While this is a natural
event and one that all women experience, there is little scientific literature
examining this characteristic change in sex hormone levels, and most
women don’t really know what  to expect. This is not really surprising in
light of the gend er imbalance present in scientific studies, but it is an issue
that is currently receiving growi ng attention. In medical terms, it is not even
entirely clear when menopause begins—the “menopause state” is confirmed
after 12 consecu tive months without a period41. This happens at a median
age of 51 years , although an extensive 2009 study reported an increase
toward 54 years.56
Before menopause, many women experience a phase called
perimenopause. This is the body sending up flags of the coming hormonal
changes. Levels of estrogen rise before the production of sex hormones
ceases, and you might experience hot flashes, night sweats, sleep
disturbances, vaginal dryness, irregular periods, mood swings, recurrent
depression, and short-term memory loss.41 Perimenopause begins, on
average, at the age of 46 and lasts for about five years.41
One thing that is known is that while menopause is a natural
progression, smoking significantly impacts the age at which it occurs. Women who smoke enter menopause about a year and a half earlier than
those who don’t.41 This already points to an obvious link between
menopause and overall well-being and more specifically , respiratory health. Early menopause is a known risk factor for various illnesses, including
cardiovascular diseases and osteoporosis. Early menopause is also directly
linked to mortality in general57. There are correlations between natural
menopause and lung health, but studies have largely failed to factor in other
things during a woman’ s life that are known to affect the function of the
lungs.57As women live longer , they will spend more years in postmen opause,
and scientists recognize that this makes it essential to understand how
hormonal shifts during this period affect the health of the lungs.57
Fortunately , the fact that proges terone levels drop after menopause means
that there is a large study population available in which reduc ed hormone
levels can be examined, and scientists are beginning to explore these
connections in more detail. A 2009 paper found that not only were estrogen and progesterone levels
significantly lower in postmenopausal women, the pressure of blood CO2 at
rest was much higher too58. This is because the central chemoreflex drive to
breathe is lessened after the menopause. This change is related to the
decrease in sex hormone concentrations and complex blood acid-base
interactions. This finding has important implications in understanding why
sleep-disordered breathing becomes more common after menopause. It is
also useful in determining the effects of HRT on ventilatory control and on
blood pH, at rest and during exercise, in both healthy women and those who
are unwell.58
The authors of a 2020 study published strong evidence of a connection
between early menopause and reduced lung function. This was the first long
running study to confirm a relati onship between pulmonary health and early
natural menopause. Using data about lung function collected when
participants were 7 and 53 years old, researchers found that women whose
menopause occurred before they were 45 had poorer lung function than
those who experienced menopau se aged 45 or later. This is the first study to
take into account factors earlier in the lives of the women, such as
childhood asthma, socioeconomic status, and parental smoking.59
By identifying that this relationship exists, scientists have made it
possible to assess women with a higher potential risk of lung problems or
those women who might be likely to develop lung disease when
menstruation ends. Early menopause triggers a susceptibility to respiratory
disease and a vulnerability to environmental factors such as air pollution
that has not previously been recognized. It is unclear whether changing
hormone levels directly accele rate the decline in lung functi on in some
women, but a clear link between estrogen fluctuations and pulmonary
health exists.Women whose respiratory function is poor before menopause may be at
an even greater risk, especially  if they are subject to other factors, for
example, regula r exposure to toxins at home or at work. Women who have
an existing lung condition, such as COPD, and experience early menopause
may subsequently suffer a more serious and progressive version of the lung
disease.59 The study recommends that the impact of menopause on asthm a
be reevaluated. It also suggests that immune dysfunction connec ted with the
main estrogen of menopause may be significant in a chronic condition
called bronchiectasis, a disorder of the airways that mainly affects
postmenopausal women. A high proporti on of the women in this study who experienced early
menopause had also had early menarche. It is believed that these women
may be generally at higher risk for lung dysfunction or disease. Interestingly , women in this same group were more likely to smoke and to
use hormonal therapies. Women in the study cohort who were still
menstruating had the lowest rate of respiratory symptoms and diseases. While this study  represents a step forward in research on the topic, more
work is needed to understand the mechanisms of menopaus e and lung
function. Howev er, it is importa nt that early menopause is understood to be
a risk factor in respiratory health. IMPACT OF HORMONE REPLACEMENT THERAPIES ON THE
BREA TH
As menopause occurs, many women choose to take a HRT for either shorter
or longer periods. There has been some uncertainty about the safety of these
medications, largely because of reports from the Women’ s Health Initiative
study , which condemned the therapy as unsafe due to links with increased
risk of coronary heart disease and breast cancer .60 The uptake of HRT
declined as a result of this publicity . It was subsequently shown that the risk
of breast cancer was low and only relevant for women with a very long
exposure to a combined HRT regimen, and that for some, estrogen may
actually reduce susceptibility . More recently , these findings were again
contradicted in research published in the British Journal of Cancer , which
reported that women taking combined HRT are nearly three times more
likely to develop breast cancer than nonusers, with risk increasing withlonger HRT use. The “Breast Cancer Now Generations Study” provided a
comprehensive update about HRT use, suggesting that many previous
investigations were not so thorough and may have “underestimated the
increased risk of breast cancer by up to 60%.61 Importantly , the heightened
risk level appears to return to normal once HRT use ends.61 There is not
thought to be increased risk for coronary disease.60
Overall, the link between meno pause and lung health is still not well
understood. Despite the fact there has been a certain amount of research
focus on HRT, the underlying condition of menopause itself has barely been
studied. What literature there is on HRT and respiratory health returns
confusing results. Research into asthma and other respiratory symptoms tends to indicate
an incre ased risk for women who take HRT, especially nonsmokers and
women with a lower BMI. However , studies of lung functio n suggest a
beneficial or at least a neutral connection with HRT.41 As we discovered
earlier , studies often contradict each other for various reasons. There may
be differences in BMI between study populations, clinical practice around
HRT use isn’t always the same,  the type and duration of HRT differs, and
there are variations in study design and even in the assessment of
menopause. There are also complex problems around distinguishing the
effects of HRT from symptoms of menopause itself. Fundamentally , as
studies have explained, more knowledge of biological mechanisms is
needed before it is possible to return truly accurate results. In 2017, Science Daily  reported the results of new research, presented at
the European Respiratory Society International Congress, which
demonstrated that oral HRT can slow the decline in lung function in
middle-aged women.62 The study followed 3,713 women for two decades
between the early 1990s and 2010 and found that those who took HRT for
two years or longer did better on lung function tests than women who had
never taken HRT. Lung function is at its best during the midtwe nties. From
then on, it decre ases incrementally . One thing that accelerates lung decline
is menopause— which raises the question, could HRT at least partly
counteract it? The wom en’s lung health was tested at the start of the survey and again
20 years  later. The measurement used was forced vital capacity  (FVC),which assesses the volume of air that can be exhaled from the lungs after
taking the deepest possible breath. Women who used HRT lost, on average,
46 milliliters less lung volume over the 20-year period than those who had
never taken it. To put this finding into context, 46 milliliters is
approximately the amount of lung volume that would be lost by a woman
who smoked a pack of cigarettes every day for three years. While
researchers do not believe this is likely to be clinically significant for
healthy women, for women who have airway disorders, the decline in lung
function could lead to increased breathlessness and fatigue, decreased
ability to work, and poorer quality of life.62
While the study does not advocate either for or against HRT, the
findings do demonstrate the importance of female sex hormones for the
maintenance of healthy lungs in middle-aged women. This research
provides another piece in the puzzle in understanding the relationship
between menopa use and lung health. The fact remains that women and their
doctors need to be better infor med about the health changes that happen
after menopause. Women with existing respiratory conditions such as
asthma should be closely observed during the menopausal transition, and
advice about medication should  be more personalized and take changing
hormonal levels into account. OSTEOPOROSIS AND BREA THING P ATTERN DISORDERS
Osteoporosis is a condition prevalent in postmenopausal women that might,
at first, appear to have no connection with breathing.63 It is a disease of low
bone mineral density or excessive bone loss and is a common cause of bone
fractures in older women. Osteoporosis affects 200 million women
worldwide, with nearly one in two women over the age of 50 likely to
suffer an osteoporosis-related fracture. In women over 45, the condition
accounts for more days of hospitalization than diabetes, heart attack, or
breast cancer .64
It can cause repeated fractures of the vertebrae attached to the ribs,
which may lead to an excessive curve in the spine called thorac ic kyphosis. Each time one of these thoracic vertebrae is broken, lung capacity shrinks,
with a reductio n in forced vital capacity of 9%. While research hasexamined the link between osteoporosis and respiration in terms of this
impact on mechanical function, very little work has been done to measure
lung health in women with osteoporosis but no diagnosis of chronic
respiratory disease. The fact that women with osteoporosis commonly complain about
breathlessness prompted a 2018 study .63 Researchers theorized that the
fragility of the rib cage typical  of bone loss and osteoporosis  negatively
impacts respirat ory function by inhibiting the body’ s responses to normal
breathing stimuli, and thus affecting the blood acid-base balance. In simple
terms, the fragility of the ribs causes instinctive changes to breathing
patterns, designed to protect weakened bones. To test this theory, scientists assessed lung function, arterial blood gas
levels, central respiratory drive, and breathing patterns of wome n with bone
fragility who had no respiratory illness, kidney disease, or anem ia, and who
were not taking any medication known to alter blood pH. The women’ s
results were compared with a control group of women who did not have
bone fragility . The results showed for the first time that women with osteoporosis or
bone loss who had never smoked displayed disturbances in blood gas
exchange and changes in breathing patterns compared to age-matched
healthy women. The differences were not the result of anatomi cal changes
or other conditions such as cardiorespiratory disease. This is the first study
to look at gas exchange and breathing patterns where participants were
selected to minimize confounding factors, such as respiratory disease,
smoking, medications, and anatomical considerations. Lung volumes at rest and during  exercise were similar in all the women,
but the differences in breathing  patterns and gas exchange values between
women with or without bone fragility were significant, even though all the
values fell withi n normal reference ranges. Differences included  changes in
the ventilatory response to CO2, lower levels of arterial CO2 and oxygen, a
higher arterial to alveolar oxygen gradient suggesting defective diffusion of
oxygen from the blood to the lungs, and higher pH levels in the blood. Interestingly , bone loss has been linked to depressive symptoms. Postmenopausal women are at increased risk of depression at the same time
of life they are vulnerable to bone loss. While several studies have found arelationship between bone loss and depression, none have identified the
reason for the connection64. Osteoporosis and bone loss are often
undiagnosed until a woman suffers a fracture. However , a 2018 review
found that depressive symptom s are indicative of bone loss, may help
identify women with these conditions, and should trigger further
investigation of bone health.64
According to a 2019 paper , the biochemical and physiological effects of
psychological stress are recognized as contributing factors in
osteoporosis.65 Researchers looked at evidence pointing to stress-associated
mental health disorders as risk factors for osteoporosis. They suggested that
therapies to address psychological health could have benefits for bone-loss
patients. Resear ch into this topic is limited, but the studies that do exist
indicate that a personalized, multifaceted approach may improve patient
outcomes, particularly in those who are at a higher risk of developing
osteoporosis. A further link exists between osteoporosis and anxiety .66 A 2018  study
of 192 women found that those with high levels of anxiety were more prone
to osteoporosis-related fracture. Anxiety levels were connected to age,
depressive symptoms, years since menopause, and age at menopause. Scientists concluded that anxiety levels in postmenopausal women were
associated with,  and predictive of, reduced bone mineral density in the
lumbar spine and hips. While it is interesting to explore the connections between osteoporosis
and breathing, there is currently no research to indicate a direct link
between menopausal depression and anxiety , physical symptoms of bone
mineral loss, and breathing pattern disorders. However , it is the case that
addressing poor breathing can significantly improve quality of life by
reducing susceptibility to a huge range of mental and physical conditions. SLOW , DEEP BREA THING AND MENOP AUSE SYMPT OMS
It has been proven that slow, deep breathing can reduce certain hormonal
symptoms of menopause. A 2012 study explored the potential of
parasympathetic activation via slow, deep, diaphragmatic breathing toreduce the frequency and severity of hot flashes. Paced breathing can
reduce the stress response, relaxing the body and mind.67
For the study , scientists designed a nine-week, three-arm clinical trial in
which participants used an audio CD to practice guided paced breathing
exercises. One group practiced  at 6 breaths a minute once a day for 15
minutes. A second group practic ed the same exercise twice a day. The third
group practiced  14 breaths a minute for 10 minutes each day (normal
breathing). Near ly 80% of the women who completed the study found the
exercises easy to do and to fit into their daily routine. All of the participants
across the three groups reporte d reductions in hot flashes. Women who
practiced paced breathing twice  a day saw the biggest improvement (52%). Those who practiced 6 breaths a minute once a day saw a 42%
improvement and those practicing normal breathing experienced a 46%
improvement. The researchers concluded that paced breathing provides a
workable intervention that can be easily applied, and a larger study is
needed to fully assess the impact of the breathing exercises on hot flash
reduction. The ebook, Recognizing and Treating Breathing Disor ders, cites earlier
studies that demonstrate women  who are unable or “unwilling” to take HRT
have successfully used breathing retraining to reduce hot flashes.68,69
This research is backed up by an email I received from a client who
wrote that she had noticed significant benefits after implementing the
breathing techni ques. She said, “I have noticed a 90 to 100% decrease in
night sweats when I go to bed with my mouth taped, and this is after only
one week.” This points to better regulation of the autonomic nervous
system and corresponds with research that connects nocturnal sweating with
sleep apnea.70 According to the 2013 paper , incidence of night sweats is
three times higher in people with untreated sleep apnea than it is in the
general population. By using MyoT ape to ensure nasal breathing during
sleep, night sweats, apnea, and the associated insomnia may all be
alleviated. WHA T’S NEXT FOR FEMALE RESPIRA TORY HEAL TH?The scientific literature explor ing the role of female sex hormones in
respiratory health is complic ated and incomplete41. Women differ
significantly in hormonal profiles over the course of their lives, and
assessment of hormonal status is still a problem in that menopause cannot
be confi rmed until 12 months after it actually occurs. Even then, it is often
difficult to determine because of the use of hormonal medications. It is important that research begins to investigate hormonal influences
on respiratory health in sufficiently large studies. Future work needs to take
into account real life factors, such as smoking, which has an antiestrogen
effect. For instance, establishin g a clear connection between asthma and
HRT is likely to be heavily influenced by understanding the role of
smoking. There is enough evidence to be sure that sex hormones do influence
respiratory health and disease throughout the course of a woman’ s life. However , the understanding of this impact is limited. Some research covers asthma and lung function, but hardly any
investigates COPD. It seems fairly clear that women who reach puberty
early and have irregular periods also suffer with more asthma and poor
lower lung function. Asthma and respiratory symptoms are known to
fluctuate during the menstrual cycle, and this suggests the possibility of
therapeutic interventions. Changes in respiratory health around menopause are likely but very
understudied and difficult to measure due to HRT use. Better understanding
of these areas has great potential to improve treatment and outcomes for
women with asthma and COPD. The 2012 review of the literature on
respiratory healt h in women from  menarche to menopause concludes firmly
with this statement, “The era for investigating respiratory health in 2,000
men and 29 women has passed.”41
OceanofPDF .comDCHAPTER FOUR TEEN
SUGAR, SUGAR
WHA T IS DIABETES? iabetes is a long-term disease that affects the way the body
metabolizes blood sugar or glucose, an important source of energy. Glucose comes from the food we eat, especially foods rich in
carbohydrates. During digestion, those carbohydrates are broken down into
simple sugars that enter the bloodstream via the intestines.1 When this
happens, beta cells in the panc reas secrete insulin, which is a hormone.2
Hormones are chemical messeng ers produced by the body and released into
the blood to trigger specific responses. Insulin’ s job is to enable the cells to
absorb blood sugar to release energy. The relationship between  insulin and
glucose is similar to that of carbon dioxide (CO 2) and oxygen. Just as CO2
is needed to release oxygen from the blood, insulin is necessary to unlock
the ener gy in blood glucose. In a healthy system, insulin helps regulate blood sugar , making sure
there is never too much (hyper glycemia ) or too little (hypoglycemia )
glucose in the blood for the body’ s vital systems to function.3,4 In a diabetic
body , this proce ss is compromised, either because the pancreas produces
insuf ficient or no insulin (type 1) or because the body is unable to use
insulin properly (type 2). When this happens, glucose can’t be absorbed by
the cells, and levels of blood sugar become chronically high. TYPE 1 DIABETESType 1 diabetes is an autoimmune disorder that results in excessive sugar in
the bloodstream . People with this type of diabetes are not able to produce
their own insulin due to an immune system malfunction that destroys the
insulin-producing beta cells of the pancreas. Instead, they have to inject
insulin every day to keep blood sugar under control. This type of diabetes tends to occur during childhood or early
adulthood. Its cause has not yet been determined, but scientists believe it
begins with a genetic predispos ition and is initially set off by an immune
system activated by, for example, a viral infection, environmental triggers,
or a genetic condition.5 The immune system attacks the beta cells in the
pancreas, producing a single insulin-destroying antibody . According to TrialNet, an international network of researchers working
to understand type 1 diabetes, if you have a relative with type 1 diabetes,
you have a 1 in 20 chance of developing the disease, compared to a risk
factor of 1 in 300 for the general population.2,6 In child ren under the age of
five years, incidence is increasing. In the United States, figures suggest that
1 child in every  400 to 600 is affected, and 15% to 20% of new diagnoses
are in children under five.7 Because type 2 diabetes is also to some extent
hereditary , peop le often confuse the two conditions, but it is important not
to lump the two types of diabetes together . TYPE 2 DIABETES
This is the more  common type of diabetes, affecting around 90% to 95% of
adult diabetics. Type 2 diabetes manifests as difficulty using and producing
insulin, otherwise known as insulin resistance. Blood sugar levels become
too high because the body can’t respond normally to insulin. This causes
the system to compensate by producing ever-increasing amounts of the
hormone. Over time, the pancre as becomes exhausted by its efforts to meet
the demand for insulin. It becom es unable to produce sufficient insulin, and
blood sugar levels rise even higher .3,4
Whenever imba lances exist, the body’ s systems will try to restore
homeostasis. If any aspect of those systems is faulty , long-term adaptations
occur that can drain the body’ s resources, impacting overall health. Oneexample of the body’ s attempt to restore homeostasis, of course, is the
biochemical response to habitual overbreathing. According to key statistics from Diabetes UK, contributing factors in
type 2 diabetes include obesity , age, genetic predisposition,8 socioeconomic
status, and ethnicity ,9 In part, this is because people from deprived
backgrounds are more likely to experience physical inactivity , a poor diet,
and tobacco use.10
The onset of type 2 diabetes can be difficult to identify , as it progresses
more slowly and without the acute metabolic disturbances seen in type 1
diabetes.11 As many as half of all type 2 diabetics may be undiagnosed.11
WHY DIABETES LEA VES YOU BREA THLESS
Abnormal respir atory function is a feature of both types of diabetes.12 A
2017 study describes the negative impact type 2 diabetes has on lung
health.13 Researchers explain that insulin resistance, chronic low-grade
inflammation, and damage to the veins and autonomic nervous system all
contribute to the lung deterioration associated with type 2 diabetes, causing
physical changes that include changes to the tissues.13
Diabetes is recognized as a risk factor for sleep-disordered breathing,
sleep apnea, and daytime sleepiness.13 Researchers recommend that patients
with type 2 diabetes should be considered at risk of pulmonary
dysfunction.13 The paper notes that in previous studies, declines in lung
function could be detected up to three years before type 2 diabetes was
diagnosed.13 In another paper , which examined lung health in Native
Americans with diabetes, impaired pulmonary function was observed
before diabetes occurred. What’ s more, the risk of diabetes increased by 2%
for every 1% decrease in forced ventilatory capacity ,14 a measure of lung
volume. Also, both types  of diabetes can cause a type of nerve damage called
neuropathy . Neuropathy can affect the phrenic nerve , an important nerve
responsible for motor control of the diaphragm.15 This is one factor that
may lead to respiratory symptoms, respiratory failure, and even death in
diabetics.When the body is not able to process blood sugar properly ,
complications occur on a “microvascular” and “macrovascular” level—both
in the small and large blood vessels. The blood vessels essentia lly become
“clogged” with excess glucose. On a microvascular level, this affects the
tiny blood vessels in the skin and eyes and can lead to problems that include
blindness,16 damage  to the retinas and nerves, and kidney failure.16 On a
macrovascular level, it affects the feet,17 impacts organs including the heart
and brain, and can lead to heart attack and stroke.12 The first obvious sign
of these problems may be excessive breathlessness. According to the National Kidn ey Foundation, around 30% of type 1
diabetics and 10% to 40% of type 2 diabetics will eventually suffer from
kidney failure.18 One outward symptom of kidney failure is breathlessness. Acute breathlessness can be caused by a serious condition called diabetic
ketoacidosis or metabolic acidosis, which involves disruptions to the blood
acid-base balanc e that adversely affects the respiratory system.19 Metabolic
acidosis can lead to respiratory failure and contribute to the development
and progression  of disease. Much like respiratory acidosis, this type of
acidosis commonly causes hyperventilation, a fast breathing rate, and a
decrease in blood CO2 that evolves into overbreathin g with an increased
tidal volume.19 Left untreated, it can be fatal.19
Dysfunctional breathing is prevalent in type 2 diabetes. One study found
that patients with type 2 diabete s had significantly lower end-tidal CO2 and
a much higher respiratory rate than a control group of healthy people. Scientists conclu ded that lung function was impaired in the diabetic patients
and that they would benefit from a program to improve it.20
Earlier research, which investig ated lung function in patients with type
1 diabet es, identified the lung as a “target organ” for diabetes.21 Another
paper examined 45 patients with type 2 diabetes and found a “strong and
inverse relationship” between the duration of the diabetes and diminished
lung volumes, concluding that poor blood sugar control was directly related
to decreases in the volume of the lungs22. Severa l other studies have also
associated diabetes with reduced lung function and respiratory muscle
weakness.23–26
Gas exchange in the lungs occur s in the alveoli, where a thin membrane
separates capillary blood from the air. Any damage to this membrane willnegatively affect the lung’ s ability to absorb oxygen into the blood and
release CO2. Scientists have suggested that changes in lung function,
especially reduced gas exchange, may occur in patients with diabetes as a
result of damage to the alveoli.27
A study of yogic techniques, including breathing exercises and
relaxation, found that the exerc ises led to better lung functio n in type 2
diabetic patients, improving forced expiratory volume and forced vital
capacity .28 Researc hers suggested that the increase in lung function was due
to pract ices designed to improve respiratory muscle stamin a and lung
expansion and to conscious breathwork, which relaxed the respiratory
process, suppor ting better lung elasticity and function.28 Like previous
research in healthy patients and people with a range of conditions, yoga was
found to be helpful in diabetes , reducing obesity , improving oxygenation,
opening the airways, and increasing recruitment of the alveoli.28
Diabetics should find breathing exercises helpful. Light, slow, deep,
breathing reduces stress, which  we know is instrumental in the onset and
progression of disease. Lower sensitivity to CO2 helps maintain
homeostatic balance in the blood acid base, and nasal breathing from the
diaphragm supports healthy lung volumes and respiratory muscle function. In addition, functional breat hing harnesses CO2, an important
vasodilator . Poor vasodilation is a major issue in diabetes and can
compromise circulation in the legs, leading to painful ulcers.29 One 2015
study reported that CO2 therapy was beneficial in treating foot ulcers in
diabetic patients  by increasing blood flow to the affected area.30 In that
experiment, synthetic CO2 was dissolved in water and applied directly to
the feet to improve tissue oxygenation, just as the Romans and ancient
Greeks used to do, bathing in waters rich in carbonic acid to cure a variety
of illnesses. NICK’S ST ORY
Nick Heath is an Oxygen Advantage instructor . He is also a type 1 diabetic. Nick was just 11 years old when he was diagnosed. For 14 years, he
received “standard care” for his condition, but the results were mediocre atbest. At the age of 25, he bega n to eat better and exercise regularly . His
blood sugar improved, and at the time, he thought it probable that he had
achieved the best control he was ever likely to have over his diabetes. Despite this improvement, over the next few years, he still felt that
something was amiss. Nick was doing everything he could from a
nutritional and exercise perspe ctive, but he was still unable to maintain
consistent ener gy levels, and he often felt drained. When he was 30 years old, Nick found the Oxygen Advantage . After his
first night using a lip tape to ensure nasal breathing during sleep, he woke
up noticeably refreshed and full of vitality . He emailed his wife at work to
say that either he was crazy or taping was the best thing ever.
_OceanofPDF.com_The_Breathing_Cure_-_Patrick_McKeown.txt
Summarize the following text section accurately and concisely. Maintain specific details and numerical information, and use anti-repetition mechanisms:

        She is highly active, enjoys eatin g a healthy
diet, doesn’t smoke, and rarely drinks alcohol. She has a sedent ary job with
an 8- to 10-hour  day, but she walks between four and five kilom eters, works
out every day, and sleeps well for seven or eight hours every night. Despite
the care she gives to her health, Emma found herself struggling with PMS
symptoms that gradually became more and more dif ficult to cope with. Emma had been  taking an oral contraceptive since her late teens. In her
late twenties, she took a break  from her pill. After three years with no
hormonal contraceptives, she began to take a combined contraceptive pill. This was when her “hormonal rollercoaster” began. At first, Emma chalked
her PMS  symptoms of mood swings, fatigue, bloating, and brain fog down
to the particular pill she was prescribed. Her doctor switche d her to a
different combin ed pill. For the next three months, Emma’ s symptoms were
constant. She was bloated all the time, her mood was low, she had problems
with her digesti on, and her energy levels were “on the floor. ” Despite her
regular exercise regime and healthy diet, she gained two kilos in body
weight. She was in a constant state of stress. After much research, Emma switched to a more localized contra ceptive,
opting to have an IUD inserted. The IUD is different from an oral
contraceptive in that the release of hormones is much more direct so that the
hormones are not constantly circulating in the bloodstream. Next, she
prioritized her well-being to combat the debilitating PMS symptoms she
had been experiencing. Synthetic hormones were still being released into
her body, even with the IUD, so she wanted to do everything she could to
support her health while her system adapted to the new contraceptive. In the following months, she did several things that significantly
improved her condition:
• She began taking daily supplements of diindolylmethane (DIM), magnesium, and a
vitamin B complex. DIM is a natural supplement found in vegetables including kale,
broccoli, and cabbage. It helps the body metabolize estrogen. Emma learned that
hormonal contraceptives deplete the body of key nutrients such as B vitamins10—
something she wished her doctor had told her. • She made the switch to nasal breathing. While Emma was not a habitual mouth
breather, she did always breathe through her mouth during exercise. She worked to
ensure that she breathed only through her nose, even on a 100-km cycle. This left
her feeling much calmer during exercise and throughout the rest of the day. • She began practicing breath holds and long, slow breaths. Emma never considered
herself a fast breather, but each month, around the same time she experienced PMS
symptoms, she noticed that her breath felt shallow. She would struggle to take a full,
deep inhalation, almost as though her body was not capable of getting the oxygen it
required. By becoming aware of her breath, she felt better able to control it. She now
uses breath holds to reset her system to get suf ficient oxygen into her body. • Emma began practicing meditation. She found that stopping for 15 to 20 minutes a
day to “reset and reenter” had a profound ef fect on her PMS symptoms and on her
daily life. Her PMS lows became much easier to deal with, and she felt better able to
pull herself out of the “PMS hole” she found herself in on a monthly basis. Her
concentration became sharper, and she began experiencing the best sleep she had
ever had. Emma had always been told that PMS is normal, that symptoms
including fatigue, brain fog, bloating, and low moods are par for the course,
and that she should “deal with it and take a painkiller. ” She was shocked to
realize that nobody had ever explained why she experienced these
symptoms, what was happening  in her body to make her feel this way. Now
she understands that her feelings of breathlessness are largely caused by the
drop in CO 2 during the premenstrual phase of her cycle. Emma’ s PMS has not completely disappeared, but every month her
symptoms are less severe and more manageable. She has lost the extra two
kilos she was carrying, she no longer has dramatic mood swings or brain
fog, and her bloating is much less extreme. Her quality of life has improved
because, in her words, she has much less of a battle to fight each month. For wom en who suffer from PMS, the connection to hyperventilation is
big news. It means that many symptoms previously believed to be hormonal
and unavoidable are actually the result of a hormone-driven change inbreathing pattern s. That is something that can be addressed with breathing
exercises and by moderating blood sensitivity to CO 2. If you suffer from PMS, keep an eye on your breathing. If your BOL T
score decreases,  your breathing gets faster, or you experience air hunger,
then practice breath holds, begin  light, slow, and deep breathin g, and work
to restore full-time nasal breathing. That should help relieve your
symptoms. HOW PREGNANCY AFFECTS BREA THING
It makes sense that breathing would change during pregnancy. After all, you
are now breathing for two. Oxygen demand is higher due to a 15% increase
in metabolic rate and a 20% increase in oxygen consumption. 11 The space
within the abdominal cavity, where the diaphragm rises and falls, becomes
incrementally smaller as pregnancy progresses. The increase in sex
hormones in the system leads to a significantly higher incidence of
hyperventilation,12 Early on, there is a rise in minute ventilation of around
40% to 50%,11 levels of blood CO2 drop, and the ventilatory responses to
hypoxia and hypercapnia increase13. The changes in pregnancy that lead to hyperventilation are believed to
be caused by a heightened response to blood CO2. There is a close
relationship between blood sensitivity to CO2 and the relative ratio of the
hormones, progesterone, and estrogen. As well as maintaining pregnancy,14
progesterone acts as a respiratory stimulant in men and women. Levels of
the hormone increase around 100-fold during pregnancy. 15
Sex hormones are instrumental in respiratory changes during pregnancy. Even back in 1979, researchers reported that the respiratory response to
pregnancy was “largely mediated by the action of proges terone and,
perhaps to a lesser extent, estrogens, at least in the first and second
trimesters. ”16 Estrogen, which increases around 80-fold during pregnancy,
is known to improve the functioning of progesterone receptors. 13 The 1979
paper stated that breathlessness during pregnancy is likely to be caused by
hormones, but at that time, the relationship between hormones, functionalrespiratory change, and the development of symptoms was not clearly
defined. 16
More recent work has demonst rated that hyperventilation at rest, even
during the first trimester of pregnancy, is linked to an increase in ventilation
with no change in respiratory rate. 17,18 It is now understood that
hyperventilation during pregnancy is caused by alterations to the blood
acid-base balance, cerebral blood flow, metabolism, variations in sleep
patterns, and changes in the central chemoreflex drive to breathe, triggered
by the increased concentration of sex hormones. 12
There are, of course, mechanical factors to consider too. For instance, as
the size of the fetus and therefore the uterus increases, there is progressively
less room for the breathing muscles. During the second half of the
pregnancy, residual lung volume decreases by as much as 22% and
respiratory resistance becomes greater. The diaphragm is displaced upward
by abou t five centimeters, increasing its ability to generate tension as
muscle fibers lengthen. 19 The diaphragm may have to work harder as load
increases, but widening of the chest prevents further loss of lung volume. 20
The gradual extension of the abdominal muscles causes their fibers to
lengthen by up to 115%, their thickness reduces, and their angle of function
changes. This inhibits their ability to stabilize the pelvis—which may be a
factor in back pain during pregnancy. 19. Around 70% of healthy pregnant women report breathlessness during
their daily activities. This often begins during the first trimester, suggesting
that mechanical changes to the diaphragm and lungs are not to blame. It is
more likely that breathlessness is caused either by hyperventilation
associated with pregnancy or by a heightened perception of respiratory
discomfort as the result of increased ventilation. Not surprisingly, the incidence of sleep-disordered breathing increases
among pregnant women. The physiological and anatomic al changes
intrinsic to gestation can unma sk or exacerbate obstructive sleep apnea
(OSA). 21 If this is left untreated, the limitations in upper airway flow can
lead to serious consequences for both maternal and fetal health. While not
the focus here, it should be noted that, generally in the realm of respiratory
disorders, uncontrolled maternal asthma has been found to be associated
with an increased risk of spontaneous abortion. 22Healthcare providers should screen expectant mothers for OSA to
ensure the well-being of both mother and baby. This is especiall y important
in preeclampsia, a primary cause of maternal and fetal illness and mortality,
which sleep-diso rdered breathing has been proven to increase the risk and
severity of. It is believed that the repetitive limitations to airflow that occur
during sleep-disordered breathing are linked to surges in nocturnal blood
pressure and poor health in both mother and baby—and may be just as
damaging as full apneas. 21
One 2016 paper about OSA during pregnancy describes sleep apnea as a
modern epidemic. 23 It is now accepted that the condition is widespread in
women, particu larly during pregnancy. According to curren t evidence,
sleep-disordered breathing is present in 50% of high-risk pregnancies and in
15% of otherwise healthy, obese  pregnant women. It should be no surprise
that pregnancy contributes to sleep disorders. By its nature, it causes
anatomical, physiological, and hormonal changes, including narrowing of
the uppe r respir atory tract, which can increase the risk of OSA or worsen
existing apneas. 24
During pregnancy, OSA contributes to a five-fold increase in maternal
mortality due to complications including pulmonary embolism23 (a
blockage of an artery in the lungs). A 15-year study of matern al deaths in
Michigan found a connection with OSA and sleep-disordered breathing and
demonstrated that, even after the birth, OSA presents a risk for women. 25
Maternal OSA has also been linked to poor fetal outcomes, fetal growth
restriction,23 low birth weight,26 preterm delivery,23 cesarea n sectio n, and
preeclampsia. 27,28 It has been connected to a low Apgar score in babies in
the five minutes after delivery. 24 The Apgar score is a generalized measure
of health  that assesses appearance (skin color), pulse (heart rate), grimace
response (reflexes), activity (muscle tone), and respiration (breathing rate
and effort). 29 A 2012 study set out to determine whether poor pregnancy
outcomes were related to OSA. It concluded that babies are at an increased
risk of complications in the areas previously listed when the mother has
sleep apnea. This can impact the health of the child long term. 24
Children born significantly preterm commonly suffer from medical
problems and growth restrictions in early childhood. 30 They frequently have
lower weight, height, and head circumference than their classmates. Thepreterm children were much more likely than normal term children to have
serious dental malocclusions, and deep bite and overjet were also
prevalent. 30 According to pediatric dentist Dr. Kevin Boyd, restricted fetal
growth can cause problems that will result in suboptimal airway  health once
the baby is born. In Chapter Eight, we discussed how dental problems and
compromised airways in children can lead to childhood mouth breathing,
and subsequent cognitive, developmental, and behavioral issues. When fetal development is poor due to frequent drops in blood oxygen,
as can be the case for mothers with OSA, the baby may have cognitive
problems that progress into child hood and may not receive appro priate care. A 2020 review confirmed that children with restricted inter-uterine growth
and small birth weight had significantly lower cognitive scores than those
born at an average gestational age. 31 While these children had similar
cognitive scores to those born preterm, they were unlikely to receive the
follow-on care or to be included in the rehabilitation programs that are
available to preterm babies. 31
Another review explored the role of placenta health in chronic  disease
later in adulthood. 32 Much research has demonstrated how low birth weight
contributes to the onset of certai n diseases, including obesity, heart disease,
stroke, and diabetes. Chronic hypoxia and elevated stress levels, both
symptomatic of sleep apnea, cause changes to the organs of the unborn
baby. The review cites a study of 187 men and 47 women that found that
sudden cardiac death was linked  to a thin placenta at birth. Fetal  growth and
lifelong health can be strongly  influenced by the health of the placenta,
which requires continual adequate oxygenation through healthy breathing
during pregnancy. ANXIETY DURING PREGNANCY AND AFTER
Anxiety in new mothers is common. As a woman takes on a new role and
new responsibilities, it could be considered an appropriate adaptive
response. 33 However, some mothers suf fer with severe, invalidating anxiety,
depression, and other mood disorders in the period shortly before and after
the birth of their child. Hormone fluctuations can play a part, as can
psychological issues—perceived  or real challenges and fear— which mayincrease in the case of an unexpected or unwanted pregnancy,33 or when
assisted reproductive technology has been used. 34
It is now genera lly acknowledg ed that new mothers are vulnerable to
postpartum depression, but the prevalence of anxiety disorders during
pregnancy has not been as wide ly studied. Many women experience new or
worsening anxie ty symptoms in the months before and after birth: 21% of
women have clinically significa nt anxiety during pregnancy, and 64% of
these women continue to suffer with anxiety after giving birth. 33 Research
suggests that prenatal anxiety is a major factor in susceptibility to postnatal
depression. Untreated anxiety and depression, which often exist
comorbidly, can have a serious impact on the mother and baby. 33 Anxiety
during pregnancy can contri bute to numerous problems, including
preeclampsia, more time off work, nausea, increased visits to healthcare
providers, spontaneous early labor and delivery, low birth weight, difficulty
breastfeeding, and a more difficult birth with an increased likelihood of
PTSD. Pregnancy-related or postpartum anxiety can produce feelings of
constant worry, fatigue, nervousness, insomnia, mood swings, poor focus or
memory, hot flashes, nausea, and sleep disturbance. At its worst,
postpartum anxiety inhibits the mother ’s ability to care for her child,
causing conside rable distress and resulting in a sickly infant or even
infanticide. There isn’t much information about generalized anxiety in pregnant
women and new mothers, although it is believed that anxiety is more
prevalent in postpartum women than in the general population. In one study,
between 10% and 50% of new mothers with anxiety also displayed
symptoms of depression. 35 In another, 65% with generalized anxiety also
reported depres sion, panic disorder, or agoraphobia. It is believed that
generalized anxiety lasting more than six months may be more common in
postnatal women33 and that anxiety in new mothers is actually more
common than depression. 35 It can be challenging to achieve a clear
diagnosis of anxiety during pregnancy because it is normal for women to
experience a certain level of worry at this time. 36 Also, there is no data
about preexisting anxiety disord ers in women before becoming pregnant, so
it is impossible to ascertain to what extent anxiety is pregnancy related. Generalized anxiety disorder during pregnancy can present as
nervousness, fatigue, difficulty concentrating, persistent “worry” thoughts,
muscle tension, and sleep distur bance. Due to the physiological changes of
pregnancy, especially hormone-induced hyperventilation, pregnant women
may be at greater risk for panic disorder. While there is research suggesting
that pregnancy may provide some kind of protection against panic
symptoms, the role of premenstrual hormone changes in panic disorder
suggests that fluctuations in sex hormones make new mothers more
vulnerable to anxiety and panic disorder. 36 One review has confirmed this
increased susceptibility,37 and some researchers hypothesize that this may
be due to the sharp drop in progesterone after delivery. 37
During pregnancy, progesterone levels are high. This supports the
pregnancy, but it also causes hyperventilation and a reduction in blood CO2. After the baby is born, progesterone drops and CO2 rises, triggering panic
symptoms. Too much blood CO2 can cause panic attacks in patients who
have a high sensitivity to blood CO2, as the increase  in air hunger triggers
feelings of fear. 38 Conversely, panic symptoms  can be triggered by
hyperventilation when blood CO2 drops to levels that are too low. The
important thing to understand is that by improving functional breathing
patterns, it is possible to normalize levels of blood CO2 so that they are
neither too high nor too low. It is also possible to reduce the body’ s
sensitivity to CO2 so that normal fluctuations do not cause panic-inducing
air hunger. Panic symptoms include breathlessness, hyperventilation, chest pain, a
sense of choking or nausea, dizziness, and paresthesia (numbness and
sensations like pins-and-needles). All of these are also symptoms of
breathing pattern disorders. The symptoms of panic attacks point to a correlation with poor
oxygenation and sympathetic activation. Cognitive function abruptly
declines, feelings of exhaustion occur, the patient becomes increasingly
anxious to prevent further attacks, and quality of life suffers. In pregnant
women and new mothers, the anxiety around future attacks can become
severe enough to cause agoraphobia and social isolation. 33 There is also
evidence that anxiety in the mother during pregnancy impac ts on infanttemperament, producing babies who are more “difficult,” exacerbating
maternal anxiety and stress. 34
During and immediately after pregnancy, women are also more
vulnerable to experiencing other mental disorders such as OCD and PTSD. Left untreated, these problems can have a significant impact on the physical
and mental health of mother and child and other family members. 33 For the
most successful results, resear chers recommend an integrate d treatment
approach in which medicines are prescribed alongside psycho educational
options, such as relaxation exercises and cognitive behavioral therapy. There is no research into the therapeutic benefit of breathing exercises for
postpartum anxiety and depression, but a considerable body of research
does clearly indicate the link between blood CO2, sensitiv ity to CO2, and
these psychological disorders. While a few studies discuss the hormonal implications of abortion and
miscarriage, there is nothing  in the literature to connect hormonal
fluctuations in abortive pregna ncy to respiratory health. In women who
suffer very early pregnancy loss, the luteal phase is shorter for the next few
cycles. 39 Early pregnancy loss is also associated with lower levels of luteal
estrogen and progesterone. Heightened anxiety, depression, and insomnia
are, not surprisin gly, common after miscarriage. This is partly due to stress
and to fluctuati ons in sex hormones. A breathing practice would help
moderate hormone-induced hyperventilation during this difficult time,40
regulating important factors that influence sleep and mood. Important: The breathing exercises in this book should not be
practiced if you are in your first trimester of pregnanc y. Practice
relaxation and work to gently  restore nose breathing. In your second
trimester, you may practice gentle relaxation, nasal breathing, and slow
breathing. Throu ghout your pregnancy, it is very important to approach any
exercises very gently. You should not practice any breath holds while
pregnant. HORMONAL CONTRACEPTIVES AND THE BREA TH
Progestogens and estrogens combined in oral contraceptive pills have been
in widespread use since the 1960s. While much publicity has been given tothe potential side effects in terms of cardiovascular health, little research
has been done into the ef fects on breathing and the respiratory system. 41
One 1979 study did find that women taking a progesterone-o nly oral
contraceptive pill had a significa ntly greater minute ventilation than women
ovulating normally, except when the control subjects were in the late luteal
phase of their cycle. 16 This added weight to the idea that progesterone acts
as a respiratory stimulant, a theory that has since been confirmed. In terms  of respiratory symptom s, a 1999 paper found no indication that
hormonal contraceptives influenced asthma severity in women with mild
asthma. 42 In a 2001 cross-sectional study of the general population in
Copenhagen, no marked increase in asthma, asthma medication, wheezing,
or coughing on exertion was found in women using oral contr aceptives,43
although some studies showed that asthma symptoms were slightly
worsened by hormone replace ment therapy (HRT) in postmenopausal
women. In a 1995 study, researc hers found that women who had previously
taken oral contraceptives had a higher risk of developing asthma,44 in
contrast to a 2006 Australian study that reported a 7% decrease in adult-
onset asthma for every year of oral contraceptive use. 45 A study of women
in North ern Europe again found the opposite—that oral contraceptive users
displayed a higher risk of developing asthma—but when examined
alongside body mass index data, it was unclear whether the hormone pill or
body weight was the primary factor in the asthma symptoms. 41 A 2015
paper reported  that hormonal contraceptive use reduced asthma
exacerbations in nonobese women,46 while they increased the risk of
asthma in obese women. 47
An investigation of bronchia l hyperactivity (BHR) show ed less
variability in symptoms over the course of the menstrual cycle in women
using hormonal contraceptives, but the study did not describe how levels of
BHR were affected by contrac eptive use. 41 It makes sense  that women
whose asthma symptoms vary a lot through their menstrual cycle may
experience more  stability by using a hormonal contraceptive,  but studies
have returned contradictory results as to the relationship between overall
asthma susceptibility and contraceptive use. Clearly, observational research examining the connection between oral
contraceptives and respiratory health often produces results that are difficultto analyze. Studies are subject to the problem of “confounding by
indication. ” This is the scientifi c term for the difficulty in assessing a risk
factor or treatment in relation to an outcome when there are “confounding”
variables that could also be affecting the outcome. This is one reason why a
study may draw inaccurate conclusions. For example, in studies into the
side effects of a medication, patients who are prescribed the medication
may be inherent ly different from people who do not take it—they are, after
all, taking the drug for a reason. This very fact can distort the findings of
research. For example, oral contraceptives are often used to treat polycystic
ovary syndrome  (PCOS). PCOS is linked with asthma, lower lung function,
diabetes, and cardiovascular disease. Therefore, PCOS may be a significant
factor confoun ding (complic ating) the relationship between oral
contraception and respiratory disorders. This, however, has not been
considered in any of the studies described. The relationship is further
complicated by the fact that hormone contraceptives can sometimes cause
irregular menstruation. 41
In gene ral, the scientific literature on this topic is inconsistent and
problematic. The makeup of oral contraceptives has changed over time—
modern pills have a higher progesterone content and lower estrogen
compared with those that were used some years ago. Each pill used in the
early 1960s was roughly equivalent in terms of dosage to seven of today’ s
pills. 48
The 2012 review concludes that it is “likely and biologically plausible”
that oral contraceptives affect the airways in diverse ways. While some
studies indicate that asthma can be caused by contraceptives in some
women, others demonstrate the opposite. It is important, therefore, for
healthcare professionals to be aware of the possibility that hormonal
contraceptives might affect respiratory health in different ways and to listen
to their patients and assess them on an individual basis. The likelihood that
these medication s impact the airway is sufficient for researchers to advocate
that respiratory symptoms and disorders be included in trials of new oral
contraceptive pills. I recentl y talked  to Geor gie, a healthy 25-year -old woman who is very
fit with a high level of endurance. In the weeks before we spoke, Geor gie
had stopped taking her combine d oral contraceptive pill and returned to hernatural 28-day cycle. She tracks her cycle daily, logging her temperature via
a fertility and ovulation app called “Natural Cycles. ” She also takes her
BOL T score every day. Geor gie’s average BOL T score is around 30 or 31
seconds at rest, but during the midluteal/luteal phase of her cycle, there is a
marked decreas e of between 6 and 10 seconds. At the same time, she
experiences increased anxiety, lower motivation and a lack of focus. Since coming off the combined  contraceptive pill, she has noticed the
drop in her BOL T score is not so severe. Geor gie told me:
I know it usually takes around  three months for the hormone s to
fully adjust back into their natural rhythm when you come off the
pill, but for me an awareness of how my hormones fluctuate,
especially in terms of respiratory function, is comforting. It
improves my understanding about how to train in an athletic sense,
and it helps me to know when  I need to look after myself a little
more. Besides oral contraceptives, other methods of contraception are also in
common use. Nonoral options include inter-uterine devices (IUDs) and
implants, both of which release a synthetic progesterone hormone called
levonor gestrel. There are also injectable medications. Most list depression
and anxiety as side effects,9 though no direct link has yet been made to
breathing pattern disorders or respiratory health. It is possible, though the link has not been investigated, that the
recognized psychological side effects of hormonal contraceptives are linked
to low levels of blood CO2 triggere d by the hormone changes, just as
hyperventilation is a common factor in the luteal phase of the menstrual
cycle. The low levels of blood CO2 intrinsic to hyperventilation are
associated with panic attacks, and panic symptoms lessen when levels of
CO2 are normalized. Breathing exercises that normalize blood biochemistry
and decrease the ventilatory response to CO2 should help alleviate cyclic
depressive symp toms and create a positive feedback loop in which panic
symptoms are better controlled. In very rare cases, contraceptive  devices have been known to negatively
affect the health  of the respirato ry system in a directly physical  manner. Inone case, a young woman who was experiencing shortness of breath and
severe chest pain attended the emer gency department, where an X-ray
revealed that her IUD had become displaced and was in her abdominal
cavity. The device was removed, resolving her symptoms. IUDs should be
regularly checked that they are still correctly positioned. A misplaced IUD
should be considered by doctors where the cause of symptoms is not
clear. 49 In another case, a single-rod subdermal contraceptive implant
migrated into the lung of a 37-year -old woman. 50 Only those with the
relevant training should ever undertake the insertion and removal of these
implants. INFERTILITY AND BREA THING
In 2007, Austrian scientists examined changes in end-tidal CO2 pressure
during the menstrual cycle. 51 End-tidal CO2 provide s a measure of how
much CO 2 is in the blood. Researchers examined 160 women with a histor y
of regular menstrual cycles, measuring levels of blood CO2 every day. The
women’ s menstrual cycles were monitored using ultrasound and by
recording levels  of hormones, including estrogen and progeste rone, in the
blood and urine. The change in end-tidal CO2 during the menstrual cycle
was found to follow a regular pattern. They concluded that this could
provide a promising method of natural family planning, and that it should
be possible to identify the fertile phase of the menstrual cycle by measuring
end-tidal CO 2. 51
While CO 2 levels can help identify what’ s going on with the hormones,
there are clear aspects of health  that can cause complications for fertility. One such factor, described in a 2018 study, is psychological stress. 52 The
connection betw een stress and infertility has been debated for years. Women who experience infertility report heightened feelings of depression
and anxiety, and it is clear that infertility causes stress. What is less certain
is whether stress can cause or contribute to infertility. According to the 2018 review, recent research has documented the
effectiveness of psychological interventions in reducing mental distress and
significantly increasing rates of conception. The review concludes thattherapeutic approaches to reliev e stress may be the most effective way to
achieve both goals for women struggling to conceive. Cognitive behavioral
therapy (CBT) is suggested, but it is worth remembering that research has
found slow, diaphragm breathi ng to be as effective as CBT in treating
patients with panic attacks. 53 Slow, deep breathing works via different
mechanisms, addressing the biochemical trigger for stress as well as the
psychological factors. It would therefore make sense that breathing
reeducation could be useful in supporting women with infertility-related
stress. At the very least, it will certainly do no harm. Citing stress as a factor, a 2015  study examined the influence of sleep
on fertility. Stress certainly contributes to poor sleep, and the review set out
to exam ine by which mechanisms sleep disorders might affect fertility. In
the United States, infertility affects 15. 5% of all women and 24. 3% of
women who have never had a child. 54 According to the review, many more
women than men have insomnia. Menstrual transitions, pregnancy, and
menopause all create a vulnerability to sleep continuity disturbance, and so
women are more at risk for sleep problems throughout their lives. Traditionally, it was believed that mood swings, lifestyle changes, or
hormonal fluctuations create a susceptibility to insomnia. However, the
study suggests that the opposite  may be true—a disturbance in sleep may
influence fertilit y. If, for example, insomnia is caused by hyper arousal, the
body is reacting to a real or perceived threat. In this instance, insomnia may
be the evolutionary response to less-than-optimal circumstances for
reproduction. Sleep disorders  and disturbances are increasingly recogn ized as
pertinent to women’ s health and well-being, particularly in relation to the
menstrual cycle, pregnancy, and menopause. 54 Little is currently known
about how and to what extent fertility is affected by sleep quality and
quantity, but sleep problems are frequently comorbid with infertility. The
review conclude s that, at the very least, treatment of sleep disorders would
enhance the quality of life for women with fertility problems. At best, one
or more sleep disorders represent “moderating factors for infertility or
response to treatment. ” If this is indeed the case, treatment for sleep
disorders may increase the chance of natural conception, improve theresponse to fertility treatment, and boost the potential for successful
carriage to term. 54
Again, as we discovered in Chapter Seven  on sleep disorders, correct
breathing plays a vital role in sleep quality. This is yet another  therapeutic
reason to address breathing in sleep disorders, whether it impacts fertility
directly or indirectly. A study reported in Reuters Health  in 2018 further examined the link
between infertility and sleep disorders,55 suggesting that women who have
trouble sleeping may be more than three times as likely to experience
infertility and that women with insomnia are four times more likely to
struggle to conceive. The study  specifically examined women with sleep
disorders other than OSA. Difficulty conceiving is often caused by a
hormone imbalance called polycystic ovarian syndrome, though blocked
fallopian tubes, anatomical problems with the uterus, sexually transmitted
infections, smok ing, diet, age, and excessive alcohol consumpti on can also
play a role. The 2018 study examined data from 16,718 women, all newly
diagnosed with sleep disorder s over a 10-year period, 2000 to 2010,
alongside a control group of 33,436 women with no sleep problems. At the
start of the study, the women ranged in age from 20 to 45. Results, before
age and other health issues were taken into account, showed that women
with sleep disorders were around 2. 7 times more likely to experience
infertility. With age and other medical conditions factored in, women with
sleep problems were 3. 7 times more likely to be infertile. Sleep disorders
are frequently related to chronic  health problems such as high cholesterol,
hypertension, and lung disease. Women who sleep badly are also more
susceptible to irregular menstrual cycles, depression, anxiety, and thyroid
disorders. While the study did not examine whether a direct causal link exists
between sleep disorders and infertility, and researchers lacked data on
certain things that impact fertility, the results indicated that poor sleep may
be a factor for women strugglin g with infertility. CBT is the standard first-
line approach for treating insom nia, but breathing exercises can be effective
in addressing sleep disorders and the underlying stress that may be at theirroot. If you are trying for a baby, a gentle practice of slow breathing, sleep,
and relaxation will boost your physical and mental resilience and health. MANAGING MENOP AUSE
At a certain point in every wom an’s life, menstruation will spontaneously
and perm anently cease, and menopause will begin. While this is a natural
event and one that all women experience, there is little scientific literature
examining this characteristic change in sex hormone levels, and most
women don’t really know what  to expect. This is not really surprising in
light of the gend er imbalance present in scientific studies, but it is an issue
that is currently receiving growi ng attention. In medical terms, it is not even
entirely clear when menopause begins—the “menopause state” is confirmed
after 12 consecu tive months without a period41. This happens at a median
age of 51 years, although an extensive 2009 study reported an increase
toward 54 years. 56
Before menopause, many women experience a phase called
perimenopause. This is the body sending up flags of the coming hormonal
changes. Levels of estrogen rise before the production of sex hormones
ceases, and you might experience hot flashes, night sweats, sleep
disturbances, vaginal dryness, irregular periods, mood swings, recurrent
depression, and short-term memory loss. 41 Perimenopause begins, on
average, at the age of 46 and lasts for about five years. 41
One thing that is known is that while menopause is a natural
progression, smoking significantly impacts the age at which it occurs. Women who smoke enter menopause about a year and a half earlier than
those who don’t. 41 This already points to an obvious link between
menopause and overall well-being and more specifically, respiratory health. Early menopause is a known risk factor for various illnesses, including
cardiovascular diseases and osteoporosis. Early menopause is also directly
linked to mortality in general57. There are correlations between natural
menopause and lung health, but studies have largely failed to factor in other
things during a woman’ s life that are known to affect the function of the
lungs. 57As women live longer, they will spend more years in postmen opause,
and scientists recognize that this makes it essential to understand how
hormonal shifts during this period affect the health of the lungs. 57
Fortunately, the fact that proges terone levels drop after menopause means
that there is a large study population available in which reduc ed hormone
levels can be examined, and scientists are beginning to explore these
connections in more detail. A 2009 paper found that not only were estrogen and progesterone levels
significantly lower in postmenopausal women, the pressure of blood CO2 at
rest was much higher too58. This is because the central chemoreflex drive to
breathe is lessened after the menopause. This change is related to the
decrease in sex hormone concentrations and complex blood acid-base
interactions. This finding has important implications in understanding why
sleep-disordered breathing becomes more common after menopause. It is
also useful in determining the effects of HRT on ventilatory control and on
blood pH, at rest and during exercise, in both healthy women and those who
are unwell. 58
The authors of a 2020 study published strong evidence of a connection
between early menopause and reduced lung function. This was the first long
running study to confirm a relati onship between pulmonary health and early
natural menopause. Using data about lung function collected when
participants were 7 and 53 years old, researchers found that women whose
menopause occurred before they were 45 had poorer lung function than
those who experienced menopau se aged 45 or later. This is the first study to
take into account factors earlier in the lives of the women, such as
childhood asthma, socioeconomic status, and parental smoking. 59
By identifying that this relationship exists, scientists have made it
possible to assess women with a higher potential risk of lung problems or
those women who might be likely to develop lung disease when
menstruation ends. Early menopause triggers a susceptibility to respiratory
disease and a vulnerability to environmental factors such as air pollution
that has not previously been recognized. It is unclear whether changing
hormone levels directly accele rate the decline in lung functi on in some
women, but a clear link between estrogen fluctuations and pulmonary
health exists. Women whose respiratory function is poor before menopause may be at
an even greater risk, especially  if they are subject to other factors, for
example, regula r exposure to toxins at home or at work. Women who have
an existing lung condition, such as COPD, and experience early menopause
may subsequently suffer a more serious and progressive version of the lung
disease. 59 The study recommends that the impact of menopause on asthm a
be reevaluated. It also suggests that immune dysfunction connec ted with the
main estrogen of menopause may be significant in a chronic condition
called bronchiectasis, a disorder of the airways that mainly affects
postmenopausal women. A high proporti on of the women in this study who experienced early
menopause had also had early menarche. It is believed that these women
may be generally at higher risk for lung dysfunction or disease. Interestingly, women in this same group were more likely to smoke and to
use hormonal therapies. Women in the study cohort who were still
menstruating had the lowest rate of respiratory symptoms and diseases. While this study  represents a step forward in research on the topic, more
work is needed to understand the mechanisms of menopaus e and lung
function. Howev er, it is importa nt that early menopause is understood to be
a risk factor in respiratory health. IMPACT OF HORMONE REPLACEMENT THERAPIES ON THE
BREA TH
As menopause occurs, many women choose to take a HRT for either shorter
or longer periods. There has been some uncertainty about the safety of these
medications, largely because of reports from the Women’ s Health Initiative
study, which condemned the therapy as unsafe due to links with increased
risk of coronary heart disease and breast cancer. 60 The uptake of HRT
declined as a result of this publicity. It was subsequently shown that the risk
of breast cancer was low and only relevant for women with a very long
exposure to a combined HRT regimen, and that for some, estrogen may
actually reduce susceptibility. More recently, these findings were again
contradicted in research published in the British Journal of Cancer, which
reported that women taking combined HRT are nearly three times more
likely to develop breast cancer than nonusers, with risk increasing withlonger HRT use. The “Breast Cancer Now Generations Study” provided a
comprehensive update about HRT use, suggesting that many previous
investigations were not so thorough and may have “underestimated the
increased risk of breast cancer by up to 60%. 61 Importantly, the heightened
risk level appears to return to normal once HRT use ends. 61 There is not
thought to be increased risk for coronary disease. 60
Overall, the link between meno pause and lung health is still not well
understood. Despite the fact there has been a certain amount of research
focus on HRT, the underlying condition of menopause itself has barely been
studied. What literature there is on HRT and respiratory health returns
confusing results. Research into asthma and other respiratory symptoms tends to indicate
an incre ased risk for women who take HRT, especially nonsmokers and
women with a lower BMI. However, studies of lung functio n suggest a
beneficial or at least a neutral connection with HRT. 41 As we discovered
earlier, studies often contradict each other for various reasons. There may
be differences in BMI between study populations, clinical practice around
HRT use isn’t always the same,  the type and duration of HRT differs, and
there are variations in study design and even in the assessment of
menopause. There are also complex problems around distinguishing the
effects of HRT from symptoms of menopause itself. Fundamentally, as
studies have explained, more knowledge of biological mechanisms is
needed before it is possible to return truly accurate results. In 2017, Science Daily  reported the results of new research, presented at
the European Respiratory Society International Congress, which
demonstrated that oral HRT can slow the decline in lung function in
middle-aged women. 62 The study followed 3,713 women for two decades
between the early 1990s and 2010 and found that those who took HRT for
two years or longer did better on lung function tests than women who had
never taken HRT. Lung function is at its best during the midtwe nties. From
then on, it decre ases incrementally. One thing that accelerates lung decline
is menopause— which raises the question, could HRT at least partly
counteract it. The wom en’s lung health was tested at the start of the survey and again
20 years  later. The measurement used was forced vital capacity  (FVC),which assesses the volume of air that can be exhaled from the lungs after
taking the deepest possible breath. Women who used HRT lost, on average,
46 milliliters less lung volume over the 20-year period than those who had
never taken it. To put this finding into context, 46 milliliters is
approximately the amount of lung volume that would be lost by a woman
who smoked a pack of cigarettes every day for three years. While
researchers do not believe this is likely to be clinically significant for
healthy women, for women who have airway disorders, the decline in lung
function could lead to increased breathlessness and fatigue, decreased
ability to work, and poorer quality of life. 62
While the study does not advocate either for or against HRT, the
findings do demonstrate the importance of female sex hormones for the
maintenance of healthy lungs in middle-aged women. This research
provides another piece in the puzzle in understanding the relationship
between menopa use and lung health. The fact remains that women and their
doctors need to be better infor med about the health changes that happen
after menopause. Women with existing respiratory conditions such as
asthma should be closely observed during the menopausal transition, and
advice about medication should  be more personalized and take changing
hormonal levels into account. OSTEOPOROSIS AND BREA THING P ATTERN DISORDERS
Osteoporosis is a condition prevalent in postmenopausal women that might,
at first, appear to have no connection with breathing. 63 It is a disease of low
bone mineral density or excessive bone loss and is a common cause of bone
fractures in older women. Osteoporosis affects 200 million women
worldwide, with nearly one in two women over the age of 50 likely to
suffer an osteoporosis-related fracture. In women over 45, the condition
accounts for more days of hospitalization than diabetes, heart attack, or
breast cancer. 64
It can cause repeated fractures of the vertebrae attached to the ribs,
which may lead to an excessive curve in the spine called thorac ic kyphosis. Each time one of these thoracic vertebrae is broken, lung capacity shrinks,
with a reductio n in forced vital capacity of 9%. While research hasexamined the link between osteoporosis and respiration in terms of this
impact on mechanical function, very little work has been done to measure
lung health in women with osteoporosis but no diagnosis of chronic
respiratory disease. The fact that women with osteoporosis commonly complain about
breathlessness prompted a 2018 study. 63 Researchers theorized that the
fragility of the rib cage typical  of bone loss and osteoporosis  negatively
impacts respirat ory function by inhibiting the body’ s responses to normal
breathing stimuli, and thus affecting the blood acid-base balance. In simple
terms, the fragility of the ribs causes instinctive changes to breathing
patterns, designed to protect weakened bones. To test this theory, scientists assessed lung function, arterial blood gas
levels, central respiratory drive, and breathing patterns of wome n with bone
fragility who had no respiratory illness, kidney disease, or anem ia, and who
were not taking any medication known to alter blood pH. The women’ s
results were compared with a control group of women who did not have
bone fragility. The results showed for the first time that women with osteoporosis or
bone loss who had never smoked displayed disturbances in blood gas
exchange and changes in breathing patterns compared to age-matched
healthy women. The differences were not the result of anatomi cal changes
or other conditions such as cardiorespiratory disease. This is the first study
to look at gas exchange and breathing patterns where participants were
selected to minimize confounding factors, such as respiratory disease,
smoking, medications, and anatomical considerations. Lung volumes at rest and during  exercise were similar in all the women,
but the differences in breathing  patterns and gas exchange values between
women with or without bone fragility were significant, even though all the
values fell withi n normal reference ranges. Differences included  changes in
the ventilatory response to CO2, lower levels of arterial CO2 and oxygen, a
higher arterial to alveolar oxygen gradient suggesting defective diffusion of
oxygen from the blood to the lungs, and higher pH levels in the blood. Interestingly, bone loss has been linked to depressive symptoms. Postmenopausal women are at increased risk of depression at the same time
of life they are vulnerable to bone loss. While several studies have found arelationship between bone loss and depression, none have identified the
reason for the connection64. Osteoporosis and bone loss are often
undiagnosed until a woman suffers a fracture. However, a 2018 review
found that depressive symptom s are indicative of bone loss, may help
identify women with these conditions, and should trigger further
investigation of bone health. 64
According to a 2019 paper, the biochemical and physiological effects of
psychological stress are recognized as contributing factors in
osteoporosis. 65 Researchers looked at evidence pointing to stress-associated
mental health disorders as risk factors for osteoporosis. They suggested that
therapies to address psychological health could have benefits for bone-loss
patients. Resear ch into this topic is limited, but the studies that do exist
indicate that a personalized, multifaceted approach may improve patient
outcomes, particularly in those who are at a higher risk of developing
osteoporosis. A further link exists between osteoporosis and anxiety. 66 A 2018  study
of 192 women found that those with high levels of anxiety were more prone
to osteoporosis-related fracture. Anxiety levels were connected to age,
depressive symptoms, years since menopause, and age at menopause. Scientists concluded that anxiety levels in postmenopausal women were
associated with,  and predictive of, reduced bone mineral density in the
lumbar spine and hips. While it is interesting to explore the connections between osteoporosis
and breathing, there is currently no research to indicate a direct link
between menopausal depression and anxiety, physical symptoms of bone
mineral loss, and breathing pattern disorders. However, it is the case that
addressing poor breathing can significantly improve quality of life by
reducing susceptibility to a huge range of mental and physical conditions. SLOW, DEEP BREA THING AND MENOP AUSE SYMPT OMS
It has been proven that slow, deep breathing can reduce certain hormonal
symptoms of menopause. A 2012 study explored the potential of
parasympathetic activation via slow, deep, diaphragmatic breathing toreduce the frequency and severity of hot flashes. Paced breathing can
reduce the stress response, relaxing the body and mind. 67
For the study, scientists designed a nine-week, three-arm clinical trial in
which participants used an audio CD to practice guided paced breathing
exercises. One group practiced  at 6 breaths a minute once a day for 15
minutes. A second group practic ed the same exercise twice a day. The third
group practiced  14 breaths a minute for 10 minutes each day (normal
breathing). Near ly 80% of the women who completed the study found the
exercises easy to do and to fit into their daily routine. All of the participants
across the three groups reporte d reductions in hot flashes. Women who
practiced paced breathing twice  a day saw the biggest improvement (52%). Those who practiced 6 breaths a minute once a day saw a 42%
improvement and those practicing normal breathing experienced a 46%
improvement. The researchers concluded that paced breathing provides a
workable intervention that can be easily applied, and a larger study is
needed to fully assess the impact of the breathing exercises on hot flash
reduction. The ebook, Recognizing and Treating Breathing Disor ders, cites earlier
studies that demonstrate women  who are unable or “unwilling” to take HRT
have successfully used breathing retraining to reduce hot flashes. 68,69
This research is backed up by an email I received from a client who
wrote that she had noticed significant benefits after implementing the
breathing techni ques. She said, “I have noticed a 90 to 100% decrease in
night sweats when I go to bed with my mouth taped, and this is after only
one week. ” This points to better regulation of the autonomic nervous
system and corresponds with research that connects nocturnal sweating with
sleep apnea. 70 According to the 2013 paper, incidence of night sweats is
three times higher in people with untreated sleep apnea than it is in the
general population. By using MyoT ape to ensure nasal breathing during
sleep, night sweats, apnea, and the associated insomnia may all be
alleviated. WHA T’S NEXT FOR FEMALE RESPIRA TORY HEAL TH. The scientific literature explor ing the role of female sex hormones in
respiratory health is complic ated and incomplete41. Women differ
significantly in hormonal profiles over the course of their lives, and
assessment of hormonal status is still a problem in that menopause cannot
be confi rmed until 12 months after it actually occurs. Even then, it is often
difficult to determine because of the use of hormonal medications. It is important that research begins to investigate hormonal influences
on respiratory health in sufficiently large studies. Future work needs to take
into account real life factors, such as smoking, which has an antiestrogen
effect. For instance, establishin g a clear connection between asthma and
HRT is likely to be heavily influenced by understanding the role of
smoking. There is enough evidence to be sure that sex hormones do influence
respiratory health and disease throughout the course of a woman’ s life. However, the understanding of this impact is limited. Some research covers asthma and lung function, but hardly any
investigates COPD. It seems fairly clear that women who reach puberty
early and have irregular periods also suffer with more asthma and poor
lower lung function. Asthma and respiratory symptoms are known to
fluctuate during the menstrual cycle, and this suggests the possibility of
therapeutic interventions. Changes in respiratory health around menopause are likely but very
understudied and difficult to measure due to HRT use. Better understanding
of these areas has great potential to improve treatment and outcomes for
women with asthma and COPD. The 2012 review of the literature on
respiratory healt h in women from  menarche to menopause concludes firmly
with this statement, “The era for investigating respiratory health in 2,000
men and 29 women has passed. ”41
OceanofPDF. comDCHAPTER FOUR TEEN
SUGAR, SUGAR
WHA T IS DIABETES. iabetes is a long-term disease that affects the way the body
metabolizes blood sugar or glucose, an important source of energy. Glucose comes from the food we eat, especially foods rich in
carbohydrates. During digestion, those carbohydrates are broken down into
simple sugars that enter the bloodstream via the intestines. 1 When this
happens, beta cells in the panc reas secrete insulin, which is a hormone. 2
Hormones are chemical messeng ers produced by the body and released into
the blood to trigger specific responses. Insulin’ s job is to enable the cells to
absorb blood sugar to release energy. The relationship between  insulin and
glucose is similar to that of carbon dioxide (CO 2) and oxygen. Just as CO2
is needed to release oxygen from the blood, insulin is necessary to unlock
the ener gy in blood glucose. In a healthy system, insulin helps regulate blood sugar, making sure
there is never too much (hyper glycemia ) or too little (hypoglycemia )
glucose in the blood for the body’ s vital systems to function. 3,4 In a diabetic
body, this proce ss is compromised, either because the pancreas produces
insuf ficient or no insulin (type 1) or because the body is unable to use
insulin properly (type 2). When this happens, glucose can’t be absorbed by
the cells, and levels of blood sugar become chronically high. TYPE 1 DIABETESType 1 diabetes is an autoimmune disorder that results in excessive sugar in
the bloodstream. People with this type of diabetes are not able to produce
their own insulin due to an immune system malfunction that destroys the
insulin-producing beta cells of the pancreas. Instead, they have to inject
insulin every day to keep blood sugar under control. This type of diabetes tends to occur during childhood or early
adulthood. Its cause has not yet been determined, but scientists believe it
begins with a genetic predispos ition and is initially set off by an immune
system activated by, for example, a viral infection, environmental triggers,
or a genetic condition. 5 The immune system attacks the beta cells in the
pancreas, producing a single insulin-destroying antibody. According to TrialNet, an international network of researchers working
to understand type 1 diabetes, if you have a relative with type 1 diabetes,
you have a 1 in 20 chance of developing the disease, compared to a risk
factor of 1 in 300 for the general population. 2,6 In child ren under the age of
five years, incidence is increasing. In the United States, figures suggest that
1 child in every  400 to 600 is affected, and 15% to 20% of new diagnoses
are in children under five. 7 Because type 2 diabetes is also to some extent
hereditary, peop le often confuse the two conditions, but it is important not
to lump the two types of diabetes together. TYPE 2 DIABETES
This is the more  common type of diabetes, affecting around 90% to 95% of
adult diabetics. Type 2 diabetes manifests as difficulty using and producing
insulin, otherwise known as insulin resistance. Blood sugar levels become
too high because the body can’t respond normally to insulin. This causes
the system to compensate by producing ever-increasing amounts of the
hormone. Over time, the pancre as becomes exhausted by its efforts to meet
the demand for insulin. It becom es unable to produce sufficient insulin, and
blood sugar levels rise even higher. 3,4
Whenever imba lances exist, the body’ s systems will try to restore
homeostasis. If any aspect of those systems is faulty, long-term adaptations
occur that can drain the body’ s resources, impacting overall health. Oneexample of the body’ s attempt to restore homeostasis, of course, is the
biochemical response to habitual overbreathing. According to key statistics from Diabetes UK, contributing factors in
type 2 diabetes include obesity, age, genetic predisposition,8 socioeconomic
status, and ethnicity,9 In part, this is because people from deprived
backgrounds are more likely to experience physical inactivity, a poor diet,
and tobacco use. 10
The onset of type 2 diabetes can be difficult to identify, as it progresses
more slowly and without the acute metabolic disturbances seen in type 1
diabetes. 11 As many as half of all type 2 diabetics may be undiagnosed. 11
WHY DIABETES LEA VES YOU BREA THLESS
Abnormal respir atory function is a feature of both types of diabetes. 12 A
2017 study describes the negative impact type 2 diabetes has on lung
health. 13 Researchers explain that insulin resistance, chronic low-grade
inflammation, and damage to the veins and autonomic nervous system all
contribute to the lung deterioration associated with type 2 diabetes, causing
physical changes that include changes to the tissues. 13
Diabetes is recognized as a risk factor for sleep-disordered breathing,
sleep apnea, and daytime sleepiness. 13 Researchers recommend that patients
with type 2 diabetes should be considered at risk of pulmonary
dysfunction. 13 The paper notes that in previous studies, declines in lung
function could be detected up to three years before type 2 diabetes was
diagnosed. 13 In another paper, which examined lung health in Native
Americans with diabetes, impaired pulmonary function was observed
before diabetes occurred. What’ s more, the risk of diabetes increased by 2%
for every 1% decrease in forced ventilatory capacity,14 a measure of lung
volume. Also, both types  of diabetes can cause a type of nerve damage called
neuropathy. Neuropathy can affect the phrenic nerve, an important nerve
responsible for motor control of the diaphragm. 15 This is one factor that
may lead to respiratory symptoms, respiratory failure, and even death in
diabetics. When the body is not able to process blood sugar properly,
complications occur on a “microvascular” and “macrovascular” level—both
in the small and large blood vessels. The blood vessels essentia lly become
“clogged” with excess glucose. On a microvascular level, this affects the
tiny blood vessels in the skin and eyes and can lead to problems that include
blindness,16 damage  to the retinas and nerves, and kidney failure. 16 On a
macrovascular level, it affects the feet,17 impacts organs including the heart
and brain, and can lead to heart attack and stroke. 12 The first obvious sign
of these problems may be excessive breathlessness. According to the National Kidn ey Foundation, around 30% of type 1
diabetics and 10% to 40% of type 2 diabetics will eventually suffer from
kidney failure. 18 One outward symptom of kidney failure is breathlessness. Acute breathlessness can be caused by a serious condition called diabetic
ketoacidosis or metabolic acidosis, which involves disruptions to the blood
acid-base balanc e that adversely affects the respiratory system. 19 Metabolic
acidosis can lead to respiratory failure and contribute to the development
and progression  of disease. Much like respiratory acidosis, this type of
acidosis commonly causes hyperventilation, a fast breathing rate, and a
decrease in blood CO2 that evolves into overbreathin g with an increased
tidal volume. 19 Left untreated, it can be fatal. 19
Dysfunctional breathing is prevalent in type 2 diabetes. One study found
that patients with type 2 diabete s had significantly lower end-tidal CO2 and
a much higher respiratory rate than a control group of healthy people. Scientists conclu ded that lung function was impaired in the diabetic patients
and that they would benefit from a program to improve it. 20
Earlier research, which investig ated lung function in patients with type
1 diabet es, identified the lung as a “target organ” for diabetes. 21 Another
paper examined 45 patients with type 2 diabetes and found a “strong and
inverse relationship” between the duration of the diabetes and diminished
lung volumes, concluding that poor blood sugar control was directly related
to decreases in the volume of the lungs22. Severa l other studies have also
associated diabetes with reduced lung function and respiratory muscle
weakness. 23–26
Gas exchange in the lungs occur s in the alveoli, where a thin membrane
separates capillary blood from the air. Any damage to this membrane willnegatively affect the lung’ s ability to absorb oxygen into the blood and
release CO2. Scientists have suggested that changes in lung function,
especially reduced gas exchange, may occur in patients with diabetes as a
result of damage to the alveoli. 27
A study of yogic techniques, including breathing exercises and
relaxation, found that the exerc ises led to better lung functio n in type 2
diabetic patients, improving forced expiratory volume and forced vital
capacity. 28 Researc hers suggested that the increase in lung function was due
to pract ices designed to improve respiratory muscle stamin a and lung
expansion and to conscious breathwork, which relaxed the respiratory
process, suppor ting better lung elasticity and function. 28 Like previous
research in healthy patients and people with a range of conditions, yoga was
found to be helpful in diabetes, reducing obesity, improving oxygenation,
opening the airways, and increasing recruitment of the alveoli. 28
Diabetics should find breathing exercises helpful. Light, slow, deep,
breathing reduces stress, which  we know is instrumental in the onset and
progression of disease. Lower sensitivity to CO2 helps maintain
homeostatic balance in the blood acid base, and nasal breathing from the
diaphragm supports healthy lung volumes and respiratory muscle function. In addition, functional breat hing harnesses CO2, an important
vasodilator. Poor vasodilation is a major issue in diabetes and can
compromise circulation in the legs, leading to painful ulcers. 29 One 2015
study reported that CO2 therapy was beneficial in treating foot ulcers in
diabetic patients  by increasing blood flow to the affected area. 30 In that
experiment, synthetic CO2 was dissolved in water and applied directly to
the feet to improve tissue oxygenation, just as the Romans and ancient
Greeks used to do, bathing in waters rich in carbonic acid to cure a variety
of illnesses. NICK’S ST ORY
Nick Heath is an Oxygen Advantage instructor. He is also a type 1 diabetic. Nick was just 11 years old when he was diagnosed. For 14 years, he
received “standard care” for his condition, but the results were mediocre atbest. At the age of 25, he bega n to eat better and exercise regularly. His
blood sugar improved, and at the time, he thought it probable that he had
achieved the best control he was ever likely to have over his diabetes. Despite this improvement, over the next few years, he still felt that
something was amiss. Nick was doing everything he could from a
nutritional and exercise perspe ctive, but he was still unable to maintain
consistent ener gy levels, and he often felt drained. When he was 30 years old, Nick found the Oxygen Advantage. After his
first night using a lip tape to ensure nasal breathing during sleep, he woke
up noticeably refreshed and full of vitality. He emailed his wife at work to
say that either he was crazy or taping was the best thing ever. Section summary: 

Please summarize the passage according to the guidelines below. *   Ensure accuracy : Be precise regarding facts within the document; avoid misrepresentation. * Concision : Limit yourself to crucial insights extracted primarily based upon original sources ; omit unnecessary material;
      preserve coherence across sentences/paragraphs. Your final output must adhere strictly to these standards :

**Summary:**


Note: Please rewrite/rephrase/simplify/focus on main ideas instead of copying/pasting sections verbatim. Section Summary

Emma's story highlights personal experiences battling Pre-Menstral Syndrome (
         **<font face="Arial" style="color:green">*</font>**, emphasizing self-care practices incorporating < fontface = " Arial"
style= "" >nasal</FONT>

[. ]
```
Here is a concise summarizer:

After researching online forums and consulting multiple experts,

### Overall Summaries  
#### No Title Provided  

No title selected. Select a meaningful name for consistency. ## Overview



To enhance comprehension clarity, please paraphrase rather copy-paste passages word-for-word). You're requested to simplify & concentrate core concepts exclusively dependent solely [primarily]based ]upon authentic origins. , avoiding superfluity along keeping internal cohesivity amongst phrases paragraphs. When composing summaries consistently observe strict adherence towards mentioned principles :
(accuracy precision avoidance representation)



These individuals consulted trusted advisors concerning concerns pertaining [[https://www. healthline. com/nutrition/detox](#text)[@link]

Some ladies confront difficulties coping [[http//en. wikipedia. org/wiki/Premenstra |PreMenstrar]] Symptoms (#PS). Given prior utilization of [](#note 75)] # PS-Symptomology # PsychologicalFactors#. Then started consuming nutritional substances containing indole-[[](#page][[#], [[]]], Indoles methylation pathways. [[@R|[[http]]
Within fifteen-twenty minuettes per twenty-four hrs, commencing a session involving ten mins meditation. Research demonstrates that supplementation coupled nutrition plan aids manage ([~[(wiki)|[/URL]]. {}}]. } {)}]}])}, Consequently, ~{}))}

Final Verdict:- We've got our last conclusion. So far… So let us proceed with whatever else. We'll talk briefly afterward. =====References===[1]: https:/ / en. wiki. pedia. or/g wiki/Sleep_disorder#: ^{(‘ ‘ } http:/// www. google. co. uk/#^{\*\}\*

What exactly. That implies\*. \*, 123456789012345678901234567890125768543210987654321098.
Emma started taking daily supplements of diindolylmethane, magnesium, and a vitamin B complex, and made significant lifestyle changes, including nasal breathing and meditation.
What did Emma do to alleviate her PMS symptoms?
The IUD releases hormones more directly into the body, whereas oral contraceptives do not.
What is the main difference between IUDs and oral contraceptives?
The study suggests that sleep disorders may contribute to infertility, and that addressing sleep problems could improve fertility.
What is the relationship between sleep disorders and infertility?
Type 1 diabetes is an autoimmune disorder that prevents the pancreas from producing insulin, whereas type 2 diabetes is a condition where the body becomes resistant to insulin.
What is the main difference between type 1 and type 2 diabetes?
The text does not explicitly state a direct connection between CO2 and respiratory health, but it does discuss the relationship between CO2 levels and various health issues, such as anxiety, panic attacks, and breathing disorders.
What is the connection between CO2 and respiratory health?