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HOW IS SLEEP APNEA DIAGNOSED AND TREATED


Written by Dr. Welsh, Published on 27 July 2014

How Is Sleep Apnea Identified and How Is It Treated?

Because Sleep Apnea cannot be diagnosed in the context of a routine medical visit, it requires a certain protocol to be effectively diagnosed. An effective way to establish to one's physician that you may be suffering from sleep apnea is to keep a sleep diary for fourteen days leading up to your appointment. You can use this diary as evidence that your sleeping habits are being disrupted, which may prompt your physician to set you up with an appointment with a sleep specialist.

Also, be open with your doctor about your energy levels and how your sleeping issues impact your quality of life. It's also important to share your personal and family medical history in order to provide further evidence of your deficiency.

Sleep Apnea Physical

Further evidence of sleep apnea can be evaluated via physical examination. Your doctor can look into your throat, nose and mouth in order to identify the presence of tissue which may impede the ability to breath easily during the night. For example, many adult Sleep Apnea patients have a soft palate or uvula which is larger than normal and restricts airways during sleep.

If your physician considers you a potential sleep apnea sufferer, he or she will likely recommend that you visit a sleep specialist. There are a number of tests that can accurately diagnose sleep apnea, but these tests require you to have an opportunity to be monitored sleeping comfortably.

Polysomnogram for Sleep Apnea Diagnosis

The most frequently used test for sleep apnea is known as a Polysomnogram. This test uses various diagnostic devices in order to evaluate blood pressure, heart rate, eye movement, and brain activity during sleep. This test also measures other factors, including the rise and fall of your chest, snoring, and the rate at which air flows in and out of your nose, as well as oxygen levels in your blood stream.

As you can imagine, this test is fairly elaborate, so it generally requires that you visit a specifically designed sleep laboratory or sleep center. There is no pain involved with the procedure, and it's no different than a normal night's sleep, except of course, you will be fitted with a number of sensors attached to your finger, limbs, chest, face, and scalp.

These devices will help your sleep specialist provide you with an informed diagnosis with regard to your sleep apnea, which will help him or her provide you with the most effective form of treatment to meet your needs.

CPAP Sleep Apnea Treatment

The most effective method to treat Sleep Apnea is known as a CPAP, or Continuous Positive Airway Pressure device. This works exactly how it sounds. It enhances air flow through your nose and throat, widening your airway and helping you sleep more soundly through the night. The elaborate testing during your sleep study will help your physician properly calibrate the CPAP to meet the needs of your body at rest.

There are also tests which can be administered at your home to provide diagnostic data regarding your sleeping pattern. The most commonly used device is known as a Home-Based Portable Monitor. Of course, this device will not provide the same depth of results as a Polysomnogram, but it can provide valuable data at a cheaper cost. In particular, the home monitor measures the rise and fall of the chest, heart rate, air circulation, and blood-oxygen levels. Often, this test is used as a preliminary examination for patients, in order to see if they actually need a sleep study.

What Are Sleep Apnea Treatment Options

There are a number of options available to sleep apnea patients, dependent upon the severity and source of their apnea. These options include breathing devices, mouthpieces, changes in lifestyle, and surgery. Obstructive sleep apnea is generally not treated with medication

What Are the Goals of Sleep Apnea Treatment?

  • Reduce Fatigue

  • Stop Snoring

  • Make It Easier to Breath During Sleep

Because sleep apnea is commonly associated with other conditions such as hypertension and obesity, Sleep Apnea treatment is often combined with other forms of treatment in order to relieve these other related medical conditions.

It is important to treat sleep apnea, because in doing so, you can reduce the risk of a variety of related medical conditions, especially those related to the heart and cardiovascular system, including stroke and heart attack.

The treatment that will work best for you depends both on your medical condition and your personal preferences, and your sleep specialist will help you pick the ideal treatment option to meet your needs.

For patients with mild sleep apnea, the best form of treatment may simply be a mouthpiece, combined with changes in lifestyle. On the other hand, patients that experience more severe sleep apnea will likely be most effectively treated with a CPAP or with surgery.

In some cases, your issues with daytime fatigue may come from sources other than Sleep Apnea, and if your Apnea Therapy isn't providing you the results you need, it's likely that you aren't allowing yourself adequate rest. You need seven to eight hours to become fully rested, and some patients actually need more.

If the combination of sleep and medical treatment aren't effective, you and your sleep specialist will have to explore other potential options.

Adopting Healthier Habits to Encourage Better Sleep

For patients that only have light sleep apnea, you may actually recover from your condition simply by altering your habits and lifestyle in order to improve your sleep.

  • If you suffer from a stuffy nose due to allergies or other conditions, use medications or nasal sprays to improve your condition

  • Make the effort to sleep on your side. Obstructive Sleep Apnea is most commonly an issue when a patient sleeps on his or her back. There are shirts and pillows that can inhibit back-sleeping and help alter your habits.

  • If you are overweight, make the effort to lose the weight and reach a healthier weight. Soft tissue can inhibit airways, making it harder to breath during sleep.

  • Don't take medications that cause you to become sleepy, and limit your use of alcohol, entirely if necessary. Depressants cause your airway to become more restricted because the muscles relax.

  • If you are a tobacco user, stop smoking.

  • For some patients, a simple device known as an oral appliance can mitigate the effects of sleep apnea. It can also be used for snorers.

In regard to mouthpieces, you can actually visit an orthodontist or dentist, that can built you a mouthpiece designed specifically for your mouth to increase airflow. This mouthpiece will open your mouth very slightly, preventing your tongue and your jaw from getting in the way of your breathing.

Breathing Devices for Sleep Apnea

For patients that have more troublesome sleep apnea, there are medical devices that promote airflow by actively circulating air, keeping the airway open. The most prescribed treatment for more severe sleep apnea is the CPAP. There are two types of CPAP. The most common device utilizes a mask which covers your nose and mouth, but some devices just introduce airflow through the nose. This product provides a slow and steady stream which delivers air to the throat. In doing so it makes it easier to breath.

It's important to recognize that snoring and sleep apnea are related but not identical health conditions. Just because you are no longer snoring doesn't mean that you no longer need your CPAP or have been cured of your condition. Sleep Apnea is chronic and moderate to severe sleep apnea will return if you suspend treatment.

Under most circumstances, a professional will visit your home in order to prepare the CPAP for use, dependent upon the recommendation of your physician. It's also important to recognize that your condition may change over time, and this might necessitate changing the settings on your CPAP periodically to improve air flow. Of course, this should only be done by your sleep doctor.

Some people experience side-effects as a result of using a CPAP. Most common side effects include headache, dry mouth, skin irritation, and stuffy or dry nasal passages. Also, if the CPAP isn't programmed correctly, it can lead to stomach discomfort and bloating.

For the most part, these side-effects can be easily treated, helping you to get the most out of your CPAP device. It's important to be open with your sleep doctor and the tech that comes to your home to make sure that your CPAP treatment is optimal.

For patients that experience issues with runny or dry nasal passages, there are ways to increase the moisture content of the air to improve response. Also, you may benefit from choosing a mask that fits your face more securely.

Most patients that use CPAP find that the device improves their sleep quality and their energy levels and are satisfied with the treatment.

Sleep Apnea Surgery

In major cases of Sleep Apnea, the patient may benefit most from surgery. The form of surgery required depends on the specific cause of Obstructive Sleep Apnea. In general, the goal of Sleep Apnea Surgery is simply to open airways more securely. This can be done by removing, stiffening, or shrinking soft tissue in the throat and mouth, and can also be accomplished by adjusting the jaws to increase airflow.

Soft tissue surgery can be done either as an outpatient procedure or at a hospital. If the goal is simply to shrink soft tissue, it may simply require an injection or other form of treatment, rather than surgery. If the goal is to increase the thickness of the tissue, the surgeon may make a small incision and place a bit or sterile, hard plastic into the tissue.

If the goal of the surgery is strictly tissue removal, this form of treatment will only be provided at a hospital, and you will require anesthesia. After treatment, there is a chance that you will experience pain of the throat for seven to fourteen days. Finally, pediatric patients may benefit from tonsil removal, which is a common and standard surgery.


WHAT IS SLEEP APNEA AND HOW DOES IT IMPACT HEALTH


Written by Dr. Welsh, Published on 27 July 2014

What Is Sleep Apnea?

Sleep Apnea is a relatively common medical condition which is characterized by shallow breathing or pauses in breathing during sleep. Different patients experience this condition for different reasons, and also to different severity. Some patients only stop breathing for a few seconds, while other may stop breathing for a few minutes, and actually shock themselves awake with a choking or snorting response which leads them to gasp for air. In extreme cases, breathing may stop thirty times in an hour, or even more.

For most patients, Sleep Apnea is a chronic condition which has a devastating effect upon sleep quality. This is because changes in breathing pattern alter sleeping patterns as well. In order to get a good night's sleep, we need to spend a certain length of time in deep sleep, and sleep apnea causes patients to experience reduced sleep quality, owing to reduced time spent in deep sleep.

Because sleep apnea inhibits sleep quality, one of the most common symptoms is daytime fatigue and exhaustion, because the body never recovers its sleep debt, no matter how long that the patient remains asleep.

Why Is Sleep Apnea Bad?

Sleep Apnea is a major problem, not only for its impact on sleep quality, but because it is one of the most commonly undiagnosed disorders, because it occurs as one sleeps, and many patients don't even realize they suffer from the condition. There is also no way to diagnose sleep apnea via blood testing, and the condition cannot be diagnosed through a normal doctor's appointment. Often, it is not the patient that recognizes his or her sleep apnea, but a sleeping partner, member of the family, or roommate.

Although Sleep Apnea has many causes, most patients with this condition suffer from obstructive sleep apnea. In the case of this obstructive sleep apnea, airways shrink or temporarily close during sleep, which leads to pauses in breathing, or breathing which is too shallow to meet the needs of the sleeping patient.

Snoring Most Common Symptom of Sleep Apnea

Because of this blockage, one of the most recognizable symptoms of sleep apnea is heavy snoring. Because the airway is partially blocked, the air reacts with flaps in the nose and throat, making the signature sound. This condition can occur to anyone, but patients that are obese or overweight are most likely to experience the condition.

A minority of sleep apnea patients suffer from central sleep apnea. This is a sleep-breathing disorder caused by miscalibrated signaling from the brain. The part of the brain which is in control of breathing malfunctions during sleep, leading to pauses in breathing. Most commonly, this condition is a symptom of other conditions, or the use of particular medications. These patients also rarely experience snoring.

What Are Common Risks Associated with Sleep Apnea?

  • Elevated Risk of Wrecks and Workplace Accidents resulting from exhaustion

  • Abnormal Heartbeat

  • Human Growth Hormone Deficiency

  • Testosterone Deficiency

  • Elevated Risk of Heart Failure and Cardiovascular Disease

  • Elevated Risk of Diabetes, Obesity, Stroke, Heart Attack, and Hypertension

  • Elevated Cortisol Level

What Are the Causes of Sleep Apnea?

The reason why Sleep Apnea can't be diagnosed in a normal doctor's visit is because breathing works differently while we are awake. For example, the throat muscles remain firm, leaving the airway unimpeded from the nose and mouth to the lungs. After you fall asleep, the muscles become more relaxed, which shrinks the airway. Also, while we are awake, we can consciously regulate breathing to an extent, whereas, while we sleep, the brain self-regulates breathing.

There are a number of physiological issues that can lead to Obstructive Sleep Apnea:

  • Aging increases the risk of sleep apnea, as the subconscious brain sometimes weakens its signal to keep throat muscles tight

  • Some patients have bone structures in the neck and head which naturally restrict airways

  • Obesity can cause sleep apnea, because soft tissue puts pressure on the windpipe during sleep, leading to trouble breathing during sleep

  • Abnormally large tonsils and tongue

  • Muscles of the tongue and throat relax too much, obstructing the opening of the throat

What is the Direct Physiological Effect of Sleep Apnea?

Because sleep apnea obstructs breathing, the lungs don't absorb enough oxygen, which leads to oxygen deprivation. The reason why patients wake up abruptly is because, when oxygen levels in the blood drop below a certain concentration, it causes the brain to signal the sleeping patient to awake in order to restore oxygen flow. The body responds to this signal by suddenly tightening muscles in the mouth and throat.

Because the body isn't getting enough oxygen during sleep, this vastly increases the risk of cardiovascular issues, including arrhythmia, stroke, heart attack, and hypertension. It also triggers the release of fight-or-flight hormones such as cortisol, which can cause adrenal fatigue, as the body is producing an exceptionally high level of stress hormones. This also saps the body of resources necessary to produce sex hormones such as Testosterone and Estrogen, as well as Human Growth Hormone, which impedes health and wellness and can accelerate issues associated with aging.

Sleep Apnea also has a depressant effect upon metabolism, which causes the patient to be more likely to gain weight, and also increases the risk of diabetes. Often, patients with obesity actually suffer from the condition largely because of their underlying sleep apnea, which in turn causes sleep apnea to exacerbate.

What Individuals Are Most Likely to Experience Sleep Apnea?

  • Around 50% of patients with sleep apnea are overweight or obese

  • Both women and men experience sleep apnea, but men are at an elevated risk

  • Risk of sleep apnea increases with age

  • Heredity plays a role in sleep apnea

  • Some individuals have airway structures that naturally lead them to be predisposed to sleep apnea

  • Smokers are more likely to experience sleep apnea

What are the Symptoms of Sleep Apnea

The most noticeable symptom of sleep apnea is chronic snoring. Because airways are partially or completely blocked, this leads to loud snoring, and also may lead the patient to become shocked awake resulting from lack of oxygen.

The amplitude of snoring associated with sleep apnea is often dependent upon the manner in which the patient is laying. Generally, snoring is most obtrusive when sleeping on one's back, and is less of an issue when one sleeps on his or her side. This snoring may also not occur every night, and may be loudest with the patient is excessively fatigued and exhausted. Snoring associated with sleep apnea becomes worse over time for some patients.

Although snoring is one of the characteristic symptoms of sleep apnea, many patients suffer from the condition without experiencing sleepiness.

Another symptom of sleep apnea is daytime sleepiness. This fatigue can be so severe that it impacts one's ability to drive or work. Individuals with sleep apnea often find it very easy to fall asleep any time there is a lull in activity, without regard to how long that they slept the night before.

Other common symptoms related to sleep apnea include:

  • Sore throat upon waking

  • Dry mouth in the morning

  • Frequent need to urinate throughout the night

  • Personality issues, including mood swings, depression, and irritability

  • Issues with focus and concentration

  • AM Headaches

Pediatric sleep apnea patients often experience the following symptoms:

  • Irritability

  • Anger

  • Issues with academic performance

  • Tendency to breath through one's mouth



Twenty Simple Tips to Help You Lose Weight

Millions of people in America try and fail to lose weight every year. There are countless reasons for their failures. Some people get it in their head that dieting is this big, monumental grind, and this intimidates them and makes them more likely to fail. For many people, this is simply a perspective problem.

Don't think of dieting as a single epic ordeal, think of it as a lot of small changes that amass together to help create a new and healthier you. Here are twenty simple tweaks that you can make to your life that will help you lose weight faster and more comfortably!

Before Eating, Drink a Glass of Water to Get Full Quicker

We all know how essential water is to a healthy body, but you can use water to prepare your digestive system for a smaller meal. Water fills up the stomach a bit, which will prime your body to become satiated with smaller portions, not to mention meet your hydration and filtration needs. We recommend fixing a glass of water fifteen minutes before every time you eat.

Increase Your Fiber Intake to Feel More Full

Fiber is an important nutrient that many Americans don't get enough of on a daily basis. Fiber passes through the body and is not digested, but is still incredibly important to the normal function of the digestive system. Just by adding a couple of portions of fresh veggies to your diet each day, you can counteract the feelings of hunger. Some fiber-rich vegetables that we recommend are cucumbers, cauliflower, radishes, celery, and carrots. Fiber fulfills your stomach's need for satiation without piling on calories.

Eat No More than Two Servings of Fruit Daily to Lose Weight

Fruit is an important part of a healthy diet, but it's important to remember that they are best in moderation. Fruits are sugar-rich foods that, when abused, carry some of the same risks as processed desserts and carbohydrates. By capping yourself at two servings, you prevent yourself from leaning on these sweet, natural foods as a crutch. Also, choose fruits that provide dense nutrition, such as grapefruit, fresh apples, and berries.

Eat Processed Carbohydrates Sparingly, If At All

Processed carbs are everywhere in today's society. The truth is, foods that contain processed flour are just as bad for you as sugar. They may taste different, but the body is highly effective at converting both into fat, and both have a terrible impact on your sugar levels. Because of their ubiquity, we understand if you can't avoid them altogether, but make a conscious effort to avoid these products, and choose foods with complex carbohydrates like whole wheat bread and sweet potato over other foods that go straight to the gut.

Increase Your Consumption of Healthy Fats

One of the biggest misconceptions of 20th century diet plans is the focus on fat. In reality, carbs and sugars are the biggest problems, and fats should be consumed conscientiously, but are a vitally important part of a healthy diet. Healthy fats help to control and maintain metabolism, and they also encourage the healthy production of precursor sex hormones that eventually get converted into Testosterone, Estrogen, or whatever other cholesterol-based hormones that the body needs. Fats also help you feel more full faster!

This isn't to say that you shouldn't still eat smart when it comes to fat, but these fats help process and distribute important vitamins such as Vitamins K, E, D, and A. Avoid unhealthy fats like Transfats altogether and try to reach a healthy balance of saturated and unsaturated fat.

Don't Eat Before Bed!

The human body is designed to function best when you go to sleep just a bit hungry. The way that our circadian rhythm works, energy levels are supposed to drop, along with cortisol levels, and the digestive system slows to a crawl. If you eat before bed, you put your system out of whack. Your body is more likely to convert the food you eat directly into fat, and the spike in insulin interferes with your body's ability to produce Human Growth Hormone sufficiently. Natural HGH is released while we are in deep sleep and helps our bodies heal and become rejuvenated after a good night's rest.

If you interfere with the production of HGH, you limit the rejuvenative quality of sleep. If you do get hungry before bed, and feel like it will interfere with your sleep, choose a protein-rich snack low in carbs, so your insulin levels stay in check, but your body has the building blocks necessary to meet the needs of its component systems.

Get A Full Night's Rest Every Evening

Sleep is a vitally important part of our daily cycle. In order to maintain healthy hormone levels and metabolism, it is vital to sleep a full 7-9 hours per night, whatever your body naturally needs. Sleep is when our body releases the majority of Human Growth Hormone, which encourages the body to repair and heal, while also ambiently increasing metabolism. If you sleep restlessly or fitfully, or just don't get enough sleep each night, you prevent your body from reaching the deep sleep necessary to provide optimal balance.

Drink a Glass of Lukewarm Water with a Big Squeeze of Lemon in the Morning

Lemon is a concentrated source of Vitamin C, a water-soluble vitamin that is known to kick start the metabolism and provide energy. By combining lemon juice with water which is room temperature or just a bit warmer, it energizes the body and helps you overcome morning fogginess, while also increasing your metabolism to help you burn more calories! Other ingredients in Citrus Fruits also help with the natural filtration process of the kidneys, which will be even better for your health!

Engage in Light Intermittent Fasting to Bolster Metabolism and Hormone Production

Intermittent Fasting is a diet and health strategy where you don't eat for an extended period of time each day. Some people take this to an extreme, only eating in a small window of four or five hours each day. If you're interested in a more natural way to engage in a similar diet, try only eating in the eight hour window between 11am and 7pm. This may leave you hungry for a brief while, but the body can quickly acclimate to this eating pattern, and this will enhance your metabolism and your production of natural Growth Hormone, and also encourage the body to burn fat more readily.

Include Broccoli, Brussels Sprouts, Onion, and Garlic to your Weekly Diet Routine

All of these vegetables have powerful anti-inflammatory properties which are good for your health and help promote optimal hormone balance and metabolism. Of your daily veggies, one or two of these foods (or similar foods) should be a part of your diet. Inflammation encourages the production of cortisol, which strains your body's ability to produce hormones like Testosterone and HGH, which keep your body running at peak efficiency.

Stick to a Single Cup of Coffee Per Day to Preserve Hormone Balance

We all know how great of a pick-me-up a nice hot cup of coffee is in the morning. There's also nothing wrong with caffeine in moderation. Our cortisol levels are actually supposed to be at their highest when we wake up in the morning, so a cup of coffee in the morning doesn't really interfere with the normal hormone rhythms of the body.

If you want to lose weight most effectively, stick with that one cup of coffee though. If you drink coffee later in the day, you spike your cortisol levels in the wrong pattern, which can get your natural hormone rhythm out of whack, and this can interfere with your metabolism. Pairing that cup of coffee with a workout is ideal, because caffeine does act as a performance enhancer, increasing focus and energy for your workout.

Avoid Aspartame and Sucralose to Protect Your Metabolism

When it comes right down to it, moderation is much better for you than artificial sweeteners. These products mimic many of the effects of sugar, without providing the calories. They do, on the other hand, interfere with normal insulin sensitivity, and Aspartame in particular does have some carcinogenic qualities at high doses.

The problem with sucralose is that it can actually make you more hungry and crave sweets, so you may actually be shooting yourself in the foot! There is no strong evidence that these products encourage weight loss more effectively than simple moderation.

Don't Skip the Yolk!

Many diets in the past recommended only eating egg whites, but you are missing out on a lot of potent nutrients if you don't eat the egg yolk as well. Compared to most things in the modern American diet, a couple of eggs in the morning is an excellent, relatively low calorie source of vital nutrients such as phosphorus, B12, and Choline. Eggs are also an excellent source of good cholesterol!

Include High Intensity Interval Training to Your Workout Routine to Boost Hormone Levels

We all know that cardiovascular exercise is good for the heart and for the health, but did you know that if you include anaerobic, high intensity periods to your cardio, that you can vastly increase the results of your exercise? The body releases natural HGH in response to vigorous activity that really puts pressure on the muscles. Cardio itself doesn't quite cut it. But, if you sprint as hard as your body can handle it periodically during your run, you activate the muscles and heart in a way that encourages the release of these natural hormones.

Engage in Anaerobic Exercise To Build Muscle and Encourage Weight Loss

Muscle is denser than fat, and burns calories at a significantly high rate. One of the best ways to lose weight is simply to lift weights! You don't even have to get a gym membership. A couple of milk jugs filled with water is more than enough for an upper body workout. After you have a routine established, you can find cheap weights online or at various second-hand stores, or you can shell out for a set of brand new weights if that's your thing.

Engage in Basic Cardio No More than Twenty Minutes per Day to Maximize Weight Loss

There are definite benefits to cardiovascular exercise when it comes to health, but for weight loss, trainers recommend no more than 20 steady minutes of measured cardio. If you are using cardio for weight loss, convert your process into a High Intensity Interval routine to provide the benefits of cardio while amplifying weight loss rather than stagnating it. The benefits of a forty minute jog aren't significantly better than a twenty minute jog when it comes to weight loss goals, but if you sprint every few minutes you will maximize your gains in the extended time.

Cut Soy, Wheat, and Dairy from your Diet for Seven Days-As a Test

If you are trying to lose weight, it's important to understand your body. There are many, many people across the United States that are sensitive to one or more of these three common products, and a vast portion of these folks don't even realize it. Make the conscious effort to avoid food products containing these ingredients for a week, and see if it doesn't make you feel better. If it does, consider going to get an allergy test to find out exactly which foods are causing you problems. One of the most prominent symptoms of food sensitivity is hormone imbalance which causes metabolism to sink, which inhibits weight loss.

Cut Back Starches to One Serving Per Day to Lose Weight

Starches play an important role in that they readily provide energy, but in the modern diet, they are incredibly prevalent and most of us eat far too much. The old Food Pyramid played a role in the modern obesity epidemic, because it encouraged a far higher level of carbohydrate consumption than is healthy and natural. In order to get the nutrients and energy available from carbohydrate starches, just include them in a single meal each day. Starches include pastries, wraps, rice, potatoes, pastas, and breads.

Avoid "Health Foods" Like Energy Bars and Fruit Juice to Lose Weight

There are a lot of foods that sound like they are great for you, but, in practice, are terrible for you. In reality, most fruit juices have the same or more calories than sodas of the same volume, and are very inefficient means of providing the nutrients associated with fruits. Whenever you have the option, choose real fruit over fruit juice. Energy bars provide their energy via sugars and carbohydrates, and there's really not much better about them than a candy bar. If you are looking for a little boost from a snack during the day, choose a nutrient-dense fruit or a measured portion of pecans or walnuts.

Take Fifteen Minutes Each Day to Pause, Relax, and Clear Your Mind to Lose Weight

Stress is both physical and psychological. By taking just fifteen minutes of your time to pause and let yourself be comfortably idle, you can unwind yourself and put yourself at ease. Psychological stress is linked with increased cortisol and adrenaline, which drain your body of healthier hormones such as Human Growth Hormone, and can leave you fatigued and exhausted. Most people find that fifteen minutes is more than enough time to help them remain focused and on target.


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