The Sleep Revolution: Why Your Breathing at Night Could Be Sabotaging Your Health - Insights from the Innersight Podcast #24

We spend nearly a third of our lives doing it, yet many of us still don’t fully understand why sleep is so essential. With rising interest and questions from clients, it’s become clear that this basic biological function deserves a deeper look. To help us explore the subject, we invited Dr. Karjieker, one of South Africa’s few dedicated sleep specialists, to shed light on why sleep truly is our superpower.

The Importance of Sleep

Evolution has hardwired sleep into our biology, it’s not optional. Sleep is a deeply restorative and healing process, crucial to the body’s repair and long-term health. Our bodies are comparible to machines made of cells: any machine that runs non-stop will eventually break down. Fortunately, our bodies have built-in repair systems, activated largely during sleep, and supported by good nutrition.

While sleep may feel like downtime, it's anything but; it's when our body and brain reset. Without sufficient rest, our systems become overworked, and chronic issues can creep in over time.

Modern Challenges to Healthy Sleep

Unfortunately, many people live with ongoing sleep issues without realizing it. From waking frequently during the night to feeling perpetually tired during the day, these issues are often dismissed as just part of life. It is important to identify underlying causes rather than simply masking symptoms. For example, obstructive sleep conditions like sleep apnea often go unnoticed but have a significant impact on rest quality.

Shift work, another common modern reality, can also severely disrupt the natural sleep-wake cycle. Humans are designed to be awake during the day and sleep at night. Going against this rhythm, like working overnight and trying to sleep during daylight hours, can lead to chronic sleep disturbances over time.

Understanding “Normal” Sleep

One of the most frequently asked questions is, “How many hours should I sleep?” The truth is, there is no universal number. While some people feel fully rested after just four hours, others need seven or more. What matters more than the number of hours is whether you feel refreshed, alert and functional during the day.

Variability is normal; some people fall asleep quickly whilst others take time. Some wake up at the same time every day without an alarm, while others rely heavily on one. What’s important is recognizing when something feels off: frequent waking, excessive tiredness, or difficulty falling or staying asleep, and investigating the root cause.

Recognizing Hidden Sleep Issues

One of the most overlooked aspects of sleep health is that many people don’t even realize they have a sleep problem. According to Dr. Karjieker, up to 20% of the population snores heavily, and between 5% and 9% may suffer from serious obstructive sleep disorders like sleep apnea. That higher end is especially common among men in professions like long-distance trucking, where poor sleep doesn’t just impact the individual, but becomes a public safety concern.

Waking up feeling refreshed is a key indicator of good sleep. If you're not, it's time to assess your sleep patterns. Did you go to bed at a reasonable hour or did you crash at 1 a.m. after a night out? If you’re waking up unrefreshed even after what should be a full night's rest, something isn’t right.

The problem is, most people don’t bring sleep issues up with their GP. And often, it’s only when a more serious health condition like a heart arrhythmia or high blood pressure develops, that underlying sleep problems come to light. This highlights the importance of early detection and intervention; the goal is prevention, not just reactive treatment.

The Link Between Sleep and Chronic Disease

Unresolved sleep disorders, particularly sleep apnea, are linked to a host of serious health problems including diabetes, ischaemic heart disease and hypertension. Treating poor sleep with a sleeping pill might offer short-term relief, but it doesn’t address the root cause and that can be dangerous. Instead, the focus should be on identifying and correcting what's disrupting sleep in the first place. Dr. Karjieker recommends starting with simple but effective sleep hygiene habits:

Practical Sleep Hygiene Tips:

1. Cut Caffeine Early:

   Caffeine is a leading culprit of poor sleep as it blocks adenosine receptors in the brain, which are critical for making you feel sleepy. In some people, caffeine can linger in the body for 6–8 hours, leading to difficulty falling asleep or waking up at 2 a.m. wide-eyed. As a rule, you should stop consuming caffeine by lunch time, especially if you're already struggling with sleep.

   
   

   If your day doesn’t start until that first strong cup of coffee, it’s worth asking why. Relying on caffeine to get going may be a sign of poor-quality sleep. Coffee isn’t inherently bad but it shouldn’t be a daily necessity just to function. Instead, it should be an occasional treat, not a lifeline.

   
   

2. Be Careful with Green Tea and Regular Tea:

   Many believe green tea is a healthy night time choice, but it's surprisingly high in caffeine. Even traditional teas can cause problems if steeped too long. Instead, caffeine-free options like South African rooibos or chamomile are better for evening relaxation.

   
   

3. Watch Your Exercise Timing:

   Physical activity is great but not too late. Exercising after 7 p.m. can overstimulate your body, making it difficult to wind down and fall asleep.

   
   

4. Know Your Medication Side Effects:

   Statins, a common cholesterol medication, are often prescribed at night but can lead to insomnia in some people. If you’re experiencing sleep issues and take statins, consider asking your doctor whether switching to a morning dose or a different medication might help.

Modern Sleep Disruptors:

Technology has brought countless conveniences, but when it comes to sleep, it's often more foe than friend. One of the most common culprits is our phones. Exposure to blue light, especially the flickering kind from screens, suppresses melatonin production. Melatonin is a hormone naturally released by the pineal gland when it gets dark, helping to regulate the body’s sleep-wake cycle. Disrupting it can make falling asleep far more difficult.

Blue-blocking glasses have gained popularity as a way to combat this, but the simpler and more effective solution is limiting screen time before bed and sleeping in complete darkness. Hotel blackout curtains work for a reason: the darker your sleep environment, the more likely you are to sleep deeply and longer.

Medication Misuse and the Hidden Risks

Many people turn to over-the-counter antihistamines or prescription sleeping pills to treat insomnia, often without understanding the long-term consequences. First-generation antihistamines (like those found in common allergy meds) cross the blood-brain barrier, causing drowsiness as a side effect. Over time, this can lead to cognitive decline, memory issues, and even increase the risk of dementia.

Sleeping pills like zolpidem are designed for short-term use, typically no longer than four weeks, yet, many people remain on them for years. Newer sleep medications may prove safer in the long run, but they should still be used cautiously and only when absolutely necessary.

It is essential to exhaust all natural and lifestyle-based solutions before reaching for pharmacological fixes, and that includes cutting caffeine, adjusting exercise timing, managing reflux through diet and optimizing sleep routines.

Other Hidden Saboteurs

Reflux is another under recognized disruptor. It’s not just uncomfortable when stomach acid flows upward at night, it can trigger shortness of breath or coughing, waking you up and impairing sleep quality. People with a history of pregnancy or weakened valves are particularly vulnerable. In these cases, even sleeping slightly elevated or avoiding late meals can help.

Environmental factors also matter. Temperature, the weight of your blanket and having a consistent bedtime routine can all influence sleep quality. There's no one-size-fits-all approach here, what’s important is creating conditions that work for your body.

Sleep Disorders in Children and Misdiagnosed ADHD

Children aren’t immune to sleep issues either. In fact, a lack of sleep in children, particularly due to obstructive issues like enlarged tonsils or adenoids can mimic symptoms of ADHD. When kids don't get restorative sleep, they often become hyperactive just to stay awake during the day. The result is that they’re misdiagnosed, and the underlying issue is missed. A simple tonsillectomy or sleep assessment can dramatically improve attention, behavior and daytime energy.

Barriers in Primary Care: A System Under Strain

The modern healthcare system also presents challenges. GPs today often have just 10–15 minutes per appointment, barely enough time to identify chronic sleep problems, especially when patients don’t recognize the signs themselves. And with many people now choosing GPs based on availability rather than longstanding relationships, it's harder for doctors to see the bigger picture across years of care.

That’s why it’s crucial for individuals to be proactive. If you suspect a sleep problem, start with lifestyle changes. If that doesn’t help, speak to your GP. Ideally, they’ll help you implement sleep hygiene protocols first and if necessary, they can refer you to a sleep specialist. Medication should always be the last resort.

Essential Questions for Identifying Sleep Disorders:

1. Do you wake up with a dry mouth?

2. Do you wake up to urinate during the night (especially if you're male and under 60)?

3. Do you wake up feeling unrested or tired?

   
   

These questions, though simple, can reveal deeper issues such as sleep apnea or poor airway function that might otherwise go unnoticed.

Breathing through your mouth, especially while sleeping or exercising, is a red flag. It often indicates airway obstruction or nasal issues that can be treated. Mouth breathing during sleep can lead to dry mouth, snoring, poor oxygenation and even more disrupted sleep.

Proper nasal breathing, which warms, filters, and humidifies the air, improves not just oxygenation but athletic performance and mental clarity.

Diagnosing Sleep Disorders: Tools, Tests, and Clinical Red Flags

So how do you know if your sleep issues are more than just a phase or some late-night caffeine? Start with validated screening tools like the STOP-BANG questionnaire and the Epworth Sleepiness Scale (ESS).

• STOP-BANG assesses risk factors for obstructive sleep apnea (OSA) such as snoring, tiredness, observed apneas, blood pressure, BMI, age, neck circumference and gender. Its sensitivity and specificity exceeds 95% making it a powerful initial screening tool.

• The Epworth Sleepiness Scale evaluates how likely you are to doze off in different scenarios. If your score is high, that’s a big red flag.

If these screening tools suggest significant risk, the next step is formal testing, typically a polysomnogram (PSG). This gold-standard sleep study can be done:

• At home (more affordable and suitable for straightforward cases),

• Or in a sleep lab (for complex or unclear situations).

Importantly, South African medical aids like Discovery now fund sleep studies if there are associated PMBs (Prescribed Minimum Benefits) such as hypertension, diabetes or arrhythmias which are commonly linked to untreated sleep apnea.

Treatment Options:

Once diagnosed with sleep apnea, many patients are prescribed a CPAP (Continuous Positive Airway Pressure) machine, the gold standard for moderate to severe cases. It works like a reverse vacuum, gently blowing air into your airways to keep them open during sleep.

 CPAP works incredibly well in theory. However in practice, compliance is the challenge.

“Around 60% of CPAP machines end up in the cupboard, unused. Only about 40% of patients remain compliant long-term.”

Dr. Karjieker’s team has implemented remote monitoring and follow-ups to boost usage rates, but without accountability, many patients abandon the device due to discomfort or inconvenience. And in many cases, underlying problems are ignored such as:

• Allergic rhinitis

• A deviated nasal septum

• Reflux

• Obesity

Without treating these root causes, patients may struggle to tolerate CPAP or need it when they could have used less invasive treatments.

Dr. Karjieker strongly recommends that ENTs be involved earlier in the process not just when CPAP fails.

“If a patient has a blocked nose or a narrowed airway, that should be treated before or alongside starting CPAP, not as a last resort.”

Alternatives to CPAP: Dental Devices and Anatomical Fixes

Not every sleep apnea patient needs a machine. In some cases, mandibular advancement splints (MAS) which are oral devices fitted by dentists, can be highly effective, especially in those with smaller jaws or large tongues. The device holds the jaw slightly forward, preventing the tongue from falling back and blocking the airway.

These are less bulky than CPAP, and often easier to tolerate and for many, it's a worthwhile tradeoff to stop disruptive snoring and get better sleep. In rare and more complicated cases, sleep endoscopy can be performed to visualize what’s actually obstructing the airway while the patient is sedated. It’s limited though; patients are examined on their backs, whereas real-life snoring may happen in different positions. It is better to rely on clinical exam, patient history and imaging instead.

A Holistic, Long-Term Approach to Better Sleep

For successful sleep treatment, Dr. Karjieker advocates for a holistic, patient-specific plan that includes:

• ENT review for structural issues

• Addressing nasal blockages

• Reflux management

• Weight loss support and accountability

• Avoiding a “CPAP-first, fix-later” mindset

Telling someone to lose weight is easy; helping them do it is harder. Proper follow-up, check-ins and care coordination between GPs, ENTs, sleep physicians and even dentists is essential for lasting success.

The Hidden Culprit: Your Tongue

Did you know that when you gain weight, one of the first places fat is stored is your tongue? A bulky tongue base can actually block your airway while you sleep, even before you’ve gained noticeable body weight elsewhere.

The good news? Losing weight reduces tongue fat too, making it a surprisingly effective way to treat airway obstruction. Weight loss is never easy, but newer GLP-1 medications (like semaglutide) have been game changers for some. Still, sustainable changes in diet, sleep hygiene and accountability remain the cornerstone of treatment.

Anatomy is Changing And Not for the Better

There’s another factor at play: our jaws are shrinking. Compared to ancient skulls, modern humans have smaller jaws and less room in their mouths, likely due to softer, more processed diets. This makes airway obstruction more common than ever.

And it’s not just the U.S. battling rising obesity rates; Mexico currently leads the world in obesity prevalence, which is directly linked to rising sleep apnea cases.

New Tech, New Hope

Sleep medicine is evolving quickly, and Dr. Karjieker is excited about innovation:

• Tongue nerve stimulation implants that keep your airway open at night

• External devices that contract your tongue muscles while you sleep

• Custom surgeries that improve airflow by stiffening tissues or opening the nasal passages

One promising surgical approach combines septoplasty (to open the nose) with tonsillectomy and soft palate stiffening, offering a 68–70% success rate, which outperforms CPAP compliance in the long run.

Dr. Karjieker’s “Plan A”: Free and Simple First Steps

Before referring patients for expensive tests or devices, Dr. Karjieker starts with basic, effective strategies:

Plan A (for Snorers and Mild Obstruction):

1. Start a nasal steroid spray like Flonase (fluticasone). It takes 2 weeks to work, and it's safe with minimal absorption.

2. Don’t eat late. Aim for an empty stomach at bedtime. If you can’t avoid it, take a dose of Gaviscon to reduce nighttime reflux.

3. Avoid alcohol before bed. It worsens snoring by relaxing the muscles and inflaming the nasal passages.

4. Use the SnoreLab app. Record baseline snoring, then compare after two weeks of Plan A. It’s a great, low-cost way to track progress.

“If Plan A works, you don’t need to see me. If not, then it’s time for Plan B, C or D.”

He often identifies signs of obstruction just by looking at patients, from their posture and voice to eye puffiness and throat redness. Even floppy eyelid syndrome can be a giveaway.

What Does a Sleep Study Actually Look Like?

At-home sleep studies involve:

• A finger probe (oxygen levels)

• A chest strap (breathing effort)

• A nose sensor (airflow)

They’re fairly easy to use and are now often mailed to patients. You sleep in your own bed, which is far more natural than a hospital setting.

In-lab studies add:

• Brainwave monitoring (EEG)

• REM cycle evaluation

• Full technician support

They're more detailed but far less comfortable and may not reflect typical sleep patterns due to the unfamiliar environment.

Understanding the Numbers

Sleep apnea severity is based on the Apnea-Hypopnea Index (AHI):

• 0–5: Normal

• 5–15: Mild

• 15–30: Moderate

• 30+: Severe (some reach 100+ events/hour)

Those with severe scores should likely start CPAP immediately, but milder cases might succeed with lifestyle changes, dental devices or surgery.

In Conclusion:

Many people are living with undiagnosed sleep apnea: waking with dry mouth, getting up multiple times at night or feeling constantly tired without realizing why. Start with Dr. Karjieker’s Plan A; if you improve, great, no further action needed. If not, see your GP and request a referral to the appropriate specialist - ENT, sleep physician or dentist, depending on your symptoms.

Dr. Karjieker is based in Cape Town (Vincent Pallotti and Christiaan Barnard hospitals), and you can find him online at:

• breathe-right.co.za

• sleep-right.co.za

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