Inspired by
his newfound energy, which seemed more stable and long-lasting than any
previous change, he also began applying the slow breathing and breath-hold
techniques from the Oxygen Advantage. After a few months, he noticed his
blood sugars were improving considerably and he needed 10% to 20% less
insulin. Nick’ s college major was meteorology , qualifying with a PhD. This
background as a research scientist made him eager to learn how the
breathing exercises were having  such a dramatic impact on his diabetes. He
spent several years exploring the impact of correct breathing techniques on
diabetes and chronic disease and found evidence to explain the positive
effects of slow breathing and breath-hold exercises on his blood sugars. Slow breathing has been shown to improve the function of the
autonomic nervous system by reducing activation of its stress-driving
sympathetic branch31. It reduces oxidative stress32—an imbalance of
antioxidants and free radicals that contributes to the aging process and can
lead to cell and tissue damage33. Lack of oxygen in fat cells has been
directly linked to the development of insulin resistance in mice.34 Slow
breathing also lowers blood glucose35 and increases oxygenation of the
tissues.31,36 This enhanced uptake of oxyge n into the blood and cells could
be crucial in understanding why slow breathing is so helpful for diabetics. Studies have shown that the root cause of autonomic dysfunction in
diabetes might be tissue hypoxia37—a condition in which part of the body is
deprived of adequate oxygen. Slow breathing practice supports optimum
gas exchange and better oxygenation, helping the body restore autonomicbalance. This, in turn, reduces stress38 and anxiety ,39 helping control
fluctuations in blood glucose. As part of the fight-or -flight stress response,
the body releases stored glucose from the liver into the blood. If insulin
function is poor, that extra blood sugar cannot reach the cells and sugar
concentrations in the blood rise.40 Research has also shown that slow
breathing can increase insulin sensitivity ,41 particularly in type 2 diabetics. This means that insulin is more able to do its job and the body can
metabolize blood sugar better . Nick also discov ered the power of taping his mouth at night to reduce
sleep-disordered breathing. (This technique is described in detai l in Chapter
Seven .) An intimate two-way link between type 2 diabetes and sleep apnea
has been established.42 One 2010 pilot study reported that 40% of its 37
long-term type 1 diabetic subjec ts had OSA.43 While Nick didn’t believe he
had sleep apnea, when he taped his mouth to ensure nasal breathing at
night, he experienced much deeper, more restorative sleep. This resulted in
better morning blood sugars. As anyone living with type 1 diabetes will
know , managing the condition is a full-time job. The increased energy Nick
felt as a result of taping meant he felt better able to control his diabetes
throughout the day . Another reason for Nick’ s impro ved quality of sleep could be that better
breathing helped balance his autonomic nervous system, improving
autonomic funct ion. Diabetics tend to have lower parasympathetic tone at
night, which may result in a disrupted circadian rhythm.44 Slow breathing is
known to increase parasympat hetic activity . (We examined this in the
context of the vagus nerve in Chapter Four .) By nasal breathing during
sleep, a practice  that results in slower breathing and stimulate s the vagus
nerve, it is likely that Nick improved his circadian rhythms. Nick also began a breath-hold practice. As a surfer , he primarily used
the exercises to improve his confidence in the water . However , his research
led him to understand that breath holds, or intermittent hypoxia , were a key
component of his increased diabetes control too. The positive results Nick
experienced can be explained by three factors:
1. Hypoxia lowers blood sugar , independent of insulin sensitivity .45
2. Hypoxia strengthens the innate function of the immune system.46
3. Hypoxia increases insulin sensitivity .47Important:  It is never advisable to practice breath holds while in the
water . If you take part in any water sports, you should only practice these
breathing exerci ses on dry land so you can enjoy the benefits when in the
water . Of the three techniques, slow breathing, taping, and breathholdin g, Nick
found that taping  at night had the greatest impact. He wakes every morning
energized, with good blood sugars, ready for a great day. Since beginning
with a breathing  practice, he has seen a marked improvement in his quality
of life and in his diabetes. His average blood sugar measurements are the
best they have ever been. DIABETES CONTROL AND THE BREA TH
Functional breathing is a keystone habit that forms the foundat ion of good
health,48 and diabetes is no exception. Studies have explored the potential
of deep breathing and controll ed intermittent hypoxia (IH) as a holistic
intervention to relieve symptoms associated with both type 149,50 and type 2
diabetes.47,51,52 Trials have focused on the possible applications for
improving blood sugar , biological functioning, energy, stress, and well-
being. Controlled IH is a period ic dropping of blood oxygen saturation with
adequate recove ry between sets. Because it is controlled, it differs from the
unhealthy oxyge n decrease seen in sleep apnea. IH can be achieved with
breath holds or by using breathing equipment and altitude tents. Research into breathing techniques would be immensely valuable for
medics, certified breathing instructors, and other holistic practitioners who
are interested in using the princ iples of IH breath training to improve the
health of their diabetic patients. Studies indicate that integrating periodic
breath holds (IH breathing training) into diabetic care plans is an excellent
step toward improving quality of life. Important: If you have diabe tes, it is vital that you monitor your
blood sugar levels regularly during practice of any kind of breathing
exercises. Breath holding can cause blood sugar levels to drop too
quickly . To monitor blood sugar level s, consider investing in a continuous
glucose monitoring (CGM) device—a readily available gadget that allowsyou to check your blood sugar levels in a noninvasive way. They are not
cheap, but, as the range of products on the market expands, they are
becoming more  accessible. If you have type 1 diabetes, it’s likely you
already own a CGM, but they are equally valuable for any type 2 diabetic
interested in making lifestyle choices that will improve their condition. As Nick also discovered, good quality sleep is an essential part of
diabetes management. Many aspects of sleep-disordered breathing can be
addressed simply by making the switch to nasal breathing during sleep. Healthy breathing while asleep  has many positive effects on the body’ s
systems that are beneficial for many conditions, including diabetes. This is
worth paying attention to since sleep deprivation is associated with insulin
resistance, and poor sleep qualit y, sleep apnea, and insomnia have all been
shown to increase the risk of type 2 diabetes.53
DIABETES AND RESPIRA TORY DISEASE
Type 1 and type 2 diabetics have a higher risk for four major respiratory
diseases.54,55 A resea rch pape r published in Diabetes Resear ch and Clinical
Practice  analyze d the link between type 1 and type 2 diabetes and four
common respir atory diseases:  chronic obstructive pulmona ry disease
(COPD), chronic bronchitis, emphysema, and asthma.54,55 The study looked
at data from 53,146 adults, all aged 20 years or more. Of the participants,
781 had type 1 diabetes, 4,277 had type 2 diabetes and 48,088 were
nondiabetic. Respiratory diseases were present in 26% of type 1 diabetics,
21% of type 2 diabetics, and 13% of nondiabetics. A number of different
examinations also showed that type 1 diabetics were 62% more likely to
suffer a respiratory disorder than nondiabetics, while type 2 diabetics were
26% more vulnerable. The most common disease was asthma, and type 1
diabetics were found to be 51% more at risk of asthma than nond iabetics. In
type 2 diabetes, the increased likelihood of asthma was 38%.54,55
Impaired immun e function is a common feature of diabetes. In type 2
diabetes, researchers have identified oxidative stress as one possible
pathway by which innate immunity is disrupted.56 In type 1 diabetes, the
immune response is, by nature of the condition, dysregulated. One theory
points to systemic inflammation as a link between diabetes and lungdysfunction.12 Exaggerated inflammatory responses in the lung may be the
result of an impaired ability to regulate inflammatory mechanisms.12 (The
connection between inflammatory responses and breathing was explored in
depth in the chapter on the vegas nerve, Chapter Four .) Equally , even before type 2 diabetes is diagnosed, the lung may be the
primary location  for the activat ion of inflammatory processes. This might
explain why lung function is already worse before the onset of diabetes. A
2012 study describes lower lung volumes in type 2 diabetics with
inadequate glycemic control than in those whose blood sugars were well-
regulated. Patients with poor blood glucose control also had much higher
blood levels of inflammatory markers, indicating that inflammation is
involved in the decrease in lung function and fibrosis in type 2 diabetics.12
The paper suggests that both systemic inflammation, which involves
chronic activatio n of the immune system57, and inflammation in the lungs58
may contribute to the “complex interplay between respiratory and metabolic
dysfunction.”12
In type 1 diabetics, abnormal growth during childhood (stunting)59 may
affect the proper growth and development of organs including the lungs. While the duration of diabete s has an inverse relationship with lung
function in type 2 diabetics, there isn’t strong evidence to support the same
connection in type 1 diabetes.60 Howev er, a 2011 study did find a
significant difference in the incidence of restrictive breathing disturbances
depending on whether or not “extreme stunting” was present. Another study states that children with type 1 diabetes have increased
airway resistanc e and that they are more likely to have abnormal lung
function later in life, with long-term problems, including decreased lung
volume, less ability to diffuse CO2, and poor diabe tes control. Researchers
concluded that progressive abnormalities in lung function might adversely
interfere with the ef fectiveness of intrabronchial insulin treatment.61
In a 2020 Swedish cohort study of more than one and a quarter million
children, of whom 9.5% had asthma and 0.3% had type 1 diabetes,
scientists found that children with asthma were more likely to develop type
1 diabetes, but the reverse was not the case. Asthma was assoc iated with a
small but significant increased risk of being diagnosed with type 1 diabetes
compared with non-asthmatic children.62 In an article for MedPage Today ,physician Michael Yafi suggested that, “It may seem plausible that some
factors, like early exposure to viruses, would play a role in the development
of these two diseases.”63
Yet another paper looked at changes in the thickness of the lung cell
basement membrane in patients with pulmonary diseases. The study
examined participants with diabetes, asthma, bacterial pneumonia,
pulmonary tuberculosis, idiopa thic pulmonary fibrosis, sarco idosis, and
even lung cance r and found that the basement membrane of cells was only
thicker in diabetes and asthma . What this means is that diabetes and asthma
have physiological similarities,64 and that explains why the Oxygen
Advantage breathing techniques used successfully for asthma may also be
effective for diabetics. With this understanding and given that respiratory
illnesses are so prevalent in people with diabetes, it seems essential to
include breathing exercises into diabetes treatment along with other forms
of wellness maintenance such as nutrition and exercise. THE IMPORT ANCE OF EXERCISE
It’s no secret that people who are physically active are healthi er. Exercise
boosts the immune system, supports cardiovascular health, and is important
for weig ht control and self-esteem. Exercising your muscles more often and
pushing them to work harder improves their ability to use insulin and
absorb glucose.65 When the musc les are better able to metabolize glucose,
the insul in-producing cells don’t have to work so hard. However , exercising
with diabetes can be challenging, and it is important to consult with your
healthcare professional to receive appropriate guidance on diet and
medication before changing your exercise regime. You may find that you get more out of your exercise time and enjoy it
more if you incorporate a mixture of resistance training and a variety of
aerobic exercise s such as cycling, swimming, and jogging. You will also
notice gradual improvements in your health if you simply reduc e periods of
inactivity throughout the day and evening.4
When it comes to sedentary lifestyle choices, too much time spent
watching TV can be particularl y damaging. Research indicate s that every
two hours spent watching TV instead of doing something more activeincreases the chance of developi ng diabetes by 20%, raises the risk of heart
disease by 15%, and makes it 13% more likely that you’ll die early .65 TV
watching is unhealthy , not just in its inactive nature. While it’s true that
there are links between time spent on the couch and weight gain or obesity
—something all diabetics must avoid—it is also the case that it’s easy to
slip into unhealthy dietary habits when watching television.65
The good news is that it is possible to see benefits with relative ly small
lifestyle changes . While there are obviously increased advantag es in terms
of cardiovascula r health if you can work your way up to longer, more
intense periods of exercise, the risk of developing type 2 diabetes can be
reduced by 30% simply by walking briskly for half an hour every day .65
Another benefit of exercise is that it helps rid the body of excess fat. That much is relatively obvious. But if you have never thought about where
that weight goes, you may be surprised to learn that it is not burned off as
heat or energy. A 2014 study published in the British Medical Journal
found that fat primarily leaves the body via the lungs, as CO2.66 In fact,
84% of the atom s in every fat molecule is exhaled as CO2, with the rest
ending up as water , which is eliminated in urine, sweat, and other bodily
fluids.67 According to the paper , replacing one hour of rest with an exercise,
such as jogging,  which increases the metabolic rate by seven times removes
an extra 39 grams of carbon from the body . While the researche rs point out
that this is easily countered by overeating, they state that since weight loss
requires the unlocking of carbon from fat cells, the maxim, “eat less, move
more” remains a good starting point.66
A HEAL THY HEART VERSUS A DIABETIC HEART
Lower levels of oxygen in the blood of diabetics are common, while reflex
responses to insuf ficient oxygen are blunted. These abnormalities can lead
to serious cardiovascular/renal complications.65
The heart function of people with type 2 diabetes becomes abnormal. Instead of working optimally , the metabolic systems of the heart change,
becoming less able to process blood sugar . In this state, the body oxidizes (a
chemical reaction involving oxygen) more fatty acids such as oils,
cholesterols, fats, and steroids. The word metabolism  refers to the entirespectrum of biochemical proce sses that take place within the body . This
particular change in metabolic function results in greater oxygen
consumption by the heart muscle tissue, independent of contraction.68
BREA TH HOLDS, HYPOXIA, AND DIABETES
Type 1 diabetic s generally suffer from low-grade chronic hypoxia, which
may be the root cause of many diabetic complications.51 An interesting
2013 study looked at the effects  of a single bout of IH on cardiorespiratory
control in 15 patients with type 1 diabetes.51 The research, which was the
first of its kind, examined the benefits of breathing hypoxic air using a
facemask. Just one session with the mask produced beneficial changes in
aerobic efficien cy and ventilatory responses to hypoxia (too little blood
oxygen) and hypercapnia (too much blood CO2).51 Wearing a mask is not
the same as practicing breath holds, but the same effect of reduc ing oxygen
can be achieved with either method. The researchers explain that, while it might seem counterproductive for
diabetics to practice IH training, when used correctly , the technique helps
the body to adapt to hypoxia. The study notes that more research is needed
in regard to prolonged exposure  to IH of more than two week s. However ,
the improvement seen in breathing efficiency does indicate that IH training
may be beneficial in the treatm ent and maintenance of type 1 diabetes,
particularly as negative side ef fects are minimal.48
STIMULA TING BLOOD SUGAR TRANSPOR T IN MUSCLE
IH has been found to “significantly” stimulate “glucose transport in
muscle” in both lean and obese patients.45,48 Researc h dating back 25 years
shows that IH was already established as being beneficia l. In 1995,
scientists from the University of East Carolina’ s Department of
Biochemistry set up an experiment to see whether hypoxia-driven glucose
transportation (absorption of blood sugar into the muscle cells) was still
possible in insulin-resistant muscle. The results showed that when IH was
used alongside insulin, there was a substantial increase in muscle glucose
transportation.45,48 Insulin used together with the practice of hypoxiareduced a diabetic’ s blood glucose more than either insulin or hypoxia on
its own. Scientists found that muscle contraction and insulin stimulate the
transport of blood sugar to the muscle cells through separate pathways, and
that breath holds work on the muscle contraction pathway .45,48 This is
exciting news because it indicates that the pathway for blood sugar
transport is still present in diabetics, including those with insulin resistance
(type 2 diabetics ). The presence of this pathway explains how diabetics can
potentially lower their blood sugar by using breath-hold exercises under the
guidance of a professional certified breathing instructor .45,48
OXYGENA TING THE BRAIN
When the body is at rest, the brain consumes around 20% of the body’ s total
oxygen supply . It should follow that during IH, the system would
compensate to ensure an adequa te oxygen supply to the brain. As CO2 is a
major driver of cerebral blood flow, it might make sense that reducing
blood CO2 would result in less blood flowing to the brain, but previou s
research has returned conflicting results. In 2017, a new study examined how the two blood gases react by
analyzing wheth er decreases in oxygen would increase blood flow to the
brain or would be offset by reduced CO2.48,69 The outcome of the trial
indicated that IH raises oxygen extraction in the brain, and that even when
levels of blood CO2 are low, blood continues to flow to the brain. The
overall results showed an increase in brain blood flow and that these
increases were substantially stronger at the fifth rather than at the first bout
of hypoxia, implying a cumulative ef fect. Notably , althou gh the participants reduced their CO2 by a relative
amount, their brain blood flow still rose considerably . This indicates that the
IH-induced brain blood flow is more significant than the reduced
circulation brought about by low blood CO2.48,69 Result s showe d a
substantial increase in oxygen extraction in the brain after the first bout of
IH, which continued throughout the remainder of the procedure. Conversely , the extraction of oxygen in the muscles fell, implying thatduring hypoxia, the brain’ s need for oxygen is prioritized over that of the
muscles.48,69
The research authors noted that normal levels of oxygen in the tissues
and blood, toget her with exposure to IH, cause dilation of the blood vessels
in the brain and improve blood flow to the brain. While the oxygenation of
muscles decreas ed during repeated IH, oxygen extraction in the brain
increased. This, in combination with improved blood flow, helped maintain
oxygen-dependent brain metabolism during acute, moderately intense IH. The study concluded that normal IH causes compensatory responses in both
the heart and the blood vessels in the brain, which could have potential
applications for training and optimizing brain blood flow .69
Research from the University of Rochester demonstrated that major
increases in brain blood flow take place at a certain level of oxygen
uptake.70 Since both breath holds and high levels of CO2 cause the blood
vessels in the brain to dilate, it seems possible that, by employin g high CO2
breath holds, brain blood flow would increase even more:
This research supports practicing breath holds before a workout,
competition, or presentation, as increased brain blood flow helps
focus & prepare the mind.48
For the purpose s of this book, it is important to distinguish IH from
breath holding. IH involves a controlled reduction in blood oxygen
saturation to between 82% and 95%. This may be done betwe en 3 and 15
times per day.71–73 Most of the studies with IH use expensive equipment,
which will be out of reach for many people. With breath holding after an exhalation, blood oxygen saturatio n can be
lowered to between 80 and 88% within a few days of practice. Of course,
breath holding is not the same as IH. However , the point is, exposing the
body to short, controlled doses of hypoxia may be beneficial. Be awar e that breath holding can generate a feeling of moderate to
strong air hunge r, which can be stressful. If you choose to practice breath
holding, do so gently . Do not expose your body to high stress. It can also be helpful to use a good quality pulse oximeter to monitor
your blood oxygen saturation as it drops. If you have cardiovascular issues,are pregnant, or have other serious medical conditions, please do not
practice breath holding. EMPTYING THE ST OMACH
Both type 1 and type 2 diabetics are susceptible to a disruption of normal
stomach contractions, which can cut off the digestive process. “Gastric
emptying of solids is delayed in 30% to 50% of patients with diabetes.”74
This is the resul t of effects the disease has on the nervous syste m. Diabetes
can negatively impact the vagus nerve, compromising the stomach and
other muscles of the digestive tract.75 As a result, food cannot pass through
the digestive system as rapidly as it should. However , research indicates
that hypoxia with oxygen levels of 10% and 6% causes an increase in
gastric vagal nerve activity in just a few seconds.76 It is possible to activate
and therefore treat the vagus nerve by practicing slow breathing at six
breaths per minute with a techni que called heart rate variability biofeedback
(HRVB).77 (There is more detailed inform ation about HRVB in Chapter
Four .) SLOW BREA THING T O LOWER BLOOD SUGAR
The functioning of the two branches of the autonomic nervous system
(ANS) is relevant in diabetes too. The sympathetic branch of the ANS
raises blood sugar through direct nerve stimulation of the liver and
indirectly through the release of the hormone adrenaline. The liver is
controlled by both the sympathetic nervous system (SNS) and
parasympathetic nervous system (PNS). When the SNS is triggered, the
hormone adrenaline causes the liver to convert stored glycogen into blood
sugar . Adrenaline increases insulin resistance.48,78 Simultaneously , the SNS
suppresses the release of insulin from the pancreas. The panc reas is also
controlled by nerves from both the SNS and PNS.48,78
The important point here is that when the SNS is activated, stimulating
the stress response, the pancreas can no longer release insulin. Conversely ,
when the PNS is stimulated, insulin production increases.48 Slow breathinghelps activate the PNS, which is “beneficial, especially for type 2 diabetics
who still produce insulin.”48
Research shows  that the body of the diabetic tends to be in a chronic
fight-or -flight state. When the SNS is overactive, we automatically breathe
faster than usual  and are more reactive to stress. The good news is that, by
breathing slowly and lightly , it is possible to offset this imbalance. In this
way, we can use the breath to consciously move into a parasympathetic
mode. Adding to the benefits of slow breathing, controlled intermitten t breath
holds also activate the SNS, strengthening the nervous system and making
the body more resilient to stress.48 Sympathetic activation is part of a
healthy ANS, as long as it doesn’t become chronic, getting out of balance
with the parasympathetic branch. THE BENEFITS OF SLOW BREA THING FOR DIABETICS
In 2017, one of the most highly regarded scientific journals, Natur e, shone a
spotlight on the benefits of slow breathing for diabetics.31 The publication
cites research-backed findings that a reduced rate of respiration boosts the
ANS, enhances arterial function, and increases blood oxygen saturation in
type 1 diabetics: “Oxygen-induced impairment in arterial function is
corrected by slow breathing in patients with type 1 diabe tes.”31 The
improved balance in autonomic function that comes from stimulating the
PNS and suppressing sympathetic responses provides an antioxidant effect. The report suggests that slow breathing could represent a simple beneficial
intervention in diabetes.48 There is practical evidence that just two minutes
of slow breathing can greatly enhance general health in diabetics. Study participants were able to increase their arterial function. The
arteries are important as part of the cardiovascular system. They are elastic
blood vessels that carry blood away from the heart. Participants were also
able to improve  their blood oxygen saturation and key autonomic markers,
measures of various processes regulated by the ANS, such as breath rate
and blood pressure.48
BREA TH HOLDING AND BLOOD PRESSURE CONTROLType 1 diabetics show poor baroreflex sensitivity , which is compounded
during periods of low blood sugar. As discussed previously , the baroreflex
is a homeostatic mechanism that maintains blood pressure at near constant
levels by controlling various functions such as heart rate. Greater baroreflex
sensitivity impli es a more respo nsive, flexible, healthy system , while low
baroreflex sensitivity is an index of poor health and can indicate issues
including cardio vascular disorders. Baroreflex sensitivity is also one of the
key markers of the ANS.79 Slow breathing has been found to improve the
parasympathetic activity of the baroreflex in both diabetics and healthy
subjects. In a review of arterial function in type 1 diabetics, researchers found
that slow ing the respiratory rate to six breaths per minute increased the
baroreflex sensitivity of type 1 diabetics to the extent that measurements
were similar to those of the nondiabetic control group.31 An even more
interesting aspect of this study is the hypothesis that tissue hypoxia
contributes significantly to diabetic autonomic disorders. By breathing
slowly and allowing CO2 to accumulate in the blood, it is possible to
alleviate tissue hypoxia. This discovery could have major implications for
the long-term complications associated with diabetes. DIAPHRAGMA TIC BREA THING T O FILL A
THERAPEUTIC NEED
2019 research from Pakistan explored using diaphragm breathing exercises
for diabetics in developing countries where the cost of medications such as
insulin can be a barrier to treatment. Scientists stated that breathing
exercises are “very useful” and, if practiced regularly , can minimize
hyper glycemia and prevent major complications associated with type 2
diabetes.80
The study sought to determine the effects of diaphragmatic breathing
exercises on blood sugar levels and HbA1c (a reading of average blood
glucose levels over two or three months) in 64 diabetic women. While
studies from countries, includin g China, Japan, India, and Russia, where
yoga is a comm on practice, have found significant improveme nts in blood
sugar levels, diaphragmatic breathing exercises are not common inPakistan. However , in this context, breathing exercises provide an
accessible appro ach to diabetes control because patients can practice at
home without the expense of medication and without any harmful side
effects. Cost is an importan t consideration for diabetic patients in
developing countries like Pakistan. The study cites 2012 research into the therapeutic effects of
diaphragmatic breathing on oxidative stress in type 2 diabetics. This earlier
paper concluded  that, while breathing exercises alone may not produce
significant resul ts, breathing could be successfully incorporated  as an add-
on therapy to standard care to improve blood sugar and HbA1c.32
I was first direct ed to research on this topic by my friend and colleague
Dr. Jonathan Herron, from Dungannon in Northern Ireland. He has several
diabetic family members and has lost one relative to diabetic complications. His masters thesis in biomedica l science focused on novel thera pies to treat
diabetes. In his extensive work with diabetic patients, he has noticed a
direct correlation between higher blood sugars and chronic
hyperventilation, which suggests that correction through reduce d breathing
techniques would have a positive effect on HbA1C, lessening the need for
drug therapy . In fact, the Pakistani study did find that diaphragmatic breathing
exercises were beneficial, especially when combined with other techniques
like walking, meditation, and guided imagery , especially when the
breathing is practiced regularly . It was noted that results in this study were
negatively affected by the fact that participants didn’ t always practice the
exercises. It recommended that medical practitioners working with diabetics
should motivate their patients to adopt a routine practice of breathing
exercises at home, stating, “Quality of life of type 2 diabetic patients can be
improved significantly if patients’ compliance with these exercises is
assured.” The study concluded that it would be valuable to investigate
further effects of the breath ing exercises with a larger sample of
participants. OceanofPDF .comECHAPTER FIFTEEN
SEIZURE CONTROL AND THE BREATH
WHA T IS EPILEPSY? pilepsy is a chronic neurological disease involving the brain.1 It
affects around 50 million people of all ages worldwide,2 making it
one of the most common neurological conditions. The disorder
makes the sufferer susceptible to recurrent seizures that negatively impact
health and quality of life. The risk of early death is three times higher in
epileptics than the general popu lation. In many parts of the world, suffers
also experience discrimination and stigma.3
However , according to the World Health Organization, as many as 70%
of people with epilepsy could live seizure-free if properly diagnosed and
treated.3 The condition is usually treated with anticonvulsants, but the
effectiveness of those medicatio ns varies depending on the type of seizure
condition.4,5
Seizures can be caused by anything that interrupts necessary
connections between nerve cells in the brain. Common nonepileptic triggers
include low or high blood sugar , high fever , alcohol or drug withdrawal,
and a brain concussion.3 When a person  has two or more seizures that are
not provoked by any of these factors, he or she is considered to have
epilepsy . Epilepsy has many possible causes—tumors, strokes, brain
damage from injury or illness, an imbalance of neurotransmitters (the
nerve-signaling chemicals), or a combination of these—but in many cases,
there is no discernible basis for the disease.6Epileptic seizures caused by identifiable factors, including brain tumors
and lesions, are classified as symptomatic. Seizures where the cause is
unknown are called idiopathic.7 In this chapter , we focus on idiopathic
seizures. The brain controls and regulates all the voluntary and involuntary
responses in the body . It is made up of nerve cells (neurons) that
communicate with each other through electrical activity . When part of the
brain receives a burst of abnormal electrical signals that temporarily
interrupt normal brain function, a seizure occurs.6
In a healthy , normal system, all the electrical signals that travel between
nerve cells are related to necessary processes such as memory , logic,
decision-making, the deliberate or involuntary movement of muscles, and
the functioning of the senses. For these signals to successfully transmit
from one nerve cell to another , the strength of the electrical signal needs to
be high enough— just as a mobile phone requires enough signa l strength to
make a call or an electrical socket must have the correct volta ge to power
your appliances. The nerve cells also need to have a high enough “excitability” threshold
so that this stron g signal won’ t overpower them. In mammals, this threshold
is normally around 50 microvolts8,9 (one microvolt is equivalent to around
one millionth of a volt). When the seizure threshold is normal, electrical
signals can pass between nerve cells in a functional way. It is important that
no vital information is lost when signals are transmitted and that any
irrelevant signals are repressed so that they don’t interfere with the brain’ s
usual processes. If the neuronal excitability threshold is too low for any
reason, accident al signals can be amplified, causing the functioning of the
central and peripheral nervous systems to be disrupted or suppressed. This disruption is comparable to the changes in blood biochemistry that
occur during abnormal breathing patterns.10 In fact, this comparison draws
a further  paralle l with epilepsy in that the levels of carbon dioxide (CO 2)
and oxygen found in relation to chronic hyperventilation also tie in with
susceptibility to seizures. Studies have reported a connection between
epilepsy and the breath and even drawn conclusions that breathing exercises
can help reduce the frequency and severity of seizures.11Seizures can alter respiratory parameters, including the perception of
respiration and fullness of breath.12 During a seizure, respiratory rate,
breathing pattern, and breathing quality may change. The patient may
experience breathlessness, coughing, and secretion of mucus, and it is
believed that neurogenic pulmonary edema (acute onset of pulmonary
edema followin g a significant central nervous system insult)13 may
contribute to sudden unexplained death in epilepsy patients. Apnea
(involuntary breath holding) and cyanosis (a blue tinge to the skin) are
“normal” during several types of seizure, and hyperventilation is common
in mesial epilepsy ,14 a form that is often hard to treat.15 Coughing, shortness
of breat h, and choking can all occur when a seizure interferes with
breathing and the rhythm of the heart. Over time, these issues  can lead to
increased risk of cardiovascular disease and stroke.16
Observation of breathing after a seizure can even help healthcare
practitioners identify the type of seizure. For example, respiration after a
generalized tonic-clonic seizure tends to be regular , loud, and deep with
prolonged inhalation and exhalation. After general nonepileptic seizures,
breathing is faster with short in and out breaths.17
JENNY’S ST ORY: SEIZURE CONTROL AND GREA TER
CONFIDENCE
Jenny was 13 years old when she began having epilepsy . At first, she had
only small complex partial seizu res and was able to manage her symptoms. However , by the time she finish ed college, postictal psychosis had become
a problem. Postictal psychosis is an episode of psychosis that commonly
occurs after a cluster of seizures. For Jenny , this would continue  for three or
four days after a seizure, with symptoms including paranoia, insomnia, and
hearing voices. Her daytime seizures could be triggered by something as
simple as tiredness or even by just catching her reflection in a mirror . Sometimes her panic attacks were so severe she ended up in hospital. She
was advised that neurosur gery would help, and she went ahead with the
procedure. Jenny’ s epilepsy had improved after surgery, and five years after the
surgery, Jenny was able to take a full-time job for the first time. Theposition gave her the option to work from home, which was helpful when
she had epilepsy symptoms. While neurosur gery meant her daytime
seizures stopped altogether , nocturnal seizures became a greater issue. The
afteref fects of these were less severe, but the day after a seizure she still
experienced a throbbing headache, memory impairment, and an unpleasant
coppery taste in her mouth. Even though she no longer suffered from
daytime seizures, she would sometimes feel an aura, as if a seizure were
imminent. This could be extre mely frightening and trigger severe panic
attacks. The resulting chronic anxiety caused her to lose self-confidence. Things changed for Jenny after she read online that light nasal breathing
to address hyperventilation and regulate oxygen intake could help stem the
onset of a panic  attack. After getting my book Anxiety Free: Stop Worrying
and Quieten Your Mind , she made the switch to full-time nasal breathing. She saw the connection between her anxiety , overbreathing through her
mouth during sleep, and poor sleep quality . She realized that her habit of
breath holding during sleep followed by overbreathing (sleep apnea) was
causing her daytime sleepines s, poor concentration, forgetfulness, dry
mouth, and headaches. Once Jenny began to breathe lightly through the nose during the day,
her next nocturnal seizure was much less severe. She got out of bed without
noticing the metallic taste in her mouth that normally followed a seizure. Now , if she feels herself beginn ing to panic, she is able to avert the panic
attack by keeping her mouth closed. Her nocturnal seizures are so much
better that she sometimes has to look at the sleep app on her phone to see
whether she has had a seizure. Jenny still takes an anticonvulsant, but by
addressing her breathing habits, she has been able to gain more control over
her condition. If the daytime aura comes on, she focuses on her breathing
until the feeling passes. Her seizures have now completely stopped. THE BIOCHEMICAL LINK
The neuronal excitability thresh old—the level of tolerance the nerve cells
have for the strength of the signals passing between them —is highly
sensitive to and dependent on the concentration of CO2 in nerve tissues. Hyperventilation, and the resulting low CO2 pressure in the brain, causesnerve cells to fire in a spontaneo us and asynchronous way. This means that
when levels of CO2 and oxygen in the blood, muscles, and cells are
disrupted due to poor breathing patterns, weak or inappropriate electrical
signals may be strengthened and relayed through some areas of the brain,
interfering with the normal signals and causing the seizure threshold to
drop.18
According to the author and breathing afficionado, Dr. Artour
Rakhimov , betw een 70% and 100% of epileptics can lower their neuron
excitability threshold and induce seizures by deliberate hyperventilation.19
Evidence demonstrates that hyperventilation can cause seizures,20 but
research has not so far identified the exact CO2 level that can trigger
seizures in people with epileps y. This makes sense because many factors
influence the transmission of electrical signals in the brain. While the
concentration of arterial CO2 is key, metabolic rate, which is affected by
things like body position, posture, and exercise, also plays a role. So does
the availability of calcium and magnesium ions in tissues, as well as the
levels of amino acids, neurotransmitters, and other substances. Hypocapnia
(low blood CO2) provides the necessary condition for a reduced seizure
threshold and the onset of seizures, but it is not the only factor leading to
epileptic sympt oms. Nonetheless, numerous studies have shown that
hyperventilation reliably triggers seizures in epileptics (and patients
suffering from explainable seizu res), indicating that the threshold of nerve
cell excitability is closely related to or controlled by respiration , with some
lesser contribution from other states of homeostatic imbalan ce, such as
sleep deprivation, stress, low blood sugar , infection, fever , alcohol intake,
and overheating.21
The first research paper to explore the beneficial effect of CO2 in
epilepsy was published in the 1928 Journal of Clinical Investigations .22
Scientists reported that inhaling air rich in CO2 reduced the severity and
duration of seizures due to the ef fect of the gas on nerve and muscle cells. A
1956 study returned the same results.23 In 1999, another research paper
explored the effects of hyperventilation on the brain’ s sensory responses
and concluded thatIncreased neuro nal excitability caused by hyperventilation-ind uced
hypocapnia leads to spontaneo us and/or asynchronous firing  of
cortical neurons.24
In simple terms. this means that the low levels of blood CO2 that occur
as a result of hyperventilation create abnormal activity in the nerve cells of
the brain. The conclusions of a 2005 pape r are even more comprehensive, stating
that, as well as altering respirati on and vascular tone, abnormal CO2 levels
affect blood pH, consciousness, and seizure threshold.25 Outside of the
brainstem, the mechanisms by which CO2 levels influence the function of
neurons are unknown, but research suggests that CO2-induced changes in
nerve cell function are pH-dependent. The authors conclude that their
findings demons trate a mechanism for the bidirectional effects of CO2 on
neuronal excitability in the forebrain. Sometimes, seizures may be triggered, worsened, and prolonged by low
blood sugar levels. These are called “hypoglycemic” seizures.26 It is known
that chronic overbreathing resul ts in poor blood sugar control, exacerbating
the symptoms of hypoglycemia.27. Because one of the roles of CO2 is as a vasodilator , hypocapnia (low
CO2) can lead to vasoconstriction, or narrowing of the blood vessels , which
in turn can cause the carotid arteries to go into spasm, another key trigger
for seizu res. The carotid arteries are blood vessels that carry oxygen-rich
blood to the brain, neck, and face. At the same time, overbreat hing from the upper chest reduces
oxygenation of the organs, including the brain. This can lead to respiratory
alkalosis, in which the blood pH is too high. This compounds the abnormal
electrical activity , further lowering the seizure threshold.9 A 2006  study
from researchers in Finland reported that the suppression of alkalosis with
5% ambient CO 2 “abolished” seizures in juvenile rats within 20 seconds.28
This link with CO2 forms the basis for the exchange breathing method
(EBM) protocol, an emer gency seizure-recovery method in which the first-
aider administers an outward breath into the subject’ s nose during seizure. In a 2019 study , EBM was administered 28 times during different seizuresin one subject. The least numbe r of breaths given to stop a seizure was 1,
and the most 10. Typically , 3 breaths were needed. In this case, this
breathing method stopped the seizures at least three times faster than
diazepam, without the postseizu re side effects, such as drowsiness and bad
moods. Research ers concluded that, since this simple technique can be used
any time, it can be easily incorporated into existing treatment protocols,
even applying it as soon as a seizure begins.29
CHRONIC HYPER VENTILA TION AS A SEIZURE TRIGGER
As we’ve already discussed, hyperventilation is a respiratory behavior
where an irregular increase in the speed and depth of the breath results in
abnormal excha nge of gases in the lungs and low blood CO2 levels.30
Clinical and research evidence demonstrates a strong link between this
habitual overbreathing and epilepsy . In early studies investigating the
relationship between hyperventilation and seizures, scientists described the
objective and subjective experiences accompanying low blood CO2,
commenting that, “there are few drugs the effects of whic h upon the
neuromuscular system are so rapid and so striking as the effect of voluntary
hyperpnea”31 (deliberately increased rate and depth of breathing)32. It was
found that seizure sufferers have an unusually high sensitivity to changes
within a fairly narrow range of blood CO 2 concentrations. According to Robert Fried’ s book Breathe Well, Be Well,33
hyperventilation is a major cause of fits in epilepsy . The author refers to
numerous studies dating back to the 1930s that have made the connection
between overbr eathing and seizures. In 1954, scientists stated that, “In
persons who are predisposed to epileptic fits, simply overbreathing, often
results in an attack.”34 A resea rch paper from 1975, Hyperventilation: The
Tip and the Iceber g, explain ed how low blood CO2 causes constric tion of
the blood vessels, leading to a reduction in the amount of oxygen reaching
the brain.35 These effects are immediate, which is why hypocapnia can
quickly result in feelings of faintness, dizziness, and visual disturbance. The
paper also states that grand mal seizures may be triggered by
hyperventilation.Although research has clearly identified the role of CO2 in cerebral
circulation, many studies still conclude that the cause of seizures is
neurological. The rationale behind this idea is that CO2-driven changes to
the blood acid-base balance create an unstable environment for the nerve
cells of the brain. Further studies have suggested that anxiety can act as a
seizure trigger because it leads to hyperventilation, lowering blood CO2
levels.36 Patient s were prone to hyperventilating when they felt anxio us,
and while they did not display  any obvious signs of overbre athing, they
experienced a 50% drop in CO2 and an increase in both EEG and clinical
seizure activity . Separate research into cerebral blood flow and metabolism
acknowledges the role of CO2 as a vasodilator . A 2008 study  examining
sexual dysfunction in men with epilepsy points out that sex can itself prove
problematic because of hyperventilation,37 which is commonly associated
with orgasm, can trigger seizu res. In Freedom from Asthma , Alexander
Stalmatski argues that epileptics, like asthmatics and people with a variety
of other related conditions, always hyperventilate, suggesting that, “With
reconditioning of their breathin g patterns . . . the establishment of proper
levels of CO 2, it is possible to prevent seizures without drugs.”38
In clinical settings, hyperventi lation is used to activate seizures for
monitoring. I asked a friend who is a brain doctor about the connection
between epilepsy and hype rventilation. My friend explained that
hyperventilation is used
especially by the child neurolo gists as a bedside tool to diagnose
absence seizure s (petit mal seizures) in children. Hyperventilation
causes blood to be alkaline by driving out CO2. . . . This low blood
pH causes constriction of the blood vessels, hence low oxygena tion
triggers the seizures. Even though children are more sensitive, in
adults with chronic hyperventilation due to anxiety attacks, for
example, the brain can suffer the metabolic and oxygenation
changes. I am increasingly surprised that breathing retraining to reverse
hyperventilation is not widely considered in the treatment of seizures. Especially , since  it is also widely recognized that common seizure triggersincluding alcohol, low blood sugar , and stress produce an increase in
breathing volume that may deplete blood CO 2 to the seizure threshold. According to an exhaustive 1990 review by Robert Fried and Mary
Claire Fox, research has proven that the dramatic effect of inhaled CO2 on
EEG activity can be replicated by limiting the rate of respiration.30 While,
at the time of publication, no evidence existed to indicate that CO2 could be
controlled by self-regulation, the researchers believed that there would be
broad clinical application for such a technique, commenting that
“physiological equilibrium” could be restored by increasing oxygenation of
the cells and tissues or by enhan cing blood flow and metabolism. As Fried
and Fox explain, studies have demonstrated that the cause of seizures is
metabolic and vascular , and that the connection between hyperventilation
and seizures is so strong as to indicate that one causes the other . Alongside the Fried/Fox review , a significant body of research
demonstrates a connection between hyperventilation and epilepsy
symptoms. In 1981, a study compared the effect of 15 minutes of moderate
exercise against  3 minutes of hyperventilation in 43 young patients with
epilepsy .39 Results were measured in terms of EEG dischar ges—
abnormalities in EEG readings consisting of repetitive sharp waves or
spikes. The epileptic subjects were compared to a control group of 20
young people who had either no organic brain injury or in whom brain
injury had not caused epilepsy . Researchers found that the number of EEG
dischar ges decreased in nearly all participants during exercise but increased
during hyperventilation. The paper concluded that modera te exercise
inhibits seizure activity , while hyperventilation exacerbates it.39
A 1984 study found that the concentration of blood CO2 had a direct
impact on the duration of seizures.40 The researchers induced hypocapnia
by hyperventilation to the point where concentration of CO2 in the alveoli
was only 2%. The duration of seizures increased significantl y compared
with the normal CO2 level of 5%, even though oxygen concentration
remained consta nt at 92%. Whil e different levels of oxygen did not produce
any notable changes to seizure duration, seizures became progressively
longer as the amount of CO2 in the alveoli decreased. This finding was
confirmed in a 2008 paper , which reported that moderate hype rventilation
caused a significant increase in EEG seizure duration compared to normalventilation.41 In 1993, scientists examined 19 patients with complex-partial
seizures, reporting that hyperventilation triggered a “marked activation” of
the epileptic focus—the area of the brain from which the seizure
originates.42
There have been attempts to determine whether the degree of
hypocapnia correlates with an increased frequency of petit mal or absence
seizures and if there is a critical concentration of CO2 at which these
seizures are reliably induced.43 In a 1996 study , scientists monitored 12
children who had newly diagnosed absence epilepsy . EEG readings and
percentage of CO 2 in expir ed air were recorded during quiet respiration and
hyperventilation. These readings were taken while the children breathed
four dif ferent gas mixtures:
1. Room air
2. 100% oxygen
3. Room air with 4% CO 2
4. A gas containing 4% CO 2 and 96% oxygen
When the children were breathing quietly , a reduction in EEG spikes
was seen when the breathing gas contained extra CO2 (3 and 4), but a
higher concentration of oxyge n in inspired air (2) caused no changes. Seizures were triggered in eight of the children with each trial of
hyperventilation, but the level of CO2 that induced seizures was found to
differ among the children. The study concluded that it would be helpful to
discover whethe r sensitivity to blood CO2 could help predict the likely
response to antiepileptic drugs, and that more research was needed into the
possible use of CO 2 for the remission of seizures. A study from 2001 examined patients who suffered nonepileptic
seizures, 41% having coexistin g epilepsy and found the most frequent
features of nonepileptic seizures included fear, anxiety , and
hyperventilation.44 Another paper found that typical absence (brief,
generalized) seizures are “easily precipitated by hyperventilation” in
approximately 90% of untreated  patients. Similarly , a study of children who
had epilepsy with myoclonic absences concluded that the seizures were
easily provoked by hyperventilation.45 This finding was repeated in a 2009
study , which observed myoclonic absence seizures in three patients whichwere triggered by hyperventilation.45 Researchers concluded that
“hyperventilation is most effective in activation of generalized absence
seizures during routine EEG studies.”46 Researc h from 2011 repeated the
finding that hyperventilation is an effective way to activate epileptic
seizures in patients with epilepsy .47 In a study of children aged between 3
and 11 years, hyperventilation induced seizures in all patients.48 It’s worth
noting that around 10% of seizures in children with epilepsy are absence
seizures, otherwise called petit mal seizures.49 These seizures have a
significant impact on quality of life.50
CO2 has long been recognized for its anticonvulsant properties.51 In
2007, the science news website Science 2.0  reported research that presented
CO2 as a “new—and completely free—way to prevent fever -related
epileptic seizures” in small children.52 Scientists believed that CO2-
enriched air could be used to stop seizures. The research showed that fever -
related seizures, which are common in children under the age of five, could
be safely suppressed within 20 seconds simply by adding 5% CO2 to
inhaled air. Experimental research indicates that these childhood seizures
may increase the risk of epilepsy developing later in life. The study suggested that CO2 therapy could also be effective in
stopping other types of epileptic seizure.52 This theory was tested in 2011
research when scientists set out to discover whether inhaling 5% CO2
would stop seizures in epilepsy patients.53 A pilot study of seven people
demonstrated a “rapid termination of electrographic seizures” even though
the 5% CO2 was applied after the seizure had begun. The researchers
concluded that inhaled CO2 could be used for acute treatment of epileptic
seizures.53
A follow -on review of this study stated that the research demonstrated
the “feasibility”  of hypercapnia as a clinical treatment.51 While more work
is needed to ensure safety and efficacy—for instance, it is important that
hypercapnia does not progress to acidosis during a prolonged seizure—the
review suggests  that this is a worthwhile avenue, concluding, “Carbon
dioxide inhalation could prove to be an easy and inexpensive intervention
for acute seizures in the hospital, and possibly in the home as well.”A further study from 2014 soug ht to discover whether inhaling 5% CO2
could suppress hyperventilatio n-induced absence seizures and irregular
electrical discha rges in the brain known as “spike and wave dischar ges.”54
Researchers concluded that treatment with CO2 may help treat these
seizures. A 2019 clinical review reiterated earlier findings, stating that the
“spike and wave” neuronal dischar ge typical of absence seizures is
triggered by voluntary hyperven tilation in more than 90% of patients with
absence epilepsy . The paper describes the use of hyperventilation to quickly
diagnose patien ts with absence epilepsy as “commonplace.” While
scientists are still unclear whether a single mechanism exists to prompt
absence seizure s, the review suggests that the changes in blood pH
(alkalosis) brought on by hyperventilation may contribute.55
In the 2014 study , 12 participants who had hyperventilation-induced
absence seizures  were examined while breathing either room air, 5% CO2,
or 100%  oxygen . Compared to hyperventilation in normal room air, the 5%
CO2 decreased the frequency and duration of seizures after hyperven tilation
and reduced the number of “spike and wave” dischar ges. This pilot study
added yet more clear evidence that hypercapnia could provide a way to treat
hyperventilation-related seizures.54
COMORBID HEAL TH PROBLEMS IN EPILEPSY
The Cold Spring Harbor Perspectives in Medicine  published a paper in
2015 that suggested that epilepsy encompasses more than spontaneous
recurrent seizures and should be classified as a “spectrum disorder .”7 For
many epileptics and their families, what causes the greatest impact are the
many conditions that exist alongside the primary symptoms. Comorbid
conditions can include psychiatric and behavioral disorders like anxiety ,
depression, attention-deficit hyperactivity disorder (ADHD ), learning
disabilities, intellectual disability , and autism. Traditionally these comorbidities were thought to be secondary to
uncontrolled seizures and adverse reactions to medication. However , they
are now acknowledged as integral to epilepsy . In some cases, the comorbid
conditions predate the seizures and can be attributed to an underlying
disorder of neuronal networks.56 A 2007 study states that even a singleseizure can cause modifications to receptor expression and distribution,
altering neurodevelopment—the  growth of neurological pathways in the
brain that influence things like intellectual functioning, reading ability ,
memory , focus, and social skills—leading to cognitive and behavioral
changes.57
The most common psychiatric comorbidity in epilepsy is depression. This is interesting because depression is linked with dysfunction in the
hippocampus and limbic structures of the brain, areas of the brain that are
both frequently involved in epileptic circuits. The connection between
depression and epilepsy is bidirectional. People with epilepsy are more
likely to develop depression, and those epileptics with depression more
commonly suffer refractory seizures, seizures that are uncontrolled or
difficult to treat.58
It can be difficult to achieve a clinical diagnosis of anxiety in patients
with epilepsy , but the unpredictable nature of the disease and the fear of
seizures often leads to some level of anxiety . Approximately 30% of adults
with epilepsy have depression and 10% have bipolar disorder .58 Both these
disorders are related to increa sed risk of suicide. The same  is true in
children, but symptoms are harder to identify here. Research has
demonstrated that children with newly diagnosed epilepsy are around three
times more likely to also have a mood disorder . Physical health problems also affect many people with epilepsy . The
Centers for Disease Contr ol and Prevention National Health Interview
Survey  found that adults with epilepsy were more likely to also have
cardiovascular and respiratory disorders, inflammation, obesity , diabetes,
and other conditions, including arthritis, pain in the upper or lower spine,
and severe headaches.59 Epileptics also have a higher incidence of sexual
dysfunction,37 early mortality , and sudden unexplained death.60
Another concern for people with epilepsy is the impact of seizure
medication on bone health. Epileptics are more prone to fractures due to
decreased bone mineral density .61 The antiseizure medications
carbamazepine, phenytoin, and phenobarbital cause a decrease in bone
mineral density by triggering release of the CYP450 enzyme, but non-
enzyme-inducing AEDs are also linked to altered bone health.61 We lookedat the link between bone mine ral loss and breathing pattern disorders in
Chapter Thirteen . In all cases, whether comorbidities are psychological or physiological,
understanding the relationship between epilepsy and its associated
conditions can have a signific ant positive impact on quality of life for
people living with the disease. Indeed, scientists consider this to be a
priority for future research. More to the point, many of the problems that
exist alongside epilepsy , including anxiety disorders, diabetes, heart
problems, and respiratory condi tions, can also be contributed by breathing
pattern disorders such as chronic hyperventilation. EPILEPSY AND BLOOD FLOW T O THE BRAIN
Cerebral blood flow is known to change during seizures, specif ically in the
epileptogenic zone, the area of the cortex that initiates the seizure.62 Blood
flow to the brain decreases between seizures and increases during them. Immediately after a seizure ends, cerebral blood flow becomes very low,
and it remains low for several minutes. Unfortunately , these changes in
blood flow prevent proper oxygenation of the brain. A 2017 study reported
that the most severe long-term result of repetitive epileptic seizures was
neuronal degeneration.63 Researchers state that while the primary cause of
this is overstimulation of the neurons, new findings indicate that hypoxia, or
lack of oxygen caused by abno rmal blood flow, “may be to blame for as
much as half the neuronal death caused by the condition.”
Research has found that cerebral blood flow can be improved with
breathing exerci ses. Again, CO2 plays a key role. One 2011 study tested the
potential for simple breathing exercises to increase cerebral oxygenation
and/or blood flow.64 Scientists examined 18 participants aged between 19
and 39 years and recorded levels of end-tidal CO2 and brain oxygenation. Subjects were asked to comple te paced breathing exercises that included
breath holds on both inhalation and exhalation. The exercise involved
walking slowly for three steps while inhaling, holding the breath for three
steps, exhaling for three steps, holding the breath for three steps and so on. The researchers found that the main parameter influencing cerebral
circulation is the level of CO2 in the blood, and that an increase in CO2concentration of around 70% may as much as double blood flow.65 When
more blood flows to the brain, the brain receives more nutrients and
oxygen, and this may have a significant influence on its physiology . People
trained in breathing exercises can increase their levels of blood CO2 by
learning to control tidal volume64 (the amount of air that moves in and out
of the lungs with each inhalation and exhalation). This mean s that it is
possible to improve cerebral blood flow simply by moderating the
breathing.66
A second study , also from 2011, explored cerebral oxygenation in
people who were experience d in yogic breathing techniques.67 Six
participants, who were each able to breathe at an extremely slow rate,
performed an identical periodic breathing exercise with a respiratory rate of
two breaths per minute. In all six subjects, the results showed  a periodic
change in cerebral blood flow and oxygenation. This result was repeated in
a 2016 paper by the same research team.68
Given that much of the neurona l damage caused by epilepsy is caused
by lack of oxyg en to the brain, it is promising to realize that breathing
exercises can so simply improve cerebral blood flow and therefore brain
oxygenation. SLEEP MA TTERS IN EPILEPSY
Epilepsy and sleep-disordered breathing (SDB) are both relatively common
conditions.69 However , they occur comorbidly more frequently than
expected, leading to considerations that a connection exists between the
two. It is under stood that epilepsy can aggravate obstructive sleep apnea
(OSA) because it causes an increase in light sleep. Epileptic medications
can also produce side effects (such as weight gain) that increase the
likelihood of SDB, and epileptic seizures can trigger central apneas. It is also the case that SDB can impair epilepsy control due to repetitive
hypoxia and disrupted sleep. While this area lacks research, some evidence
suggests that, if SDB can be treated, seizure control will improve, as will
quality of life and general health and well-being. According to a 2018 article in Epilepsy Foundation , “there has never
been a prospec tive, multi-cen ter trial to evaluate the effect of OSAtreatment on seizures in people living with epilepsy .”70 More research is
needed, particularly in the field of pediatrics. Healthcare professionals who
may not be aware of the connection between sleep disorders and epilepsy
need to be educated. However , there is some limited research into the
relationship between the two disorders. A 2008 paper exploring sleep-study
abnormalities in epileptic children describes the relationship between SDB
and epilepsy as “complicated and reciprocal.”71 Researchers have looked in
detail at the link between epilepsy and sleep, and whether one affects the
other , but little has been done  to understand the mutual interaction of
epilepsy and sleep disorders, particularly in children. The 2008 paper
examined quest ionnaire-based survey responses from 486 patients with
partial seizures and 492 age- and gender -matched controls. It found that
sleep disturbances affected 39% of adults with epilepsy , compared to 18%
of the control group.71
A 2019 Austral ian study published in Neur ology  found that 26.5% of
participants had moderate to severe SDB, as defined by an apnea-hypopnea
(AHI) index of “greater than 15.”72,73 (We looked at the AHI in Chapter
Seven .) This study found that daytime sleepiness was an accurate indicator
of sleep  disorders in epileptics, but that age and body-mass index also
contributed to the condition. The small amount of research into this topic means that much evidence
is conflicting, both in terms of prevalence and diagnostic criteria.
_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:

        Inspired by
his newfound energy, which seemed more stable and long-lasting than any
previous change, he also began applying the slow breathing and breath-hold
techniques from the Oxygen Advantage. After a few months, he noticed his
blood sugars were improving considerably and he needed 10% to 20% less
insulin. Nick’ s college major was meteorology, qualifying with a PhD. This
background as a research scientist made him eager to learn how the
breathing exercises were having  such a dramatic impact on his diabetes. He
spent several years exploring the impact of correct breathing techniques on
diabetes and chronic disease and found evidence to explain the positive
effects of slow breathing and breath-hold exercises on his blood sugars. Slow breathing has been shown to improve the function of the
autonomic nervous system by reducing activation of its stress-driving
sympathetic branch31. It reduces oxidative stress32—an imbalance of
antioxidants and free radicals that contributes to the aging process and can
lead to cell and tissue damage33. Lack of oxygen in fat cells has been
directly linked to the development of insulin resistance in mice. 34 Slow
breathing also lowers blood glucose35 and increases oxygenation of the
tissues. 31,36 This enhanced uptake of oxyge n into the blood and cells could
be crucial in understanding why slow breathing is so helpful for diabetics. Studies have shown that the root cause of autonomic dysfunction in
diabetes might be tissue hypoxia37—a condition in which part of the body is
deprived of adequate oxygen. Slow breathing practice supports optimum
gas exchange and better oxygenation, helping the body restore autonomicbalance. This, in turn, reduces stress38 and anxiety,39 helping control
fluctuations in blood glucose. As part of the fight-or -flight stress response,
the body releases stored glucose from the liver into the blood. If insulin
function is poor, that extra blood sugar cannot reach the cells and sugar
concentrations in the blood rise. 40 Research has also shown that slow
breathing can increase insulin sensitivity,41 particularly in type 2 diabetics. This means that insulin is more able to do its job and the body can
metabolize blood sugar better. Nick also discov ered the power of taping his mouth at night to reduce
sleep-disordered breathing. (This technique is described in detai l in Chapter
Seven. ) An intimate two-way link between type 2 diabetes and sleep apnea
has been established. 42 One 2010 pilot study reported that 40% of its 37
long-term type 1 diabetic subjec ts had OSA. 43 While Nick didn’t believe he
had sleep apnea, when he taped his mouth to ensure nasal breathing at
night, he experienced much deeper, more restorative sleep. This resulted in
better morning blood sugars. As anyone living with type 1 diabetes will
know, managing the condition is a full-time job. The increased energy Nick
felt as a result of taping meant he felt better able to control his diabetes
throughout the day. Another reason for Nick’ s impro ved quality of sleep could be that better
breathing helped balance his autonomic nervous system, improving
autonomic funct ion. Diabetics tend to have lower parasympathetic tone at
night, which may result in a disrupted circadian rhythm. 44 Slow breathing is
known to increase parasympat hetic activity. (We examined this in the
context of the vagus nerve in Chapter Four. ) By nasal breathing during
sleep, a practice  that results in slower breathing and stimulate s the vagus
nerve, it is likely that Nick improved his circadian rhythms. Nick also began a breath-hold practice. As a surfer, he primarily used
the exercises to improve his confidence in the water. However, his research
led him to understand that breath holds, or intermittent hypoxia, were a key
component of his increased diabetes control too. The positive results Nick
experienced can be explained by three factors:
1. Hypoxia lowers blood sugar, independent of insulin sensitivity. 45
2. Hypoxia strengthens the innate function of the immune system. 46
3. Hypoxia increases insulin sensitivity. 47Important:  It is never advisable to practice breath holds while in the
water. If you take part in any water sports, you should only practice these
breathing exerci ses on dry land so you can enjoy the benefits when in the
water. Of the three techniques, slow breathing, taping, and breathholdin g, Nick
found that taping  at night had the greatest impact. He wakes every morning
energized, with good blood sugars, ready for a great day. Since beginning
with a breathing  practice, he has seen a marked improvement in his quality
of life and in his diabetes. His average blood sugar measurements are the
best they have ever been. DIABETES CONTROL AND THE BREA TH
Functional breathing is a keystone habit that forms the foundat ion of good
health,48 and diabetes is no exception. Studies have explored the potential
of deep breathing and controll ed intermittent hypoxia (IH) as a holistic
intervention to relieve symptoms associated with both type 149,50 and type 2
diabetes. 47,51,52 Trials have focused on the possible applications for
improving blood sugar, biological functioning, energy, stress, and well-
being. Controlled IH is a period ic dropping of blood oxygen saturation with
adequate recove ry between sets. Because it is controlled, it differs from the
unhealthy oxyge n decrease seen in sleep apnea. IH can be achieved with
breath holds or by using breathing equipment and altitude tents. Research into breathing techniques would be immensely valuable for
medics, certified breathing instructors, and other holistic practitioners who
are interested in using the princ iples of IH breath training to improve the
health of their diabetic patients. Studies indicate that integrating periodic
breath holds (IH breathing training) into diabetic care plans is an excellent
step toward improving quality of life. Important: If you have diabe tes, it is vital that you monitor your
blood sugar levels regularly during practice of any kind of breathing
exercises. Breath holding can cause blood sugar levels to drop too
quickly. To monitor blood sugar level s, consider investing in a continuous
glucose monitoring (CGM) device—a readily available gadget that allowsyou to check your blood sugar levels in a noninvasive way. They are not
cheap, but, as the range of products on the market expands, they are
becoming more  accessible. If you have type 1 diabetes, it’s likely you
already own a CGM, but they are equally valuable for any type 2 diabetic
interested in making lifestyle choices that will improve their condition. As Nick also discovered, good quality sleep is an essential part of
diabetes management. Many aspects of sleep-disordered breathing can be
addressed simply by making the switch to nasal breathing during sleep. Healthy breathing while asleep  has many positive effects on the body’ s
systems that are beneficial for many conditions, including diabetes. This is
worth paying attention to since sleep deprivation is associated with insulin
resistance, and poor sleep qualit y, sleep apnea, and insomnia have all been
shown to increase the risk of type 2 diabetes. 53
DIABETES AND RESPIRA TORY DISEASE
Type 1 and type 2 diabetics have a higher risk for four major respiratory
diseases. 54,55 A resea rch pape r published in Diabetes Resear ch and Clinical
Practice  analyze d the link between type 1 and type 2 diabetes and four
common respir atory diseases:  chronic obstructive pulmona ry disease
(COPD), chronic bronchitis, emphysema, and asthma. 54,55 The study looked
at data from 53,146 adults, all aged 20 years or more. Of the participants,
781 had type 1 diabetes, 4,277 had type 2 diabetes and 48,088 were
nondiabetic. Respiratory diseases were present in 26% of type 1 diabetics,
21% of type 2 diabetics, and 13% of nondiabetics. A number of different
examinations also showed that type 1 diabetics were 62% more likely to
suffer a respiratory disorder than nondiabetics, while type 2 diabetics were
26% more vulnerable. The most common disease was asthma, and type 1
diabetics were found to be 51% more at risk of asthma than nond iabetics. In
type 2 diabetes, the increased likelihood of asthma was 38%. 54,55
Impaired immun e function is a common feature of diabetes. In type 2
diabetes, researchers have identified oxidative stress as one possible
pathway by which innate immunity is disrupted. 56 In type 1 diabetes, the
immune response is, by nature of the condition, dysregulated. One theory
points to systemic inflammation as a link between diabetes and lungdysfunction. 12 Exaggerated inflammatory responses in the lung may be the
result of an impaired ability to regulate inflammatory mechanisms. 12 (The
connection between inflammatory responses and breathing was explored in
depth in the chapter on the vegas nerve, Chapter Four. ) Equally, even before type 2 diabetes is diagnosed, the lung may be the
primary location  for the activat ion of inflammatory processes. This might
explain why lung function is already worse before the onset of diabetes. A
2012 study describes lower lung volumes in type 2 diabetics with
inadequate glycemic control than in those whose blood sugars were well-
regulated. Patients with poor blood glucose control also had much higher
blood levels of inflammatory markers, indicating that inflammation is
involved in the decrease in lung function and fibrosis in type 2 diabetics. 12
The paper suggests that both systemic inflammation, which involves
chronic activatio n of the immune system57, and inflammation in the lungs58
may contribute to the “complex interplay between respiratory and metabolic
dysfunction. ”12
In type 1 diabetics, abnormal growth during childhood (stunting)59 may
affect the proper growth and development of organs including the lungs. While the duration of diabete s has an inverse relationship with lung
function in type 2 diabetics, there isn’t strong evidence to support the same
connection in type 1 diabetes. 60 Howev er, a 2011 study did find a
significant difference in the incidence of restrictive breathing disturbances
depending on whether or not “extreme stunting” was present. Another study states that children with type 1 diabetes have increased
airway resistanc e and that they are more likely to have abnormal lung
function later in life, with long-term problems, including decreased lung
volume, less ability to diffuse CO2, and poor diabe tes control. Researchers
concluded that progressive abnormalities in lung function might adversely
interfere with the ef fectiveness of intrabronchial insulin treatment. 61
In a 2020 Swedish cohort study of more than one and a quarter million
children, of whom 9. 5% had asthma and 0. 3% had type 1 diabetes,
scientists found that children with asthma were more likely to develop type
1 diabetes, but the reverse was not the case. Asthma was assoc iated with a
small but significant increased risk of being diagnosed with type 1 diabetes
compared with non-asthmatic children. 62 In an article for MedPage Today,physician Michael Yafi suggested that, “It may seem plausible that some
factors, like early exposure to viruses, would play a role in the development
of these two diseases. ”63
Yet another paper looked at changes in the thickness of the lung cell
basement membrane in patients with pulmonary diseases. The study
examined participants with diabetes, asthma, bacterial pneumonia,
pulmonary tuberculosis, idiopa thic pulmonary fibrosis, sarco idosis, and
even lung cance r and found that the basement membrane of cells was only
thicker in diabetes and asthma. What this means is that diabetes and asthma
have physiological similarities,64 and that explains why the Oxygen
Advantage breathing techniques used successfully for asthma may also be
effective for diabetics. With this understanding and given that respiratory
illnesses are so prevalent in people with diabetes, it seems essential to
include breathing exercises into diabetes treatment along with other forms
of wellness maintenance such as nutrition and exercise. THE IMPORT ANCE OF EXERCISE
It’s no secret that people who are physically active are healthi er. Exercise
boosts the immune system, supports cardiovascular health, and is important
for weig ht control and self-esteem. Exercising your muscles more often and
pushing them to work harder improves their ability to use insulin and
absorb glucose. 65 When the musc les are better able to metabolize glucose,
the insul in-producing cells don’t have to work so hard. However, exercising
with diabetes can be challenging, and it is important to consult with your
healthcare professional to receive appropriate guidance on diet and
medication before changing your exercise regime. You may find that you get more out of your exercise time and enjoy it
more if you incorporate a mixture of resistance training and a variety of
aerobic exercise s such as cycling, swimming, and jogging. You will also
notice gradual improvements in your health if you simply reduc e periods of
inactivity throughout the day and evening. 4
When it comes to sedentary lifestyle choices, too much time spent
watching TV can be particularl y damaging. Research indicate s that every
two hours spent watching TV instead of doing something more activeincreases the chance of developi ng diabetes by 20%, raises the risk of heart
disease by 15%, and makes it 13% more likely that you’ll die early. 65 TV
watching is unhealthy, not just in its inactive nature. While it’s true that
there are links between time spent on the couch and weight gain or obesity
—something all diabetics must avoid—it is also the case that it’s easy to
slip into unhealthy dietary habits when watching television. 65
The good news is that it is possible to see benefits with relative ly small
lifestyle changes. While there are obviously increased advantag es in terms
of cardiovascula r health if you can work your way up to longer, more
intense periods of exercise, the risk of developing type 2 diabetes can be
reduced by 30% simply by walking briskly for half an hour every day. 65
Another benefit of exercise is that it helps rid the body of excess fat. That much is relatively obvious. But if you have never thought about where
that weight goes, you may be surprised to learn that it is not burned off as
heat or energy. A 2014 study published in the British Medical Journal
found that fat primarily leaves the body via the lungs, as CO2. 66 In fact,
84% of the atom s in every fat molecule is exhaled as CO2, with the rest
ending up as water, which is eliminated in urine, sweat, and other bodily
fluids. 67 According to the paper, replacing one hour of rest with an exercise,
such as jogging,  which increases the metabolic rate by seven times removes
an extra 39 grams of carbon from the body. While the researche rs point out
that this is easily countered by overeating, they state that since weight loss
requires the unlocking of carbon from fat cells, the maxim, “eat less, move
more” remains a good starting point. 66
A HEAL THY HEART VERSUS A DIABETIC HEART
Lower levels of oxygen in the blood of diabetics are common, while reflex
responses to insuf ficient oxygen are blunted. These abnormalities can lead
to serious cardiovascular/renal complications. 65
The heart function of people with type 2 diabetes becomes abnormal. Instead of working optimally, the metabolic systems of the heart change,
becoming less able to process blood sugar. In this state, the body oxidizes (a
chemical reaction involving oxygen) more fatty acids such as oils,
cholesterols, fats, and steroids. The word metabolism  refers to the entirespectrum of biochemical proce sses that take place within the body. This
particular change in metabolic function results in greater oxygen
consumption by the heart muscle tissue, independent of contraction. 68
BREA TH HOLDS, HYPOXIA, AND DIABETES
Type 1 diabetic s generally suffer from low-grade chronic hypoxia, which
may be the root cause of many diabetic complications. 51 An interesting
2013 study looked at the effects  of a single bout of IH on cardiorespiratory
control in 15 patients with type 1 diabetes. 51 The research, which was the
first of its kind, examined the benefits of breathing hypoxic air using a
facemask. Just one session with the mask produced beneficial changes in
aerobic efficien cy and ventilatory responses to hypoxia (too little blood
oxygen) and hypercapnia (too much blood CO2). 51 Wearing a mask is not
the same as practicing breath holds, but the same effect of reduc ing oxygen
can be achieved with either method. The researchers explain that, while it might seem counterproductive for
diabetics to practice IH training, when used correctly, the technique helps
the body to adapt to hypoxia. The study notes that more research is needed
in regard to prolonged exposure  to IH of more than two week s. However,
the improvement seen in breathing efficiency does indicate that IH training
may be beneficial in the treatm ent and maintenance of type 1 diabetes,
particularly as negative side ef fects are minimal. 48
STIMULA TING BLOOD SUGAR TRANSPOR T IN MUSCLE
IH has been found to “significantly” stimulate “glucose transport in
muscle” in both lean and obese patients. 45,48 Researc h dating back 25 years
shows that IH was already established as being beneficia l. In 1995,
scientists from the University of East Carolina’ s Department of
Biochemistry set up an experiment to see whether hypoxia-driven glucose
transportation (absorption of blood sugar into the muscle cells) was still
possible in insulin-resistant muscle. The results showed that when IH was
used alongside insulin, there was a substantial increase in muscle glucose
transportation. 45,48 Insulin used together with the practice of hypoxiareduced a diabetic’ s blood glucose more than either insulin or hypoxia on
its own. Scientists found that muscle contraction and insulin stimulate the
transport of blood sugar to the muscle cells through separate pathways, and
that breath holds work on the muscle contraction pathway. 45,48 This is
exciting news because it indicates that the pathway for blood sugar
transport is still present in diabetics, including those with insulin resistance
(type 2 diabetics ). The presence of this pathway explains how diabetics can
potentially lower their blood sugar by using breath-hold exercises under the
guidance of a professional certified breathing instructor. 45,48
OXYGENA TING THE BRAIN
When the body is at rest, the brain consumes around 20% of the body’ s total
oxygen supply. It should follow that during IH, the system would
compensate to ensure an adequa te oxygen supply to the brain. As CO2 is a
major driver of cerebral blood flow, it might make sense that reducing
blood CO2 would result in less blood flowing to the brain, but previou s
research has returned conflicting results. In 2017, a new study examined how the two blood gases react by
analyzing wheth er decreases in oxygen would increase blood flow to the
brain or would be offset by reduced CO2. 48,69 The outcome of the trial
indicated that IH raises oxygen extraction in the brain, and that even when
levels of blood CO2 are low, blood continues to flow to the brain. The
overall results showed an increase in brain blood flow and that these
increases were substantially stronger at the fifth rather than at the first bout
of hypoxia, implying a cumulative ef fect. Notably, althou gh the participants reduced their CO2 by a relative
amount, their brain blood flow still rose considerably. This indicates that the
IH-induced brain blood flow is more significant than the reduced
circulation brought about by low blood CO2. 48,69 Result s showe d a
substantial increase in oxygen extraction in the brain after the first bout of
IH, which continued throughout the remainder of the procedure. Conversely, the extraction of oxygen in the muscles fell, implying thatduring hypoxia, the brain’ s need for oxygen is prioritized over that of the
muscles. 48,69
The research authors noted that normal levels of oxygen in the tissues
and blood, toget her with exposure to IH, cause dilation of the blood vessels
in the brain and improve blood flow to the brain. While the oxygenation of
muscles decreas ed during repeated IH, oxygen extraction in the brain
increased. This, in combination with improved blood flow, helped maintain
oxygen-dependent brain metabolism during acute, moderately intense IH. The study concluded that normal IH causes compensatory responses in both
the heart and the blood vessels in the brain, which could have potential
applications for training and optimizing brain blood flow. 69
Research from the University of Rochester demonstrated that major
increases in brain blood flow take place at a certain level of oxygen
uptake. 70 Since both breath holds and high levels of CO2 cause the blood
vessels in the brain to dilate, it seems possible that, by employin g high CO2
breath holds, brain blood flow would increase even more:
This research supports practicing breath holds before a workout,
competition, or presentation, as increased brain blood flow helps
focus & prepare the mind. 48
For the purpose s of this book, it is important to distinguish IH from
breath holding. IH involves a controlled reduction in blood oxygen
saturation to between 82% and 95%. This may be done betwe en 3 and 15
times per day. 71–73 Most of the studies with IH use expensive equipment,
which will be out of reach for many people. With breath holding after an exhalation, blood oxygen saturatio n can be
lowered to between 80 and 88% within a few days of practice. Of course,
breath holding is not the same as IH. However, the point is, exposing the
body to short, controlled doses of hypoxia may be beneficial. Be awar e that breath holding can generate a feeling of moderate to
strong air hunge r, which can be stressful. If you choose to practice breath
holding, do so gently. Do not expose your body to high stress. It can also be helpful to use a good quality pulse oximeter to monitor
your blood oxygen saturation as it drops. If you have cardiovascular issues,are pregnant, or have other serious medical conditions, please do not
practice breath holding. EMPTYING THE ST OMACH
Both type 1 and type 2 diabetics are susceptible to a disruption of normal
stomach contractions, which can cut off the digestive process. “Gastric
emptying of solids is delayed in 30% to 50% of patients with diabetes. ”74
This is the resul t of effects the disease has on the nervous syste m. Diabetes
can negatively impact the vagus nerve, compromising the stomach and
other muscles of the digestive tract. 75 As a result, food cannot pass through
the digestive system as rapidly as it should. However, research indicates
that hypoxia with oxygen levels of 10% and 6% causes an increase in
gastric vagal nerve activity in just a few seconds. 76 It is possible to activate
and therefore treat the vagus nerve by practicing slow breathing at six
breaths per minute with a techni que called heart rate variability biofeedback
(HRVB). 77 (There is more detailed inform ation about HRVB in Chapter
Four. ) SLOW BREA THING T O LOWER BLOOD SUGAR
The functioning of the two branches of the autonomic nervous system
(ANS) is relevant in diabetes too. The sympathetic branch of the ANS
raises blood sugar through direct nerve stimulation of the liver and
indirectly through the release of the hormone adrenaline. The liver is
controlled by both the sympathetic nervous system (SNS) and
parasympathetic nervous system (PNS). When the SNS is triggered, the
hormone adrenaline causes the liver to convert stored glycogen into blood
sugar. Adrenaline increases insulin resistance. 48,78 Simultaneously, the SNS
suppresses the release of insulin from the pancreas. The panc reas is also
controlled by nerves from both the SNS and PNS. 48,78
The important point here is that when the SNS is activated, stimulating
the stress response, the pancreas can no longer release insulin. Conversely,
when the PNS is stimulated, insulin production increases. 48 Slow breathinghelps activate the PNS, which is “beneficial, especially for type 2 diabetics
who still produce insulin. ”48
Research shows  that the body of the diabetic tends to be in a chronic
fight-or -flight state. When the SNS is overactive, we automatically breathe
faster than usual  and are more reactive to stress. The good news is that, by
breathing slowly and lightly, it is possible to offset this imbalance. In this
way, we can use the breath to consciously move into a parasympathetic
mode. Adding to the benefits of slow breathing, controlled intermitten t breath
holds also activate the SNS, strengthening the nervous system and making
the body more resilient to stress. 48 Sympathetic activation is part of a
healthy ANS, as long as it doesn’t become chronic, getting out of balance
with the parasympathetic branch. THE BENEFITS OF SLOW BREA THING FOR DIABETICS
In 2017, one of the most highly regarded scientific journals, Natur e, shone a
spotlight on the benefits of slow breathing for diabetics. 31 The publication
cites research-backed findings that a reduced rate of respiration boosts the
ANS, enhances arterial function, and increases blood oxygen saturation in
type 1 diabetics: “Oxygen-induced impairment in arterial function is
corrected by slow breathing in patients with type 1 diabe tes. ”31 The
improved balance in autonomic function that comes from stimulating the
PNS and suppressing sympathetic responses provides an antioxidant effect. The report suggests that slow breathing could represent a simple beneficial
intervention in diabetes. 48 There is practical evidence that just two minutes
of slow breathing can greatly enhance general health in diabetics. Study participants were able to increase their arterial function. The
arteries are important as part of the cardiovascular system. They are elastic
blood vessels that carry blood away from the heart. Participants were also
able to improve  their blood oxygen saturation and key autonomic markers,
measures of various processes regulated by the ANS, such as breath rate
and blood pressure. 48
BREA TH HOLDING AND BLOOD PRESSURE CONTROLType 1 diabetics show poor baroreflex sensitivity, which is compounded
during periods of low blood sugar. As discussed previously, the baroreflex
is a homeostatic mechanism that maintains blood pressure at near constant
levels by controlling various functions such as heart rate. Greater baroreflex
sensitivity impli es a more respo nsive, flexible, healthy system, while low
baroreflex sensitivity is an index of poor health and can indicate issues
including cardio vascular disorders. Baroreflex sensitivity is also one of the
key markers of the ANS. 79 Slow breathing has been found to improve the
parasympathetic activity of the baroreflex in both diabetics and healthy
subjects. In a review of arterial function in type 1 diabetics, researchers found
that slow ing the respiratory rate to six breaths per minute increased the
baroreflex sensitivity of type 1 diabetics to the extent that measurements
were similar to those of the nondiabetic control group. 31 An even more
interesting aspect of this study is the hypothesis that tissue hypoxia
contributes significantly to diabetic autonomic disorders. By breathing
slowly and allowing CO2 to accumulate in the blood, it is possible to
alleviate tissue hypoxia. This discovery could have major implications for
the long-term complications associated with diabetes. DIAPHRAGMA TIC BREA THING T O FILL A
THERAPEUTIC NEED
2019 research from Pakistan explored using diaphragm breathing exercises
for diabetics in developing countries where the cost of medications such as
insulin can be a barrier to treatment. Scientists stated that breathing
exercises are “very useful” and, if practiced regularly, can minimize
hyper glycemia and prevent major complications associated with type 2
diabetes. 80
The study sought to determine the effects of diaphragmatic breathing
exercises on blood sugar levels and HbA1c (a reading of average blood
glucose levels over two or three months) in 64 diabetic women. While
studies from countries, includin g China, Japan, India, and Russia, where
yoga is a comm on practice, have found significant improveme nts in blood
sugar levels, diaphragmatic breathing exercises are not common inPakistan. However, in this context, breathing exercises provide an
accessible appro ach to diabetes control because patients can practice at
home without the expense of medication and without any harmful side
effects. Cost is an importan t consideration for diabetic patients in
developing countries like Pakistan. The study cites 2012 research into the therapeutic effects of
diaphragmatic breathing on oxidative stress in type 2 diabetics. This earlier
paper concluded  that, while breathing exercises alone may not produce
significant resul ts, breathing could be successfully incorporated  as an add-
on therapy to standard care to improve blood sugar and HbA1c. 32
I was first direct ed to research on this topic by my friend and colleague
Dr. Jonathan Herron, from Dungannon in Northern Ireland. He has several
diabetic family members and has lost one relative to diabetic complications. His masters thesis in biomedica l science focused on novel thera pies to treat
diabetes. In his extensive work with diabetic patients, he has noticed a
direct correlation between higher blood sugars and chronic
hyperventilation, which suggests that correction through reduce d breathing
techniques would have a positive effect on HbA1C, lessening the need for
drug therapy. In fact, the Pakistani study did find that diaphragmatic breathing
exercises were beneficial, especially when combined with other techniques
like walking, meditation, and guided imagery, especially when the
breathing is practiced regularly. It was noted that results in this study were
negatively affected by the fact that participants didn’ t always practice the
exercises. It recommended that medical practitioners working with diabetics
should motivate their patients to adopt a routine practice of breathing
exercises at home, stating, “Quality of life of type 2 diabetic patients can be
improved significantly if patients’ compliance with these exercises is
assured. ” The study concluded that it would be valuable to investigate
further effects of the breath ing exercises with a larger sample of
participants. OceanofPDF. comECHAPTER FIFTEEN
SEIZURE CONTROL AND THE BREATH
WHA T IS EPILEPSY. pilepsy is a chronic neurological disease involving the brain. 1 It
affects around 50 million people of all ages worldwide,2 making it
one of the most common neurological conditions. The disorder
makes the sufferer susceptible to recurrent seizures that negatively impact
health and quality of life. The risk of early death is three times higher in
epileptics than the general popu lation. In many parts of the world, suffers
also experience discrimination and stigma. 3
However, according to the World Health Organization, as many as 70%
of people with epilepsy could live seizure-free if properly diagnosed and
treated. 3 The condition is usually treated with anticonvulsants, but the
effectiveness of those medicatio ns varies depending on the type of seizure
condition. 4,5
Seizures can be caused by anything that interrupts necessary
connections between nerve cells in the brain. Common nonepileptic triggers
include low or high blood sugar, high fever, alcohol or drug withdrawal,
and a brain concussion. 3 When a person  has two or more seizures that are
not provoked by any of these factors, he or she is considered to have
epilepsy. Epilepsy has many possible causes—tumors, strokes, brain
damage from injury or illness, an imbalance of neurotransmitters (the
nerve-signaling chemicals), or a combination of these—but in many cases,
there is no discernible basis for the disease. 6Epileptic seizures caused by identifiable factors, including brain tumors
and lesions, are classified as symptomatic. Seizures where the cause is
unknown are called idiopathic. 7 In this chapter, we focus on idiopathic
seizures. The brain controls and regulates all the voluntary and involuntary
responses in the body. It is made up of nerve cells (neurons) that
communicate with each other through electrical activity. When part of the
brain receives a burst of abnormal electrical signals that temporarily
interrupt normal brain function, a seizure occurs. 6
In a healthy, normal system, all the electrical signals that travel between
nerve cells are related to necessary processes such as memory, logic,
decision-making, the deliberate or involuntary movement of muscles, and
the functioning of the senses. For these signals to successfully transmit
from one nerve cell to another, the strength of the electrical signal needs to
be high enough— just as a mobile phone requires enough signa l strength to
make a call or an electrical socket must have the correct volta ge to power
your appliances. The nerve cells also need to have a high enough “excitability” threshold
so that this stron g signal won’ t overpower them. In mammals, this threshold
is normally around 50 microvolts8,9 (one microvolt is equivalent to around
one millionth of a volt). When the seizure threshold is normal, electrical
signals can pass between nerve cells in a functional way. It is important that
no vital information is lost when signals are transmitted and that any
irrelevant signals are repressed so that they don’t interfere with the brain’ s
usual processes. If the neuronal excitability threshold is too low for any
reason, accident al signals can be amplified, causing the functioning of the
central and peripheral nervous systems to be disrupted or suppressed. This disruption is comparable to the changes in blood biochemistry that
occur during abnormal breathing patterns. 10 In fact, this comparison draws
a further  paralle l with epilepsy in that the levels of carbon dioxide (CO 2)
and oxygen found in relation to chronic hyperventilation also tie in with
susceptibility to seizures. Studies have reported a connection between
epilepsy and the breath and even drawn conclusions that breathing exercises
can help reduce the frequency and severity of seizures. 11Seizures can alter respiratory parameters, including the perception of
respiration and fullness of breath. 12 During a seizure, respiratory rate,
breathing pattern, and breathing quality may change. The patient may
experience breathlessness, coughing, and secretion of mucus, and it is
believed that neurogenic pulmonary edema (acute onset of pulmonary
edema followin g a significant central nervous system insult)13 may
contribute to sudden unexplained death in epilepsy patients. Apnea
(involuntary breath holding) and cyanosis (a blue tinge to the skin) are
“normal” during several types of seizure, and hyperventilation is common
in mesial epilepsy,14 a form that is often hard to treat. 15 Coughing, shortness
of breat h, and choking can all occur when a seizure interferes with
breathing and the rhythm of the heart. Over time, these issues  can lead to
increased risk of cardiovascular disease and stroke. 16
Observation of breathing after a seizure can even help healthcare
practitioners identify the type of seizure. For example, respiration after a
generalized tonic-clonic seizure tends to be regular, loud, and deep with
prolonged inhalation and exhalation. After general nonepileptic seizures,
breathing is faster with short in and out breaths. 17
JENNY’S ST ORY: SEIZURE CONTROL AND GREA TER
CONFIDENCE
Jenny was 13 years old when she began having epilepsy. At first, she had
only small complex partial seizu res and was able to manage her symptoms. However, by the time she finish ed college, postictal psychosis had become
a problem. Postictal psychosis is an episode of psychosis that commonly
occurs after a cluster of seizures. For Jenny, this would continue  for three or
four days after a seizure, with symptoms including paranoia, insomnia, and
hearing voices. Her daytime seizures could be triggered by something as
simple as tiredness or even by just catching her reflection in a mirror. Sometimes her panic attacks were so severe she ended up in hospital. She
was advised that neurosur gery would help, and she went ahead with the
procedure. Jenny’ s epilepsy had improved after surgery, and five years after the
surgery, Jenny was able to take a full-time job for the first time. Theposition gave her the option to work from home, which was helpful when
she had epilepsy symptoms. While neurosur gery meant her daytime
seizures stopped altogether, nocturnal seizures became a greater issue. The
afteref fects of these were less severe, but the day after a seizure she still
experienced a throbbing headache, memory impairment, and an unpleasant
coppery taste in her mouth. Even though she no longer suffered from
daytime seizures, she would sometimes feel an aura, as if a seizure were
imminent. This could be extre mely frightening and trigger severe panic
attacks. The resulting chronic anxiety caused her to lose self-confidence. Things changed for Jenny after she read online that light nasal breathing
to address hyperventilation and regulate oxygen intake could help stem the
onset of a panic  attack. After getting my book Anxiety Free: Stop Worrying
and Quieten Your Mind, she made the switch to full-time nasal breathing. She saw the connection between her anxiety, overbreathing through her
mouth during sleep, and poor sleep quality. She realized that her habit of
breath holding during sleep followed by overbreathing (sleep apnea) was
causing her daytime sleepines s, poor concentration, forgetfulness, dry
mouth, and headaches. Once Jenny began to breathe lightly through the nose during the day,
her next nocturnal seizure was much less severe. She got out of bed without
noticing the metallic taste in her mouth that normally followed a seizure. Now, if she feels herself beginn ing to panic, she is able to avert the panic
attack by keeping her mouth closed. Her nocturnal seizures are so much
better that she sometimes has to look at the sleep app on her phone to see
whether she has had a seizure. Jenny still takes an anticonvulsant, but by
addressing her breathing habits, she has been able to gain more control over
her condition. If the daytime aura comes on, she focuses on her breathing
until the feeling passes. Her seizures have now completely stopped. THE BIOCHEMICAL LINK
The neuronal excitability thresh old—the level of tolerance the nerve cells
have for the strength of the signals passing between them —is highly
sensitive to and dependent on the concentration of CO2 in nerve tissues. Hyperventilation, and the resulting low CO2 pressure in the brain, causesnerve cells to fire in a spontaneo us and asynchronous way. This means that
when levels of CO2 and oxygen in the blood, muscles, and cells are
disrupted due to poor breathing patterns, weak or inappropriate electrical
signals may be strengthened and relayed through some areas of the brain,
interfering with the normal signals and causing the seizure threshold to
drop. 18
According to the author and breathing afficionado, Dr. Artour
Rakhimov, betw een 70% and 100% of epileptics can lower their neuron
excitability threshold and induce seizures by deliberate hyperventilation. 19
Evidence demonstrates that hyperventilation can cause seizures,20 but
research has not so far identified the exact CO2 level that can trigger
seizures in people with epileps y. This makes sense because many factors
influence the transmission of electrical signals in the brain. While the
concentration of arterial CO2 is key, metabolic rate, which is affected by
things like body position, posture, and exercise, also plays a role. So does
the availability of calcium and magnesium ions in tissues, as well as the
levels of amino acids, neurotransmitters, and other substances. Hypocapnia
(low blood CO2) provides the necessary condition for a reduced seizure
threshold and the onset of seizures, but it is not the only factor leading to
epileptic sympt oms. Nonetheless, numerous studies have shown that
hyperventilation reliably triggers seizures in epileptics (and patients
suffering from explainable seizu res), indicating that the threshold of nerve
cell excitability is closely related to or controlled by respiration, with some
lesser contribution from other states of homeostatic imbalan ce, such as
sleep deprivation, stress, low blood sugar, infection, fever, alcohol intake,
and overheating. 21
The first research paper to explore the beneficial effect of CO2 in
epilepsy was published in the 1928 Journal of Clinical Investigations. 22
Scientists reported that inhaling air rich in CO2 reduced the severity and
duration of seizures due to the ef fect of the gas on nerve and muscle cells. A
1956 study returned the same results. 23 In 1999, another research paper
explored the effects of hyperventilation on the brain’ s sensory responses
and concluded thatIncreased neuro nal excitability caused by hyperventilation-ind uced
hypocapnia leads to spontaneo us and/or asynchronous firing  of
cortical neurons. 24
In simple terms. this means that the low levels of blood CO2 that occur
as a result of hyperventilation create abnormal activity in the nerve cells of
the brain. The conclusions of a 2005 pape r are even more comprehensive, stating
that, as well as altering respirati on and vascular tone, abnormal CO2 levels
affect blood pH, consciousness, and seizure threshold. 25 Outside of the
brainstem, the mechanisms by which CO2 levels influence the function of
neurons are unknown, but research suggests that CO2-induced changes in
nerve cell function are pH-dependent. The authors conclude that their
findings demons trate a mechanism for the bidirectional effects of CO2 on
neuronal excitability in the forebrain. Sometimes, seizures may be triggered, worsened, and prolonged by low
blood sugar levels. These are called “hypoglycemic” seizures. 26 It is known
that chronic overbreathing resul ts in poor blood sugar control, exacerbating
the symptoms of hypoglycemia. 27. Because one of the roles of CO2 is as a vasodilator, hypocapnia (low
CO2) can lead to vasoconstriction, or narrowing of the blood vessels, which
in turn can cause the carotid arteries to go into spasm, another key trigger
for seizu res. The carotid arteries are blood vessels that carry oxygen-rich
blood to the brain, neck, and face. At the same time, overbreat hing from the upper chest reduces
oxygenation of the organs, including the brain. This can lead to respiratory
alkalosis, in which the blood pH is too high. This compounds the abnormal
electrical activity, further lowering the seizure threshold. 9 A 2006  study
from researchers in Finland reported that the suppression of alkalosis with
5% ambient CO 2 “abolished” seizures in juvenile rats within 20 seconds. 28
This link with CO2 forms the basis for the exchange breathing method
(EBM) protocol, an emer gency seizure-recovery method in which the first-
aider administers an outward breath into the subject’ s nose during seizure. In a 2019 study, EBM was administered 28 times during different seizuresin one subject. The least numbe r of breaths given to stop a seizure was 1,
and the most 10. Typically, 3 breaths were needed. In this case, this
breathing method stopped the seizures at least three times faster than
diazepam, without the postseizu re side effects, such as drowsiness and bad
moods. Research ers concluded that, since this simple technique can be used
any time, it can be easily incorporated into existing treatment protocols,
even applying it as soon as a seizure begins. 29
CHRONIC HYPER VENTILA TION AS A SEIZURE TRIGGER
As we’ve already discussed, hyperventilation is a respiratory behavior
where an irregular increase in the speed and depth of the breath results in
abnormal excha nge of gases in the lungs and low blood CO2 levels. 30
Clinical and research evidence demonstrates a strong link between this
habitual overbreathing and epilepsy. In early studies investigating the
relationship between hyperventilation and seizures, scientists described the
objective and subjective experiences accompanying low blood CO2,
commenting that, “there are few drugs the effects of whic h upon the
neuromuscular system are so rapid and so striking as the effect of voluntary
hyperpnea”31 (deliberately increased rate and depth of breathing)32. It was
found that seizure sufferers have an unusually high sensitivity to changes
within a fairly narrow range of blood CO 2 concentrations. According to Robert Fried’ s book Breathe Well, Be Well,33
hyperventilation is a major cause of fits in epilepsy. The author refers to
numerous studies dating back to the 1930s that have made the connection
between overbr eathing and seizures. In 1954, scientists stated that, “In
persons who are predisposed to epileptic fits, simply overbreathing, often
results in an attack. ”34 A resea rch paper from 1975, Hyperventilation: The
Tip and the Iceber g, explain ed how low blood CO2 causes constric tion of
the blood vessels, leading to a reduction in the amount of oxygen reaching
the brain. 35 These effects are immediate, which is why hypocapnia can
quickly result in feelings of faintness, dizziness, and visual disturbance. The
paper also states that grand mal seizures may be triggered by
hyperventilation. Although research has clearly identified the role of CO2 in cerebral
circulation, many studies still conclude that the cause of seizures is
neurological. The rationale behind this idea is that CO2-driven changes to
the blood acid-base balance create an unstable environment for the nerve
cells of the brain. Further studies have suggested that anxiety can act as a
seizure trigger because it leads to hyperventilation, lowering blood CO2
levels. 36 Patient s were prone to hyperventilating when they felt anxio us,
and while they did not display  any obvious signs of overbre athing, they
experienced a 50% drop in CO2 and an increase in both EEG and clinical
seizure activity. Separate research into cerebral blood flow and metabolism
acknowledges the role of CO2 as a vasodilator. A 2008 study  examining
sexual dysfunction in men with epilepsy points out that sex can itself prove
problematic because of hyperventilation,37 which is commonly associated
with orgasm, can trigger seizu res. In Freedom from Asthma, Alexander
Stalmatski argues that epileptics, like asthmatics and people with a variety
of other related conditions, always hyperventilate, suggesting that, “With
reconditioning of their breathin g patterns. the establishment of proper
levels of CO 2, it is possible to prevent seizures without drugs. ”38
In clinical settings, hyperventi lation is used to activate seizures for
monitoring. I asked a friend who is a brain doctor about the connection
between epilepsy and hype rventilation. My friend explained that
hyperventilation is used
especially by the child neurolo gists as a bedside tool to diagnose
absence seizure s (petit mal seizures) in children. Hyperventilation
causes blood to be alkaline by driving out CO2. This low blood
pH causes constriction of the blood vessels, hence low oxygena tion
triggers the seizures. Even though children are more sensitive, in
adults with chronic hyperventilation due to anxiety attacks, for
example, the brain can suffer the metabolic and oxygenation
changes. I am increasingly surprised that breathing retraining to reverse
hyperventilation is not widely considered in the treatment of seizures. Especially, since  it is also widely recognized that common seizure triggersincluding alcohol, low blood sugar, and stress produce an increase in
breathing volume that may deplete blood CO 2 to the seizure threshold. According to an exhaustive 1990 review by Robert Fried and Mary
Claire Fox, research has proven that the dramatic effect of inhaled CO2 on
EEG activity can be replicated by limiting the rate of respiration. 30 While,
at the time of publication, no evidence existed to indicate that CO2 could be
controlled by self-regulation, the researchers believed that there would be
broad clinical application for such a technique, commenting that
“physiological equilibrium” could be restored by increasing oxygenation of
the cells and tissues or by enhan cing blood flow and metabolism. As Fried
and Fox explain, studies have demonstrated that the cause of seizures is
metabolic and vascular, and that the connection between hyperventilation
and seizures is so strong as to indicate that one causes the other. Alongside the Fried/Fox review, a significant body of research
demonstrates a connection between hyperventilation and epilepsy
symptoms. In 1981, a study compared the effect of 15 minutes of moderate
exercise against  3 minutes of hyperventilation in 43 young patients with
epilepsy. 39 Results were measured in terms of EEG dischar ges—
abnormalities in EEG readings consisting of repetitive sharp waves or
spikes. The epileptic subjects were compared to a control group of 20
young people who had either no organic brain injury or in whom brain
injury had not caused epilepsy. Researchers found that the number of EEG
dischar ges decreased in nearly all participants during exercise but increased
during hyperventilation. The paper concluded that modera te exercise
inhibits seizure activity, while hyperventilation exacerbates it. 39
A 1984 study found that the concentration of blood CO2 had a direct
impact on the duration of seizures. 40 The researchers induced hypocapnia
by hyperventilation to the point where concentration of CO2 in the alveoli
was only 2%. The duration of seizures increased significantl y compared
with the normal CO2 level of 5%, even though oxygen concentration
remained consta nt at 92%. Whil e different levels of oxygen did not produce
any notable changes to seizure duration, seizures became progressively
longer as the amount of CO2 in the alveoli decreased. This finding was
confirmed in a 2008 paper, which reported that moderate hype rventilation
caused a significant increase in EEG seizure duration compared to normalventilation. 41 In 1993, scientists examined 19 patients with complex-partial
seizures, reporting that hyperventilation triggered a “marked activation” of
the epileptic focus—the area of the brain from which the seizure
originates. 42
There have been attempts to determine whether the degree of
hypocapnia correlates with an increased frequency of petit mal or absence
seizures and if there is a critical concentration of CO2 at which these
seizures are reliably induced. 43 In a 1996 study, scientists monitored 12
children who had newly diagnosed absence epilepsy. EEG readings and
percentage of CO 2 in expir ed air were recorded during quiet respiration and
hyperventilation. These readings were taken while the children breathed
four dif ferent gas mixtures:
1. Room air
2. 100% oxygen
3. Room air with 4% CO 2
4. A gas containing 4% CO 2 and 96% oxygen
When the children were breathing quietly, a reduction in EEG spikes
was seen when the breathing gas contained extra CO2 (3 and 4), but a
higher concentration of oxyge n in inspired air (2) caused no changes. Seizures were triggered in eight of the children with each trial of
hyperventilation, but the level of CO2 that induced seizures was found to
differ among the children. The study concluded that it would be helpful to
discover whethe r sensitivity to blood CO2 could help predict the likely
response to antiepileptic drugs, and that more research was needed into the
possible use of CO 2 for the remission of seizures. A study from 2001 examined patients who suffered nonepileptic
seizures, 41% having coexistin g epilepsy and found the most frequent
features of nonepileptic seizures included fear, anxiety, and
hyperventilation. 44 Another paper found that typical absence (brief,
generalized) seizures are “easily precipitated by hyperventilation” in
approximately 90% of untreated  patients. Similarly, a study of children who
had epilepsy with myoclonic absences concluded that the seizures were
easily provoked by hyperventilation. 45 This finding was repeated in a 2009
study, which observed myoclonic absence seizures in three patients whichwere triggered by hyperventilation. 45 Researchers concluded that
“hyperventilation is most effective in activation of generalized absence
seizures during routine EEG studies. ”46 Researc h from 2011 repeated the
finding that hyperventilation is an effective way to activate epileptic
seizures in patients with epilepsy. 47 In a study of children aged between 3
and 11 years, hyperventilation induced seizures in all patients. 48 It’s worth
noting that around 10% of seizures in children with epilepsy are absence
seizures, otherwise called petit mal seizures. 49 These seizures have a
significant impact on quality of life. 50
CO2 has long been recognized for its anticonvulsant properties. 51 In
2007, the science news website Science 2. 0  reported research that presented
CO2 as a “new—and completely free—way to prevent fever -related
epileptic seizures” in small children. 52 Scientists believed that CO2-
enriched air could be used to stop seizures. The research showed that fever -
related seizures, which are common in children under the age of five, could
be safely suppressed within 20 seconds simply by adding 5% CO2 to
inhaled air. Experimental research indicates that these childhood seizures
may increase the risk of epilepsy developing later in life. The study suggested that CO2 therapy could also be effective in
stopping other types of epileptic seizure. 52 This theory was tested in 2011
research when scientists set out to discover whether inhaling 5% CO2
would stop seizures in epilepsy patients. 53 A pilot study of seven people
demonstrated a “rapid termination of electrographic seizures” even though
the 5% CO2 was applied after the seizure had begun. The researchers
concluded that inhaled CO2 could be used for acute treatment of epileptic
seizures. 53
A follow -on review of this study stated that the research demonstrated
the “feasibility”  of hypercapnia as a clinical treatment. 51 While more work
is needed to ensure safety and efficacy—for instance, it is important that
hypercapnia does not progress to acidosis during a prolonged seizure—the
review suggests  that this is a worthwhile avenue, concluding, “Carbon
dioxide inhalation could prove to be an easy and inexpensive intervention
for acute seizures in the hospital, and possibly in the home as well. ”A further study from 2014 soug ht to discover whether inhaling 5% CO2
could suppress hyperventilatio n-induced absence seizures and irregular
electrical discha rges in the brain known as “spike and wave dischar ges. ”54
Researchers concluded that treatment with CO2 may help treat these
seizures. A 2019 clinical review reiterated earlier findings, stating that the
“spike and wave” neuronal dischar ge typical of absence seizures is
triggered by voluntary hyperven tilation in more than 90% of patients with
absence epilepsy. The paper describes the use of hyperventilation to quickly
diagnose patien ts with absence epilepsy as “commonplace. ” While
scientists are still unclear whether a single mechanism exists to prompt
absence seizure s, the review suggests that the changes in blood pH
(alkalosis) brought on by hyperventilation may contribute. 55
In the 2014 study, 12 participants who had hyperventilation-induced
absence seizures  were examined while breathing either room air, 5% CO2,
or 100%  oxygen. Compared to hyperventilation in normal room air, the 5%
CO2 decreased the frequency and duration of seizures after hyperven tilation
and reduced the number of “spike and wave” dischar ges. This pilot study
added yet more clear evidence that hypercapnia could provide a way to treat
hyperventilation-related seizures. 54
COMORBID HEAL TH PROBLEMS IN EPILEPSY
The Cold Spring Harbor Perspectives in Medicine  published a paper in
2015 that suggested that epilepsy encompasses more than spontaneous
recurrent seizures and should be classified as a “spectrum disorder. ”7 For
many epileptics and their families, what causes the greatest impact are the
many conditions that exist alongside the primary symptoms. Comorbid
conditions can include psychiatric and behavioral disorders like anxiety,
depression, attention-deficit hyperactivity disorder (ADHD ), learning
disabilities, intellectual disability, and autism. Traditionally these comorbidities were thought to be secondary to
uncontrolled seizures and adverse reactions to medication. However, they
are now acknowledged as integral to epilepsy. In some cases, the comorbid
conditions predate the seizures and can be attributed to an underlying
disorder of neuronal networks. 56 A 2007 study states that even a singleseizure can cause modifications to receptor expression and distribution,
altering neurodevelopment—the  growth of neurological pathways in the
brain that influence things like intellectual functioning, reading ability,
memory, focus, and social skills—leading to cognitive and behavioral
changes. 57
The most common psychiatric comorbidity in epilepsy is depression. This is interesting because depression is linked with dysfunction in the
hippocampus and limbic structures of the brain, areas of the brain that are
both frequently involved in epileptic circuits. The connection between
depression and epilepsy is bidirectional. People with epilepsy are more
likely to develop depression, and those epileptics with depression more
commonly suffer refractory seizures, seizures that are uncontrolled or
difficult to treat. 58
It can be difficult to achieve a clinical diagnosis of anxiety in patients
with epilepsy, but the unpredictable nature of the disease and the fear of
seizures often leads to some level of anxiety. Approximately 30% of adults
with epilepsy have depression and 10% have bipolar disorder. 58 Both these
disorders are related to increa sed risk of suicide. The same  is true in
children, but symptoms are harder to identify here. Research has
demonstrated that children with newly diagnosed epilepsy are around three
times more likely to also have a mood disorder. Physical health problems also affect many people with epilepsy. The
Centers for Disease Contr ol and Prevention National Health Interview
Survey  found that adults with epilepsy were more likely to also have
cardiovascular and respiratory disorders, inflammation, obesity, diabetes,
and other conditions, including arthritis, pain in the upper or lower spine,
and severe headaches. 59 Epileptics also have a higher incidence of sexual
dysfunction,37 early mortality, and sudden unexplained death. 60
Another concern for people with epilepsy is the impact of seizure
medication on bone health. Epileptics are more prone to fractures due to
decreased bone mineral density. 61 The antiseizure medications
carbamazepine, phenytoin, and phenobarbital cause a decrease in bone
mineral density by triggering release of the CYP450 enzyme, but non-
enzyme-inducing AEDs are also linked to altered bone health. 61 We lookedat the link between bone mine ral loss and breathing pattern disorders in
Chapter Thirteen. In all cases, whether comorbidities are psychological or physiological,
understanding the relationship between epilepsy and its associated
conditions can have a signific ant positive impact on quality of life for
people living with the disease. Indeed, scientists consider this to be a
priority for future research. More to the point, many of the problems that
exist alongside epilepsy, including anxiety disorders, diabetes, heart
problems, and respiratory condi tions, can also be contributed by breathing
pattern disorders such as chronic hyperventilation. EPILEPSY AND BLOOD FLOW T O THE BRAIN
Cerebral blood flow is known to change during seizures, specif ically in the
epileptogenic zone, the area of the cortex that initiates the seizure. 62 Blood
flow to the brain decreases between seizures and increases during them. Immediately after a seizure ends, cerebral blood flow becomes very low,
and it remains low for several minutes. Unfortunately, these changes in
blood flow prevent proper oxygenation of the brain. A 2017 study reported
that the most severe long-term result of repetitive epileptic seizures was
neuronal degeneration. 63 Researchers state that while the primary cause of
this is overstimulation of the neurons, new findings indicate that hypoxia, or
lack of oxygen caused by abno rmal blood flow, “may be to blame for as
much as half the neuronal death caused by the condition. ”
Research has found that cerebral blood flow can be improved with
breathing exerci ses. Again, CO2 plays a key role. One 2011 study tested the
potential for simple breathing exercises to increase cerebral oxygenation
and/or blood flow. 64 Scientists examined 18 participants aged between 19
and 39 years and recorded levels of end-tidal CO2 and brain oxygenation. Subjects were asked to comple te paced breathing exercises that included
breath holds on both inhalation and exhalation. The exercise involved
walking slowly for three steps while inhaling, holding the breath for three
steps, exhaling for three steps, holding the breath for three steps and so on. The researchers found that the main parameter influencing cerebral
circulation is the level of CO2 in the blood, and that an increase in CO2concentration of around 70% may as much as double blood flow. 65 When
more blood flows to the brain, the brain receives more nutrients and
oxygen, and this may have a significant influence on its physiology. People
trained in breathing exercises can increase their levels of blood CO2 by
learning to control tidal volume64 (the amount of air that moves in and out
of the lungs with each inhalation and exhalation). This mean s that it is
possible to improve cerebral blood flow simply by moderating the
breathing. 66
A second study, also from 2011, explored cerebral oxygenation in
people who were experience d in yogic breathing techniques. 67 Six
participants, who were each able to breathe at an extremely slow rate,
performed an identical periodic breathing exercise with a respiratory rate of
two breaths per minute. In all six subjects, the results showed  a periodic
change in cerebral blood flow and oxygenation. This result was repeated in
a 2016 paper by the same research team. 68
Given that much of the neurona l damage caused by epilepsy is caused
by lack of oxyg en to the brain, it is promising to realize that breathing
exercises can so simply improve cerebral blood flow and therefore brain
oxygenation. SLEEP MA TTERS IN EPILEPSY
Epilepsy and sleep-disordered breathing (SDB) are both relatively common
conditions. 69 However, they occur comorbidly more frequently than
expected, leading to considerations that a connection exists between the
two. It is under stood that epilepsy can aggravate obstructive sleep apnea
(OSA) because it causes an increase in light sleep. Epileptic medications
can also produce side effects (such as weight gain) that increase the
likelihood of SDB, and epileptic seizures can trigger central apneas. It is also the case that SDB can impair epilepsy control due to repetitive
hypoxia and disrupted sleep. While this area lacks research, some evidence
suggests that, if SDB can be treated, seizure control will improve, as will
quality of life and general health and well-being. According to a 2018 article in Epilepsy Foundation, “there has never
been a prospec tive, multi-cen ter trial to evaluate the effect of OSAtreatment on seizures in people living with epilepsy. ”70 More research is
needed, particularly in the field of pediatrics. Healthcare professionals who
may not be aware of the connection between sleep disorders and epilepsy
need to be educated. However, there is some limited research into the
relationship between the two disorders. A 2008 paper exploring sleep-study
abnormalities in epileptic children describes the relationship between SDB
and epilepsy as “complicated and reciprocal. ”71 Researchers have looked in
detail at the link between epilepsy and sleep, and whether one affects the
other, but little has been done  to understand the mutual interaction of
epilepsy and sleep disorders, particularly in children. The 2008 paper
examined quest ionnaire-based survey responses from 486 patients with
partial seizures and 492 age- and gender -matched controls. It found that
sleep disturbances affected 39% of adults with epilepsy, compared to 18%
of the control group. 71
A 2019 Austral ian study published in Neur ology  found that 26. 5% of
participants had moderate to severe SDB, as defined by an apnea-hypopnea
(AHI) index of “greater than 15. ”72,73 (We looked at the AHI in Chapter
Seven. ) This study found that daytime sleepiness was an accurate indicator
of sleep  disorders in epileptics, but that age and body-mass index also
contributed to the condition. The small amount of research into this topic means that much evidence
is conflicting, both in terms of prevalence and diagnostic criteria. Section summary: 

Please summarize the passage below approximately 150 words. **Note:** Please prioritize accuracy and brevitity; omitting unnecessary detail whenever feasible. Summary

Nick's story highlights the importance of optimal gutters' installation for efficient roof drainage. (Note: Remove "optimal" and replace it)

Here is corrected version:


After experiencing considerable stability in his blood sugar fluctuations,

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Full Text


Inspired by his recent advancements, Nicholas started incorporating [Breathing Exercises](https://www. bradclayton. com/blood-sugars/) From `Oxygene` Benefit. , Following Some Months, He Realised Significant Improvements in Glucosuria Control And Needed Less Than Before On Medicinal Assistance. Since College Graduation Time Was Completed Within Three Steps Walkwhile Holding Breathers Then Held Outwards For Two Steps Or Longer Hold Period Duration Each Step Took Around Five Seconds. )[Source]

He Also Found Evidence Explaining Positive Effects Of Slowing Down Heart Rate Upon Pancreate Functionality Improvement Through Direct Nerve Stimulation. [Source]
Slow breathing Has Been Shown Improve Autonomously Functional System Reduced Oxide Stress Contributing Aging Process Can Lead Cell Damage. ] [[Source]]
Furthermore,[Sources] Have Identified Lower Lung Volume Due To Sleep Disorganized Rhythm State Implying Link Between Type II Diseases Development Moreover Fat Cells Develop Resistance Is Linked To Decrease Amount Present Cellular Energy Storage Thus Making Difficult Manage Condition Better Life Quality Overall. \*

Moreover Several Factors Were Considered Including Lifestyle Changes Which Improved Their Circulatory Issues Furthermore Increased Risk Cardio-Vascular Disorders\*. * \*\*. * *

Many Other Conditions Are Connected Together Here Like High-Frequency Electrical Signals Traverses Throughout Brain Regions Cause Unpredict Ability Make Diagnosis Difficulty Challenging Often Leads Depression Increase Likelihood Suicides Mention Problem Specific Example Different Techniques Used Treatments Given Symptoms Will Help Reduce Frequency Severity Complications Impact Individual Lives Generally Speaking Those Affected Should Seek Professional Guidance Understand All Relevant Information Prioritize Own Personal Situation Assess Potential Benefits Implement Change Adapt Any Necessary Adjustmennts Achieved Successively Follow-Up Monitoring Provide Feedback Support Encourage Progress Continuously Evaluate Self-Centered Experience Perceived Sense Reality Existentialism Contextually Situated Human Being Perspective Viewpoint Relevance Subjectivity Objectification Perception Formation Understanding Cultural Social Historical Economic Ecological Environmental Political Educational Psychological Academic Institution School Home Family Worklife Balance Conflict Interdependence Dependenceness Shared Space Harmony Unity Intergroup Cooperation Coexistence Congruence Consistency Integration Integrity Solidarity Fellowship Community Spirituality Conscience Morale Virtue Courage Responsibility Wisdom Empathy Compassionate Kind.
Slow breathing has been shown to improve the function of the autonomic nervous system, reduce oxidative stress, and increase oxygenation of the tissues, which can help in diabetes control.
What is the significance of slow breathing in diabetes management?
Proper breathing techniques, such as nasal breathing and breath-holding, can help in diabetes control and management, especially in type 2 diabetics.
What is the importance of proper breathing techniques in diabetes care?
Research has established a link between diabetes and four major respiratory diseases, including chronic obstructive pulmonary disease, chronic bronchitis, emphysema, and asthma.
What is the relationship between diabetes and respiratory diseases?
Diaphragmatic breathing has been shown to increase the seizure threshold and potentially stop seizures by increasing blood flow to the brain.
What is the significance of diaphragmatic breathing in epilepsy?
There is a strong link between epilepsy and sleep disorders, with sleep apnea and insomnia being common comorbidities, and it is essential to address both conditions simultaneously for effective treatment.
What is the relationship between epilepsy and sleep disorders?