Obstructive Sleep Apnea: Symptoms, Causes, Treatments, and Natural Approaches

Sleep apnea is a potentially life-threatening condition in which the airway becomes partially or completely blocked, causing repeated breathing interruptions during sleep. This leads to chronic oxygen deprivation and fragmented sleep, affecting daily functioning and quality of life.

OSA can affect people of all ages and health conditions, but it is most common in those overweight or obese, particularly men. As obesity rates continue to climb, so does sleep apnea.

OSA symptoms vary widely, and some people have no noticeable symptoms. As a result, many remain unaware of their condition unless someone else observes their breathing disturbances during sleep. Excessive daytime sleepiness—often considered the hallmark symptom—significantly affects quality of life.

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POSA occurs when breathing disturbances worsen significantly while sleeping on the back (supine position) compared to other sleep positions.

While definitions vary, POSA is typically diagnosed when the number of breathing pauses (apneas) or partial blockages (hypopneas) in the supine position is at least twice that of non-supine positions.

Patients diagnosed with e-POSA typically respond well to positional therapy interventions, which encompass various techniques designed to discourage supine sleeping postures.

In OSA, the throat muscles relax during sleep, causing soft tissues and the tongue to collapse into the airway, blocking airflow to the lungs.

Reduced Nerve Signaling

When nerve signaling is reduced, the airway muscles lose tone, leading to partial or complete collapse and restricted airflow.

As oxygen levels drop and carbon dioxide levels rise, the brain triggers the nervous system to briefly wake the body—often with gasping or choking—to restore breathing.

These disruptions activate the body’s fight-or-flight response, chronically raising heart rate and blood pressure.

The combination of poor sleep, metabolic changes, and nervous system activation promotes weight gain, gut dysbiosis, and intestinal permeability issues, further deteriorating sleep quality. This self-reinforcing process generates widespread inflammation and oxidative stress, damaging cells and tissues throughout the body.

As inflammation intensifies, it drives insulin resistance, hypertension, cardiovascular disease, and neurological problems. The resulting increase in body fat, particularly around the abdomen, amplifies inflammation and worsens OSA symptoms—further reinforcing the cycle.

Several factors increase a person’s risk of developing OSA, which can be categorized as unmodifiable or modifiable.

Unmodifiable Risk Factors:

• Age: Risk increases with age and plateaus around 65 years.
• Sex: Men are 1.5 times more likely to have OSA than women, though the gap narrows after menopause, likely due to hormonal changes and fat redistribution.
• Race: Risk varies by ethnicity. Asians have a greater risk and disease severity despite lower obesity rates, likely due to craniofacial features. Research also shows higher odds of moderate-to-severe OSA in Asian adolescent males, increased snoring in Hispanic adults, and greater disease severity in Hispanic adolescent males.
• Craniofacial anatomy: Certain facial and skull features contribute to airway narrowing and increase OSA risk. A small jaw, receding chin, or large tongue, a shorter or steeper-angled skull base, and a lower-positioned hyoid bone (a small U-shaped bone in the neck that supports the tongue) all play a role.
• Genetics and family history: Having first-degree relatives with OSA increases risk, and the likelihood rises with the number of affected family members.

Modifiable Risk Factors:

• Body size: A high BMI and central obesity are the strongest OSA risk factors
• Neck circumference: A larger neck size (greater than 17 inches for men and 15 inches for women) increases risk by narrowing the airway
• Enlarged tonsils and adenoids: Obstruct airflow and are a significant risk factor in children
• Pregnancy: Causes hormonal changes, weight gain, and a growing uterus, which increase OSA risk. Up to half of pregnant women snore, and many develop POSA
• Air pollution: Increases OSA risk by causing airway inflammation, edema, and fluid redistribution
• Respiratory problems: Conditions such as asthma, sinus issues, and nasal congestion increase risk
• Alcohol use: Increases OSA by 25 percent and worsens apneas and oxygen saturation levels
• Smoking: Raises the risk of OSA and snoring. Secondhand smoke is also linked to habitual snoring, though former smokers do not show an elevated risk

When OSA is suspected, primary care providers use screening tools like questionnaires and sleepiness scales to assess risk and rule out other potential causes. If high risk is indicated, the next step is a referral to a sleep specialist for a clinical assessment and an overnight sleep study, known as polysomnography (PSG), which monitors brain activity, heart rate, breathing, and oxygen levels to diagnose sleep disorders. They are typically conducted at a sleep center or hospital.

If a PSG is not feasible or covered by insurance, out-of-center sleep testing or home sleep apnea testing may be more convenient and cost-effective. These at-home tests use portable devices to monitor breathing patterns, oxygen levels, and sometimes heart rate during sleep.

Functional Medicine Testing

Functional medicine practitioners may use additional tests to identify underlying factors contributing to OSA. These evaluations provide a comprehensive understanding of a patient’s health and help guide personalized treatment.

Testing may include:

• Comprehensive stool analysis: Evaluates gut microbiota composition and intestinal health to identify imbalances that may influence systemic inflammation and OSA severity
• Cardiometabolic assessments: Measure blood glucose, insulin, advanced lipid profiles, including LDL particle size and number, ApoB, and lipoprotein(a), and inflammatory markers to evaluate metabolic and cardiovascular health
• Hormonal evaluations: Assess serum thyroid hormones, like TSH, free T3, free T4, reverse T3, and thyroid antibodies, and salivary sex hormones and cortisol to determine their effects on sleep quality and respiratory function
• Nutritional assessments and food sensitivity testing: Identify micronutrient deficiencies, food allergies, and sensitivities that may contribute to inflammation, metabolic dysfunction, and poor sleep

The processes involved in OSA—such as low oxygen levels, disrupted sleep, increased sympathetic nerve activation (SNA), metabolic dysregulation, inflammation, oxidative stress, and endothelial dysfunction—can contribute to serious health complications.

Studies indicate that untreated OSA can result in numerous severe health complications, including:

• Cardiovascular diseases: Includes heart failure, atrial fibrillation, coronary artery disease, atherosclerosis, high blood pressure, stroke, and heart attacks
• Metabolic disorders: Involves insulin resistance, diabetes, metabolic syndrome, and elevated blood lipids, including high total cholesterol, triglycerides, low-density lipoprotein (LDL), and very-low-density lipoprotein (VLDL)
• Neurological and cognitive issues: Leads to impaired memory, and cognitive decline, decreased gray matter in the brain, and increased glaucoma risk
• Organ dysfunction: Contributes to nonalcoholic fatty liver disease and kidney disease
• Cancer: Includes lung, breast, prostate, and colon cancer, melanoma, and nasopharyngeal tumors
• Sexual and reproductive health: Causes erectile dysfunction, reduced fertility, and low libido and testosterone
• Gastrointestinal issues: Increases the risk of gastroesophageal reflux disease (GERD) and digestive disturbances
• Increased mortality risk: Raises the likelihood of death from all causes and sudden death during sleep

Additionally, people with OSA face more than double the risk of being involved in automobile accidents. They may also experience reduced work efficiency, difficulty with certain tasks, and higher rates of missed work and job-related disability. Pregnant women with OSA are more likely to have newborns with lower birth weights and Apgar scores.

Effective treatment should address the underlying causes of OSA while considering patient preferences, improving quality of life, and reducing complications. Treatment options include both nonsurgical and surgical approaches, sometimes combined for optimal results.

Because OSA varies between people, a personalized, multidisciplinary approach is often necessary, involving specialists, nutritionists, health coaches, and, in some cases, surgeons.

Weight Loss

For people with obesity or excess fat around the neck and airway, weight loss is one of the most effective interventions for OSA. It can reduce AHI, improve oxygen levels, and alleviate daytime sleepiness.

The Wisconsin Sleep Cohort Study demonstrated that a 10 percent weight loss was associated with a 26 percent decrease in AHI. In some cases, weight loss alone can resolve OSA. Conversely, the study found that a 10 percent weight gain predicted about a 32 percent increase in AHI.

Positive Airway Pressure

Because weight loss can be challenging, time-consuming, and difficult to maintain, positive airway pressure (PAP) therapy remains the primary first-line treatment for immediate symptom relief.

PAP devices deliver pressurized air to keep the upper airway open during sleep. Studies show that PAP can reduce AHI by 84 percent.

PAP therapy comes in three variations:

• CPAP (continuous positive airway pressure): Uses fixed pressure set during a sleep study
• BPAP (bilevel positive airway pressure): Delivers higher pressure when inhaling and lower pressure when exhaling, beneficial for those who struggle with CPAP
• APAP (auto-titrating positive airway pressure): Adjusts pressure automatically, offering effectiveness similar to CPAP with better tolerance and lower costs

CPAP improves blood pressure, sleep quality, and daytime alertness, but adherence remains a challenge—26 percent to 83 percent of users don’t use it regularly. Regular use means more than four hours per night, though full benefits require use throughout sleep.

Additionally, about one-third of people poorly tolerate PAP, experiencing side effects ranging from minor nasal dryness and irritation to rare complications like nasal injury or tissue damage from prolonged pressure.

Positional Treatment

Positional therapy is a simple, effective, and low-cost approach for POSA that discourages supine sleeping. It involves using methods such as strapping a tennis ball to the back or wearing a specially designed shirt with a built-in pouch to prevent rolling onto the back. However, many find these methods uncomfortable, which affects long-term adherence.

Oral Appliances

Also known as mandibular advancement devices or oral splints, these are worn in the mouth while sleeping to hold the jaw or tongue in a position that keeps the airway open. Oral appliances are an alternative treatment for mild to moderate OSA, particularly for those who are intolerant of or nonresponsive to PAP therapy.

Research suggests mandibular advancement devices are about 60 percent effective in reducing the AHI and can improve daytime alertness and blood pressure. However, they require custom fitting, which can be costly, and may cause side effects such as temporomandibular joint pain, tooth discomfort, dry mouth, or excessive salivation.

Pharmaceuticals

Despite numerous studies, quality evidence supporting drug treatment for OSA remains limited. However, medications are sometimes used to promote weight loss, manage OSA symptoms, or target neuromuscular factors that contribute to airway collapse.

In desperation for sleep, sleep aids may seem appealing, but they are generally not recommended for OSA except in cases of coexisting insomnia or low arousal thresholds. These medications can relax throat muscles, potentially worsening breathing issues and causing side effects that compound OSA symptoms, such as daytime sleepiness.

Examples of medications to avoid include opioids, benzodiazepines, and Z-drugs like zolpidem, eszopiclone, and zaleplon.

Sleep aids and other medications can mask symptoms without treating the root cause. By suppressing the body’s natural arousal mechanisms, they may increase the risk of complications.

If you have OSA, consult a doctor before using any medication.

Surgery

Several surgical approaches are available when standard OSA treatments fail. These interventions are typically considered only after more conservative approaches like CPAP therapy have proven ineffective or intolerable.

• Adenotonsillectomy: The first-line treatment for children, though it’s less effective in obese pediatric patients
• Uvulopalatopharyngoplasty: The most common procedure for adults, removing soft tissue at the back of the throat with a 60 percent response rate
• Maxillomandibular advancement: A more advanced procedure that repositions the jawbones with a higher success rate of 87 percent, but is typically reserved as a last resort due to its complexity
• Hypoglossal nerve stimulation: Reduces obstruction by stimulating tongue movement during sleep, though effectiveness decreases with higher BMI
• Bariatric surgery: Improves OSA in 45 percent to 86 percent of obese patients, making it an alternative option when excess weight is a major contributing factor

A positive mindset plays a crucial role in overcoming OSA management challenges, particularly in the early stages of CPAP therapy, where adherence leads to better long-term outcomes. A 2023 review suggests that mindfulness-based interventions may improve CPAP adherence.

Additionally, motivational interventions—incorporating positive thinking, goal-setting, and treatment education—have been shown to be more effective than standard care in encouraging CPAP use. These approaches help people set realistic goals, understand the health risks of untreated OSA, and align treatment with their personal values.

Beyond CPAP adherence, a positive mindset can also enhance motivation for weight loss and healthier lifestyle choices, both key to reducing OSA severity. Moreover, maintaining a calm, optimistic outlook can help reduce stress, which is linked to decreased sympathetic nervous system activity and lower inflammation—both of which may alleviate OSA symptoms.

By fostering a positive approach to treatment and lifestyle changes, people with OSA may experience better adherence, improved symptom management, and a higher quality of life.

While many people find relief with various natural remedies, this section highlights those backed by peer-reviewed research. As with medical treatments, natural approaches may have side effects or risks. Always consult a health care provider before making changes to your treatment plan, and seek guidance from a qualified nutrition professional on supplement quality, form, and dosing.

Beyond weight loss, several natural strategies can help with OSA and can be used alongside traditional treatments or, in some cases, as an alternative.

Exercise

While a combination of diet and exercise provides greater benefits for OSA management, research suggests that exercise alone can still improve symptoms, even with minimal weight loss. Studies show that exercise can reduce AHI and may help by preventing fluid buildup in the upper airway and improving muscle tone during sleep to keep the airway open.

Good Sleep Hygiene

Since OSA disrupts sleep quality, reducing other factors that interfere with rest is essential. Practicing good sleep hygiene can improve overall health. Key strategies include:

• Maintain a regular sleep schedule: Go to bed and wake up at the same time each day.
• Establish a relaxing bedtime routine: Limit screen time, dim the lights, and avoid stimulating activities before bed.
• Optimize your sleep environment: Keep the room dark, cool, and quiet.
• Avoid caffeine and heavy meals before bed: Both can interfere with sleep quality.
• Get morning sunlight and stay active: Exposure to natural light and regular movement supports a healthy sleep cycle.

Vagal Toning for Nervous System Balance

Vagal toning exercises, which stimulate the vagus nerve, can help reduce SNA activity. Simple techniques that integrate easily into daily routines may promote relaxation and mitigate some of the negative effects of chronic stress on the nervous system.

Some effective vagal toning exercises include:

• Deep breathing: particularly diaphragmatic or belly breathing
• Humming, singing, and gargling: stimulate the muscles at the back of the throat and diaphragm, creating vibrations that activate the vagus nerve
• Cold exposure: such as splashing cold water on the face, which triggers a relaxation response through vagal nerve activation

Nasal Breathing

Waking up with a dry mouth or sore throat often indicates mouth breathing during sleep. Transitioning to nasal breathing can offer several benefits, including improved oxygen uptake, reduced SNA activity, and better circulation, which may help lower blood pressure and promote relaxation. Nasal breathing also filters, warms, and humidifies inhaled air, reducing allergen intake and potentially lowering the risk of respiratory issues.

One method to encourage nasal breathing is mouth taping during sleep. Specialized tape is available for this purpose. Research suggests this technique can reduce snoring and lessen OSA severity in habitual mouth breathers. However, consult with a health care professional before attempting mouth taping, especially for those with nasal obstructions or other respiratory concerns.

Home Air Purifier

Using an air purifier can potentially reduce the long-term risk of developing or worsening OSA.

Research shows that air purification can lower indoor air pollution, reduce inflammation, and support cardiovascular health. High-efficiency particulate air (HEPA) filters are especially good at trapping allergens and airborne particles that can affect breathing during sleep.

Over-the-Counter Supplements

Several nutritional compounds may benefit OSA patients by addressing inflammation, oxidative stress, and gut health imbalances.

• Glutamine: An amino acid found in meat, dairy, and leafy greens, that may support gut barrier integrity, reduce inflammation, counteract oxidative stress, and promote sleep. Studies suggest glutamine may prevent cognitive decline triggered by inflammation in situations where there’s a deficiency of oxygen reaching the body’s tissues.
• Antioxidants: Vitamin C and E supplementation has been shown to reduce oxidative stress markers in OSA patients, potentially lowering CPAP pressure requirements and improving sleep quality.
• Butyrate: Research also indicates that OSA patients often have reduced levels of butyrate-producing gut bacteria. This short-chain fatty acid maintains gut integrity, regulates inflammation, and supports metabolic health. Dietary sources include full-fat dairy and fiber-rich foods that promote beneficial gut bacteria, while supplementation may help those with significant microbial imbalances.

Traditional Chinese Medicine (TCM)

TCM may serve as a complementary approach to managing OSA, particularly through the herbal formula Jiawei Di Tan Tang.

A 2016 study of patients with severe OSA found that participants in the control and experimental groups made lifestyle changes. While the control group saw modest improvements, those in the experimental group—who also took Jiawei Di Tan Tang—had greater reductions in inflammation and oxidative stress markers, along with decreased daytime sleepiness, fewer breathing interruptions, and less snoring.

These findings suggest that Jiawei Di Tan Tang may enhance the quality of life and improve health outcomes for people with severe OSA. Consult a qualified TCM practitioner before use.

With projections estimating that 51 percent of the global population will be obese by 2030—and given the strong linear association between obesity and OSA—timely prevention is critical. To reduce the risk of developing OSA, consider implementing the following lifestyle changes and preventive measures:

• Maintain a healthy weight.
• Use an air purifier to reduce airborne irritants.
• Sleep on your left side to support blood flow, stabilize the airway, and reduce symptoms of GERD.
• Avoid smoking and exposure to secondhand smoke.
• Limit alcohol intake, especially before bedtime.
• Exercise regularly to promote cardiovascular and respiratory health.
• Practice good sleep hygiene to improve sleep quality.
• Manage nasal congestion to encourage nasal breathing.
• Minimize sedative use whenever possible.
• Stay hydrated to keep airway mucus thin and reduce obstruction.