Full video transcripts:

Patrick McKeown
0:00

[Music] This podcast is going to be of interest to anybody with diabetes, and we're exploring type 1 and type 2 diabetes. We're also exploring the implications it has on lung function, and the connection to, for example, respiratory conditions, poor sleep, what's happening when blood sugar gets too high, and what can we do in terms of breathing exercises to help improve diabetic control. So I won't be doing much talking with this one, this one is all in the hands of Nick, so there's absolutely no pressure on Nick at this moment. Nick is an Oxygen Advantage instructor, and he also has had type 1 diabetes since you were 12 years of age, and I would like you, Nick, just to give a little bit of background how you came across breathing techniques, that you then set up the breathingdiabetic.com, and you're a PhD trained scientist, so you know something about research, and I think it's very interesting that you brought this together. So welcome, Nick.

Dr. Nick Heath
1:05

Yeah, thanks a lot, Patrick. Yeah, so excited to be on the show, and yeah, so I've actually been diabetic since I was 11. I'm 33 now, so about 22 years with type 1 diabetes, and I got into the breathing stuff, I kind of, just was a normal kid, you know, I had diabetes, but I did whatever I wanted throughout most of my life, until I got into college, I read one book that got me realizing, hey, the way I eat and exercise and move can have really dramatic impacts on my blood sugars. So I started getting into self-improvement with nutrition and exercise, and then, of course, like most people, I found Wim Hof at some point, and started trying some of the big breathing, and noticed some impacts to my energy, but felt good and all these things, but over time I never really felt fully, I felt like I had more I could be doing to improve my diabetes management and my energy levels, because I was finding huge afternoon crashes and things like that. Eventually I heard of an interview on Bulletproof Radio, I believe it was, yeah, Dave Asprey's podcast, and what, like you mentioned, I have a background in science, what really got me excited was hearing you explain the science of how optimal breathing works, not talking about any particular technique, more of a "let's change our breathing 24/7," and that all clicked with me, and you mentioned mouth tape, so I went out that night, I was driving, so I stopped at Walgreens, picked up some paper tape, and taped my mouth, and it was the best night's sleep I've had since I could remember. And the next day it happened again, and I think the next day it happened again, eventually I was emailing my wife at work, like, this is crazy, it's so simple but yet it's having these huge improvements to my energy. And so I then started incorporating some of the walking breath holds and especially slow breathing, so I started every morning with 10 to 15 minutes of slow breathing, something I still do to this day, and I started, after about two or three months, I noticed improvements in my blood sugar management, and I was like, this is really odd that something as simple as just breathing is making my blood sugars more stable. Now there's always confounding factors, it's not a controlled trial or anything, but I knew, I could feel it, I was like, this is definitely something different. And so with a background in science, even though I'm not a respiratory physiologist, I'm an atmospheric scientist, I decided I wanted to understand what's going on, so I started reading papers, I flew out to Portland — I'm in Florida, but I flew out to Portland to train with you — because I just wanted to learn more about the science of what's going on. And I would say really there was a paper in 2017 by Bernardi, and it was published in Nature Communications, so one of the world's most prestigious academic journals, and the abstract ended with, "slow breathing could be a simple beneficial intervention in diabetes." And I thought, this is crazy, it's in Nature, they're talking about slow breathing for diabetes, I'm not losing my mind, this is real stuff, you know, it seems so simple. So that's kind of led me on a journey now to understand how does breathing impact diabetes, and then, because it's so unknown, I created the Breathing Diabetic, and it's just free resources, information for people who are interested in breathing. It's not gonna fix everything, but it's so simple, and these simple principles can really help — at least with stress, with proper tissue oxygenation — a lot of things that diabetics suffer from. Slow breathing can help push it in the right direction, and for certain people like myself, can really help with blood sugar management over time. So yeah, that's kind of how I got into this, and now, you know, I work a full-time job and do a normal day job type thing, but every free minute I get, I'm reading about breathing and trying to apply it in my own life, and then get the information out, whether it be on the website or whatever.

Patrick McKeown
5:06

So Nick, in terms of you were having afternoon crashes, like, what is an afternoon crash? How did it feel, did you have to take a nap, did it really impact in terms of your productivity, or did you just feel that you weren't as focused as what you normally would be? And were you a mouth breather, for example, how was your breathing before you started coming across this? Because I suppose people might think that their breathing is good anyway, and everybody seems to think that they have good breathing. How were you breathing, or describe the afternoon crash and how was your breathing at that time?

Dr. Nick Heath
5:39

Yeah, so the afternoon crash, when I had work, it was just — I felt drained, but I was at work, so you know, you push through and you just do what you got to do. But what was interesting is my wife is a yoga teacher, and she was teaching an afternoon class, so I would get off of work and I had about 45 minutes to an hour before I'd go to the class, and I would go home and I would just immediately take a nap, like I would just walk in the door, sit on the couch and try to go to sleep for like 20, 30 minutes. And this was a few days a week when I would take the class, but I felt like that almost every day, which is — it was really odd, but I'd become a chronic mouth breather. And whether or not that's the only thing, you know, there's always lots of things, but I know I'd become a chronic mouth breather, I thought the answer to everything was to take a big breath and just relax. And so I definitely become a chronic mouth breather, and definitely at night — I didn't realize it at the time, you don't know until you experience the difference — but I felt like I was sleeping fine, but then the first time I taped my mouth, I woke up so much more refreshed, so I know I wasn't sleeping as well, so I know I was mouth breathing at night, because the tape fixed it, you know, I slept much better. And I was definitely a mouth breather during the day, and I was doing it on purpose, I really thought that was the answer, was to take big breaths. And so the afternoon crashes were pretty much daily, you know, and it wasn't — I eat pretty well, so it wasn't like a huge high-carb thing, you know, a lot of times they say if you eat a really high carbohydrate lunch that can also lead to a blood sugar spike which leads to a crash, but I mainly just eat a salad with some oil, so I'm not really eating too much sugar at lunchtime, so it was really just a metabolism problem, or some sort of energy deficiency that I was encountering, and mouth breathing seemed to be a big part of it for me, at least that it changed, it added a lot.

Patrick McKeown
7:42

So just in terms of the difference between type 1 and type 2 diabetes — type 1 is something that typically younger kids are diagnosed with, and it's not quite known what's the trigger, it could be a viral infection or something — can you just explain a little bit, in layman's terms, between type 1, for example the pancreas isn't producing sufficient insulin, versus type 2 diabetics, and then we will talk a little bit about the complications of it. So, the differences between both type one and type two, and which one is more common, which one might somebody be more likely to get, in adulthood versus childhood, etc.

Dr. Nick Heath
8:20

Yeah, so in general, type one is more in adolescence, in younger people, like how I got it when I was 11. Some people get it much earlier, some people do get late-onset type 1 diabetes, so there's a mix, but for the most part it's predominantly in children, and that's when your body actually destroys the insulin-producing cells in your pancreas, your beta cells, so it's an autoimmune disease, where your own immune system is attacking these cells, and you completely lose all insulin production. So there's no hope, at that point, of using diet or anything to reverse it, you're kind of at a point where you're not making insulin, and you have to go to either shots or an insulin pump, and then you start checking your blood sugar as regularly as you can, or you wear a continuous glucose monitor. There's a lot of different ways of managing it. But type 2 diabetes has kind of a host of different things going on, so it's metabolically driven mostly, there's books, there's all sorts of things written on it, it's the more common form, so I think upwards of like 90% of the time when you hear "diabetes," 90% of those or more is usually type 2 diabetes. And that's associated with insufficient insulin production and insulin resistance, so your body — you weren't utilizing the insulin you were producing well enough, you had insulin resistance, which was causing higher blood glucose, which was triggering your pancreas to produce more and more insulin, until it kind of taxes out. To put it in layman's terms, it gets overly worked, and you get to a point where you're not creating enough insulin and you're not utilizing it enough. And so with type 2 diabetes, a lot of things can help — exercise, nutrition, all these things can really benefit, because you do still have the ability to produce insulin, so if you can regain your insulin sensitivity, there's ways to actually manage it, some people can do it without any kind of medications, other people take drugs like metformin, or other things to help, or eventually you might need insulin as a type 2 diabetic, but the way to get there is much different. Whereas type 1 is autoimmune, type 2 is more metabolic, genetics, lifestyle —

Patrick McKeown
10:48

Genetics plays a huge role in all of them.

Dr. Nick Heath
10:48

Yeah, genetics plays a huge role in all of them, but the outcome, so once you get past type 1 or type 2, because it's all driven by glucose regulation, so you have highs and lows, and your blood sugars are fluctuating around.

Patrick McKeown
10:58

And what's so bad about that? So when blood sugar levels are going high — well, obviously, insulin, as I remember it, is a little bit like carbon dioxide, in terms of, oxygen is released from hemoglobin in the presence of carbon dioxide, that's the Bohr effect. So insulin is what allows the cells to metabolize the glucose, is that correct?

Dr. Nick Heath
11:31

Yes, and if you're not producing — so say with type 1 diabetes that the pancreas isn't producing insulin, or not producing sufficient insulin — blood sugar levels are going to go high in the blood, because the cells aren't able to use that glucose. And with type 2 diabetes, the cells aren't able to use that glucose, and blood sugar levels are going high.

Patrick McKeown
11:56

And then the problem associated with high blood sugar levels — what problems are those?

Dr. Nick Heath
12:03

Oh, that's where basically all the complications of diabetes come in, you get a lot of oxidative stress, you get the problems with blood flow, that's why you get issues with eyes with diabetics, and with feet, you hear a lot of things about diabetic shoes and things like that, it relates to autonomic dysfunction, so you get kind of swung into a more sympathetic state because you went into a stress mode.

Patrick McKeown
12:26

Yeah, more of a stress mode. There was, glucose is increasing, the blood vessels, both the small blood vessels and the larger blood vessels, are essentially getting clogged with glucose.

Dr. Nick Heath
12:34

Yeah, you can think of it like that, yeah, because it's leading to all of this inflammation and damage to the blood cells, into the arteries and veins, that eventually has arterial function deteriorate — deteriorates pretty quickly with sustained high blood sugars over time, that's one of the big complications.

Patrick McKeown
12:58

How would the person feel?

Dr. Nick Heath
12:58

Oh, it's awful, I mean, I know from — I still get highs, I still get lows, type 1 diabetes is a never-ending journey of learning, and being defeated on a daily basis when you think you've had it figured out. But the feeling of having sustained high blood sugar is one of the worst, for me — some people feel a little differently, so it's like if you look at the symptoms on WebMD or Mayo Clinic, you'll see that high and low blood sugar have similar symptoms, because different people feel them a little differently, but most people, for high blood sugars, it drains you, it gives you — you just feel exhausted, like you just want to go to sleep, you want to lie down, you don't want to do anything, you don't want to think. And so if that's sustained over weeks, months, years, it can definitely lead — I've seen graphs showing that brain size decreases pretty significantly with time in diabetes, just because of sustained glucose. Another really interesting aspect of high blood sugar is that it increases the affinity of oxygen to the hemoglobin, so for the breathing nerds, it's a left shift in the oxyhemoglobin dissociation curve, but basically what it does is it holds on to oxygen more readily, and it also binds nitric oxide in a form that's not bioavailable, so it's reducing the ability of nitric oxide to improve blood flow, and it's also reducing the amount of oxygen that's getting released to the tissue.

Patrick McKeown
14:37

So, sorry to cut across here, so this is what then is causing hypoxia, because of course if you've got a left shift of the oxyhemoglobin dissociation curve, if the hemoglobin is not releasing oxygen so readily, and if blood vessels are constricting, there's not going to be enough oxygen getting to the tissues and organs, and what are the implications of that? And this might tie in with where breathing can help, because — so first of all, the implications of hypoxia, and I think there's a confusing thing, we do some breathing exercises which deliberately create intermittent hypoxia, and you would think, well, if hypoxia is bad, why do breath holding? And we do know that breath holding can lower blood sugar levels, which is more beneficial if your blood sugar levels are high and you want to bring them down pretty quickly. So just a little bit about that, about the hypoxia.

Dr. Nick Heath
15:32

Yeah, so there's a few aspects, you just hit on both, is that you get the left shift, so the oxygen is holding on to the hemoglobin a lot more, the affinity is much stronger, so you're not getting the release into the tissues, and the added inflammation and things like that are reducing oxygen delivery. But also the blood flow aspect, so when we talk about oxygenation of the tissues, it requires oxygen and blood flow, so the more blood flow, the more oxygen, and there's actually a really nice paper showing this, in 2015 I think, in the Proceedings of the National Academy of Sciences, showing that nitric oxide is a huge regulator of blood flow, and that's really a key mechanism for oxygenating the tissue. So in diabetes, you're getting rid of those two factors, you're reducing blood flow and you're holding on to oxygen, and so this is creating — there's other factors as well, but those are the two big ones — creating tissue hypoxia. And then there's a paper, I think in 2017, showing that they basically brought this full circle, saying that the tissue hypoxia is leading to a kind of constant state of sympathetic, of stress, of fight or flight, which is then going to mess with your chemosensitivity, which is then going to exacerbate the sympathetic response. Now, because your chemosensitivity is off, you're going to be breathing more heavily, which is then, in turn, going to just go right back to more dysfunction of oxygenation, because now you're going to reduce carbon dioxide, you're not going to be getting as much blood flow.

Patrick McKeown
17:10

So it's this kind of vicious cycle in diabetes, you almost wonder if it's trying to protect you from something, because they all combine in the negative way — like, what could be going on here, because it just seems so bad when you start looking at how these feedback loops are working in a negative way.

Dr. Nick Heath
17:26

But I think — no, go ahead.

Patrick McKeown
17:26

Now, quite a number of different conditions have this negative feedback loop — anxiety is one, asthma is another, high loop gain and sleep apnea is another one. So in terms of the stress response, people with diabetes have to be very careful that they're not pushing themselves to the point of stress, and maybe that's one reason where slow breathing is beneficial, and better night's sleep, because you can help achieve a balance — you can help to dampen or reduce stress, and you can help to bring the body into relaxation, increase parasympathetic tone. And there has been studies on this going back 20 years, isn't there, with Bernardi, going back to 2000?

Dr. Nick Heath
18:12

Yeah, and that's right. So I think, when I talk to other diabetics, I usually say start with slow breathing, and if you feel comfortable, with the mouth tape, because those are going to be the two big resets. So diabetics — if you just look at a resting state of a diabetic versus a healthy control, their heart rate variability is usually much lower, indicating they're more in a sympathetic state, their baroreflex sensitivity is usually lower from baseline, and so if you look at their overnight values, of how they're shifting from sympathetic during the day to more parasympathetic-dominant at night, that shift isn't as great as you see in normal healthy individuals. So diabetes does a lot of things, and it just makes sense, right, we're under the stress of fluctuating blood sugars, all these issues, and it just stresses you out, on top of all of the emotional things. So I think, you know, diabetics are like two to three times more likely to get depression, we have a pretty high incidence of anxiety disorder, and I think a ridiculous percentage of us have just anxiety symptoms when you go in to do these questionnaires. So there's a lot of things leading to it, where the relaxation, slow breathing, activating and increasing your vagal tone, so to speak, or increasing the parasympathetic, the calming branch of the nervous system, can be super beneficial just to help reset things, help balance you out. And whether your blood sugar — so low blood sugars also can do this, low blood sugars can trigger a sympathetic response, high blood sugars can do it through the tissue hypoxia feedback loop. And so really, you just want to balance your blood sugars the best you can, but helping — slow breathing in particular has a whole host of benefits that can at least help offset some of those side effects of diabetes, help bring heart rate variability back to normal levels, help bring baroreflex sensitivity back to normal levels. For me, it helped me actually shift into a more parasympathetic state at night and sleep deeper, which is then going to downstream give you more energy for managing your blood sugars, for dealing with some of these issues. So slow breathing, with its ability to put you into that rest-and-digest state, is one of the most effective things diabetics can do. But then, if you're interested, there's the breath hold side of it that you kind of started touching on, that has other things that could be beneficial, but you have to balance it with the stress response.

Patrick McKeown
20:54

So okay, so what we're saying is that the diabetic body is already under stress because of the condition, and there's a number of aspects in terms of breathing exercises — so, breathing slow is slowing down the respiratory rate to six breaths per minute, but in and out through the nose ideally, not breathing through the mouth, and breathing low at the same time. And you mentioned that helps to strengthen the baroreflex, these are the pressure receptors that are inside the major blood vessels which are constantly monitoring your blood pressure, and it's a very important indicator of the functioning of your nervous system. And the other aspect though is breathe light — does that have a role, because you mentioned that people with diabetes often get breathless, or they have an increased chemosensitivity to carbon dioxide, and this in turn will translate into exercise intolerance, so if they go for a walk, they'll probably find themselves breathing a lot harder. So it really probably goes all together — when you're doing breathing exercises, do you ever focus on breathing light, that you're really breathing less air, to feel air hunger, because that can stimulate the vagus nerve, or do you focus on the slow breathing down to six breaths per minute, or breathing low? What would be your typical — what would you say to somebody that's listening with diabetes, what should they focus on, in terms of a description of the exercise?

Dr. Nick Heath
22:13

Yeah, so I always say the first starting point is the slow aspect. Now, of course, you can't ignore the chemistry, so you don't want to just throw it out, but as like the very general — here's the lowest hanging fruit — is to just try some slow breathing, focus on using in and out through the nose, and focus on just slowing it down to around six breaths per minute. And that's also, when you look at the science, like the papers I found, that's the most commonly used method, so if we want to have something we know is backed by science, specifically for diabetes, then we know that just slowing down the respiratory rate to around six breaths per minute — and that can fluctuate based on your comfort level, you might need to start a little higher, or you might even find that you need it lower, some people are much more comfortable around four, even lower, or in that range of four to six is usually about typical, I think.

Patrick McKeown
23:18

So that's the starting point — you're saying if people find, if people are too breathless, they may not be able to breathe in for five seconds and out for five seconds, so should they start maybe breathing in for three seconds and breathing out for three seconds?

Dr. Nick Heath
23:25

Yep, and they're slowing that down, so that's a breath every six seconds, so it's 10 breaths per minute.

Patrick McKeown
23:32

Which is probably — it would be interesting to see what is the respiratory rate in diabetes, is it above 14, 15 breaths per minute in the adult population, could it be as high as 20 breaths per minute? And this may be tying in as well — but, you know, you said that people with diabetes can suffer from anxiety, of course the condition is going to bring on anxiety, especially if there's unknowns, but the fact that if your breathing is labored and upper chest, the respiratory physiology is off, and that's going to bring on anxiety, and then we know that people with diabetes don't have good sleep, or at least there's an increased risk of sleep disorder breathing with diabetes itself. And how long would you practice your breathing exercises for, in the morning? So just to let people know, Nick, I'm based in Ireland, and it's 10 a.m. in the morning, we started about half an hour ago, Nick is in Florida, so I think it was 4:30 his time — so you can see how alive and cheery he is at 4:30 in the morning, having a podcast about scientific information. So, when you normally get up quite early, how long would you spend on your breathing exercises, and what sort of routine would you do? In other words, what I'm trying to do is get inside your head, because you're the person who knows this really well, and what has worked the best, and also tell us what's happened with your insulin — has it changed, has it stayed the same? So your routine and the benefits that you've got from it.

Dr. Nick Heath
25:09

Yeah, definitely. So my routine has kind of shifted here and there, but the only non-negotiable is at least 15 minutes in the morning of slow breathing, I use an app actually, I like to be guided to the pace. But so, talking about the chemosensitivity a little bit, I do, once I get comfortable and I'm just breathing and it feels natural, I do start to reduce the volume of my breath a little bit so that I get a little bit of air hunger, but that's never the focus, it's kind of how I feel. And then, once I make sure I do the rate, the slow breathing for 15 minutes is kind of a non-negotiable, I used to do a really strict breath hold practice after that, so I would go out and do at least five sets of walking breath holds — now I still use walking breath holds, but I incorporate them throughout the day, kind of for just my own time, I do get up early and I like to work on things I'm really interested in with breathing specifically, and so I found ways to balance those two, where I can take a little mini breaks where I do walking breath holds throughout the day, rather than making them all in one sitting, so to speak. I also do slow breathing just a couple minutes after lunch, so I've read a few papers showing that slow breathing, diaphragmatic breathing, can reduce blood sugar spikes associated with meals, and one of the ones that I get the biggest spike with is lunch, and I don't really know why, I don't eat a ton of carbohydrates, I think it's just something with my metabolism, my diurnal cycle, so I've incorporated right after lunch, I do about anywhere from two to five minutes of just slow breathing, sometimes I practice alternate nostril breathing, I'm always trying new things, just like you, I love this stuff, so it's really interesting to learn all these different ways of using it. But I do about two to five minutes of slow breathing after lunch, and then before bedtime, that's been a huge one for me, is doing around maybe 10 minutes — this one I don't set a timer or anything, I just go outside, so that I'm outside if it's not raining, and I do at least about 10 minutes of slow breathing before bed, just to kind of get me into that parasympathetic state.

Patrick McKeown
27:26

So still breathing, sitting down obviously, before sleep?

Dr. Nick Heath
27:26

Actually, I lay down.

Patrick McKeown
27:34

Yeah, I do lie down.

Dr. Nick Heath
27:34

Outside, but that's only sometimes, it just depends on if it's raining or not, to be honest. But that's somewhat newer, that's only in the past probably like six or seven months I've been doing that, but for at least three years now, every day I do slow breathing in the morning and some sort of light breath holds throughout the day. And with my diabetes management, with things like insulin — so right when I first started the Oxygen Advantage, my insulin dropped, I would say around 10 to 20 percent, I don't have exact numbers, my hemoglobin A1c, which is kind of a marker of long-term blood sugar, it dropped pretty significantly, and so I've seen big drops. Now it's kind of, I found a balance now, where I've kind of found my sweet spot, so to speak, it was kind of like it went down way — because, you know, I was changing everything about how I was breathing, and that was changing so much about my metabolism, but then it's come back up to like a — what I'm very happy with, where I feel the best energy levels I've ever had, still to this day. I still get anxiety, I still have nights where I don't sleep well, you know, there's still things that real life comes into play, but it's night and day difference for how much it's helped with just stabilizing everything throughout the day, and especially my blood sugars, and my need for insulin — I'm no longer, so this was a personal choice, but I'm no longer on an insulin pump, I just take shots, I've really simplified my life a lot in that way, and I feel that it's given me that kind of mental clarity to say, okay, I know I'm in control of what I'm doing with my body, and so it's kind of helped me to find what works for me, and find the way that it works best with my blood sugar. So yeah, it's been really nice, and I can't go a day without at least 10 or 15 minutes of slow breathing, just because I feel like it kind of resets everything for me.

Patrick McKeown
29:29

Yeah, and there's plenty of other benefits as well. And in terms of, so when you started off doing the breathing exercises — we, for 20 years, have been very cagey about asking somebody with diabetes to do any breath holding, and it was because the blood sugar levels could just drop too quickly, and they go hypoglycemic, and it was always an aspect. So when you started off, you started off with slow breathing, but did you bring in some breath holding as well, and were you monitoring your blood sugar levels more frequently, and what sort of drops did you see? Did you see any kind of things that we really need to be keeping an eye on here, because of course we want to get benefits, but we also want to avoid risk.

Dr. Nick Heath
30:22

Yeah, so with type 1 diabetes, it's so particular to what time of day, what insulin you've taken, because you're basically at a state where — if I just took insulin, it wouldn't matter what exercise I did, my blood sugar is going to drop. If I haven't taken insulin in a really long time, I can help bring it down a little bit, maybe with the breath holds, but it's really particular to the timing with food and insulin. So what I did was, most cautiously, make sure I did it at times of day that worked well with my eating, so it was either first thing in the morning before I had eaten or taken any extra insulin, from what's just my basal rate, or in the afternoons, after lunch, a few hours after lunch, where the short-acting insulin had worn off, and I'm just kind of back at my basal state, and that gives me a baseline where I know what my blood sugar is when I'm going out to do any breath holds, and then I can, if I feel bad, I'll check it or I'll stop. I'm very lucky in that I'm very sensitive to low blood sugar, so if I get low, I feel it immediately, and that's not the case for everyone, so that's why it can be very dangerous, because if you don't feel hypoglycemia that well, if you're not that sensitive to it, you could drop quickly and not notice it, and that's where the trouble could be. But with breath holds in particular, so it's a balance — the breath hold itself, as you know from the studies, it's been shown to basically transport glucose into the tissues, into the muscles, without the need of insulin, so it's kind of found another pathway, similar to exercise, where the contraction can help lower blood glucose independent of insulin, so that's how the blood-sugar-lowering effect can occur. But you have to balance the sympathetic — so when you're holding your breath and doing hypercapnic hypoxia, so when you're doing these stronger breath holds, it will induce a sympathetic response, because it's not easy, as we know, and that's kind of the benefit of it, that it's not easy, and it's a short-term stressor. But that can trigger the release of stress hormones, which will act to reduce insulin sensitivity, and will also reduce the body's endogenous production of glucose, which can increase blood sugar. So it's kind of a balance — some people, like I've noticed, sometimes my blood sugar might drop, sometimes it doesn't, and it's just — it's disappointing, to someone who's interested in understanding the mechanisms of it and the science behind it, because the body's so interesting, and every time it's gonna be slightly different, you can't reproduce it each time, the human body is so complex.

Patrick McKeown
33:11

Really.

Dr. Nick Heath
33:11

Yeah, so it's not that I know this time it's going to get me low, or this time it's not, so it's really hard to know exactly what — how each time is going to be. So that's where just being on top of it, checking your blood sugars, monitoring yourself — a lot of people wear continuous glucose monitors now, so that gives them instant feedback, even if they don't feel low, they'll be able to see it and they can adjust quickly, having snacks nearby, I always carry — I have glucose tablets in my pocket now, it's kind of my safety reserve, so that no matter where I'm at, I have sugar access. For diabetics, you can never be too cautious, so it's always better to say, just don't worry about the breath holds, focus on slow breathing, but if you're interested, you have to just take all the precautions you would take for anything. I go surfing, I have to take a lot of precautions for surfing, if I go on a hike, I have to take a lot of precautions for going on a hike, so most people with type 1 diabetes in particular are very familiar with planning, with anticipating the worst case scenario, where you don't have your supplies for three hours, what are you gonna do? And so it's really taking that same mindset you have toward normal activities, like going kayaking or surfing or to the beach, and applying those to your breathing practice, and it sounds a little crazy, but just to be safe, make sure you're prepared.

Patrick McKeown
34:38

And there's one thing I really appreciate about how you teach this, is that we should never be making it worse, you should never be feeling worse, so if it's stressing you out, if the breath holds are too much, then that's not worth it, probably at that point you should gradually build into it.

Dr. Nick Heath
34:54

And so, just be, take precautions, and then if it feels like it's too much, don't worry about it, because the breath holds are the icing on the cake.

Patrick McKeown
35:02

Yes, yeah, you know, you can get the slow breathing, and that's really where you're going to get the most benefits, with sleep and parasympathetic response. Because I suppose, Nick, as well, there's some significant relationship between lung function and diabetes, and even when we were looking through some of the papers, that there was a deterioration of lung function for up to two and three years, even before the diagnosis of type 2 diabetes. So reduced lung function and poorer breathing seems to be an issue with diabetes, and as a result, then their breathing can be faster and upper chest, so they may find it more difficult to do any sort of breath holding, so that's another aspect, is that you don't want the person holding their breath for too long, that they lose control of their breathing, that's going to feed into their symptoms. Again, the BOLT score could be useful here, especially to get an indicator of whether the person is breathing functionally or not. And, in terms of — I would intuitively expect people with diabetes to have a reduced BOLT time, now that may not always be the case, because we see it with people with anxiety, some definitely have a lower BOLT time, but some have a fairly high BOLT time. Do you see any correlation there, in terms of, could the BOLT time give any helpful feedback to people with diabetes, or is it just something to be avoided altogether?

Dr. Nick Heath
36:38

The BOLT score for diabetes, I don't think it would be avoided altogether, I think that it could be a compliment to something like testing — for diabetes, you know, it's always test your blood sugar, that's the first measurement of where you're at, but of course we know all the studies showing the usefulness of BOLT time for just an indicator of respiratory health. And so you might notice, for example, if you were to take your BOLT score and it was really low, you wouldn't not test your blood sugar, but you might know, oh, something's up with my blood sugar, and when I go to test — because either way you were going to test — it might be something where you see a correlation between low blood sugar and low BOLT score, or high blood sugar and low BOLT score, because both of those are going to affect just your mental alertness, and kind of how you — and although the BOLT score in particular doesn't have a mental component as much, because it's just that first reflex, there's still stuff going on psychologically when your blood sugar is high and low, that is just going to make even pinching your nose feel — you'll just be like, okay. You know, so there's a lot of really interesting emotional aspects of diabetes that might play a role, but I would say — I think it would be interesting, I've never done it myself, but looking at BOLT and blood sugar, because of how your blood sugar makes you feel, if there would be a correlation with the physiology of what that's doing immediately to your BOLT score, and since the BOLT score is kind of an immediate indicator of your current physiology, it would be an interesting thing to consider, if someone's a diabetic and interested in this — like, looking at when they test, say they're 200, and then they take their BOLT score and it's really low, they might say, oh — and then two hours later their blood sugar comes down and it's 100, and then they take their BOLT score and it's a little bit higher, there might be an immediate physiological feedback there going on, where the stress of the high blood sugar is reducing chemosensitivity — I'm sorry, increasing chemosensitivity, sometimes I get it mixed up too.

Patrick McKeown
38:54

Yeah, the baroreflex sensitivity and chemosensitivity.

Dr. Nick Heath
38:54

Yeah, very stylish.

Patrick McKeown
39:03

Yeah, yeah, I know, I absolutely find it fascinating, and I find it fascinating that breathwork can help people with diabetes, and it's just a little bit unfortunate that, as a diabetic, were you ever told to breathe through your nose? And this is not — I just want to kind of find out, is there any awareness out there, are there hospitals encouraging people with diabetes, both type 1 and type 2, to slow down their breathing, to strengthen the autonomic nervous system and to get a better balance? Like, for me, it makes sense, you know, if a condition is causing a lot of stress to the body, why don't we give a breathing technique that will help to balance that and activate the body's relaxation response, and even just for mental health, because stress makes people sick, and really we should be focusing on how can we bring the body into relaxation by slowing down breathing. Is it happening in any hospitals, are you aware? You know, I know Bernardi has been a pioneer with this, and has it caught on, because his research is out there for 20 years — do diabetics know about this, do diabetic foundations encourage their members, breathing through the nose and functional breathing?

Dr. Nick Heath
40:24

Not that I'm aware of, but that's why I have my website. But yes, that was the big thing, is that, when I found this, it was like, how is this not known, it's so simple, I had kind of this feeling, like, what is going on, you know, it's in Nature, this is real peer-reviewed science, it's not some woo-woo, "just breathe and feel great," it's like, this is really — like you said — it's balancing the autonomic nervous system, it's stimulating the vagus nerve, it's increasing all these really great measures of parasympathetic tone. And so, why are we not doing this? But there's so much with diabetes that — I understand why, so when I got diabetes, I didn't want to think about diabetes, I just, what do I have to do, what's the minimum requirement, I want to live my life. I think it's when you get a little older, and you realize, you know, I'm going to have some really long-term complications if I don't start managing this correctly, that you become actually interested in things like this. Now, if I was told when I was a kid, when I was 11 or 12, hey, maybe try breathing through your nose, maybe it would have been a habit that just stuck with me from there on out, so you know, there probably are some opportunities there, but I do understand that diabetes, there's so many aspects of it, with nutrition and insulin dosages and blood sugars, for a kid, things — it's a hard balance. But I do think that it's starting to get out there, I think that people like yourself, and James Nestor's book, he mentioned type 1 diabetes a couple times, and so I think that this idea of breathing, just as a way — if anything, just the stress aspect of it, and then the correlation between stress and diabetes, which is through the roof — hopefully that gives an alleyway into the other aspects of how slow breathing can help with managing diabetes. But I don't know that it's getting mainstream or anything, I don't think it's happened, I've talked with a few diabetologists that say, you know, I found your site, and now I tell my patients to at least consider it, and so I think there are people thinking about it, and I don't think anyone would object to it, it's so simple, I don't think anyone would say it's a bad idea, I just think that there's so many other things they're focused on, getting in the weeds of the science of the insulin response, whereas if you just step back and say, how are you breathing, that might be a really good starting point.

Patrick McKeown
42:58

Sleep apnea and sleep disorder breathing, including snoring, seems to be more common in diabetes than the normal population, and we spoke about this earlier on — this is going to stress the body, on top of stress already that's contributed by the condition, it really makes sense as well to apply functional breathing to help with sleep disorder breathing. And at the very start you said that when you got your mouth closed at night, it was one of the best things that you felt — you weren't sure was it real or not. Do you know why people with diabetes — not that you know why, but do you have any ideas — why do people with diabetes have an increased risk of sleep disorder breathing? Is it just because they have poorer breathing patterns anyway? We spoke about reduced lung volume, our reduced lung function, which in turn can contribute to greater collapse of the upper airways, so it's almost that everything is interlinked here, you know — you've got diabetes having poor respiratory health, poor respiratory health is impacting sleep, and in turn sleep disorder breathing is stressing the body, which in turn is going to reduce the pancreas, well certainly in type 2, releasing insulin, and that stress response. Do you have any thoughts on why diabetics are more prone to sleep disorder breathing?

Dr. Nick Heath
44:17

I don't — so I know that there's a huge association with it, I do have a paper on my to-read list that's basically saying there's a two-way interaction between obstructive sleep apnea and type 2 diabetes, that the mechanisms behind both of them are similar, and that one can exacerbate the other, so it's this kind of feedback loop. And then in type 1 diabetes, I think it's like 40% incidence of sleep disorder breathing, or sleep apnea, which is high —

Patrick McKeown
44:57

Yeah, really high, certainly in the normal population and the male population it could be as high as 40% in people aged between 50 and 70 years of age, but in a younger cohort, 40% would be way too high.

Dr. Nick Heath
45:05

Yeah, and so again, that's the thing, is there's limited studies on these correlations and calculating percentages, but we do know that another thing is that the parasympathetic tone isn't quite as high at night, so we don't get that shift to that calming, relaxation mode, because of the stress of our blood sugars. And also a big thing that's hard to measure, because it's different every night, is that diabetics wake up a lot for their blood sugars — if you wake up low, just last night I woke up low, I didn't measure something right, and I woke up and I was low, and I had to eat a little bit of glucose, so that's going to make it harder to fall back to sleep, plus the stress response of the low puts you in a sympathetic state. And so there's so many aspects of diabetes that decrease sleep. Now, with sleep disorder breathing in particular, I think you just kind of nailed some of the mechanisms that are probably there, now I don't know the exact science behind it, but I would say that all of these things are combining — the increased sympathetic response, the poor lung health, they're all coming together, and if you're breathing through your mouth at night, that's only going to exacerbate things even farther, as we know mouth breathing at night can increase the incidence of sleep apnea, of snoring, and all these things. So I think there's a really bad feedback loop here that can make sleep really poor in diabetics, and that's why taping at night, if it does anything — even if I still wake up low, like I did last night — the sleep I did get was much deeper, I feel, I still feel more energized than I ever did when I was mouth breathing at night.

Patrick McKeown
46:51

And I'm just going to share a screen, because I think it's important — this was an article, Nick, that you're probably aware of, this was published in the Journal of Clinical Medicine about three weeks ago, and I'm a co-author here, along with two ear, nose and throat doctors, Carlos O'Connor and Dr. Plaza, and we looked at the application of breathing re-education — these are the exercises from the Oxygen Advantage, part of it from the Buteyko method — to the phenotypes of sleep apnea, and it's a 10,000-word article that's available for free. And when we're looking at functional breathing patterns, we're looking at it from the three different dimensions, the breathe light, breathe low and breathe slow. But again, you know, this is a field that has quite good potential, and nasal breathing is absolutely key for people with obstructive sleep apnea. And I tape my mouth at night, and I know some people are going to say — and doctors will say — don't tape at night, but I would like to demonstrate MyoTape, and I'm going to ask you as well, would you perceive any additional factors that people with diabetes have to be careful with, if they tape their mouth at night, and are there other aspects that they have to be really — you're talking about fluctuations in blood sugar, for example — so I just put a demonstration up, and if you can answer that question, are there other things that people with diabetes need to be more careful with in terms of getting their mouth taped closed during sleep?

Dr. Nick Heath
48:22

The only thing that comes to mind immediately is that if you have a hard time feeling your hypoglycemia — so if you don't detect when your blood sugar is low, and you're getting into much deeper sleep, I guess there could be a potential that you wouldn't feel it, when you wouldn't wake up. So low blood sugar typically wakes people up pretty easily, and it induces a pretty good stress response, like, hey, we need sugar, your brain needs sugar, it's going to wake you up, once your blood sugar drops below, let's say, 70, I think it's milligrams per deciliter, because people measure in different ways. So I think that would be the biggest concern, would be if you are sleeping too deeply, which sounds kind of counter-intuitive, right. And then the other one is if putting the tape on really stresses you out, so if yes, then you don't want any added stress, so if the thought of taping makes you more stressed and it's gonna make your sleep worse, then at that point it's not worth it. So I think those would be the two big ones off the top of my head, now there might be a doctor that might point out things I'm not sure of, of course, but it seems like it's worth trying if it doesn't scare you.

Patrick McKeown
49:36

Yeah, so I'll just do a demonstration of the tape, because I think it can be a factor that people are definitely put off by, and that's fine — this is a tape that we use, it's MyoTape, and it's a tape that we actually brought out for children, and MyoTape is because of the myofunctional therapy and the application for dentistry, so it's a cotton-based tape, I think you're familiar with this, Nick, you've come across it — and we stretch it, we give it quite a tension, you know, even almost to its limit, maybe not quite, and that's the tape there, so there's an elastic tension there, you see that, it's padding my lips. But in terms of perceived risk, this is bringing the lips together, but if the person needs to mouth breathe, they can vibrate, so it's not that we're blocking them out, and it's also — what we're doing is looking to strengthen the tone of the orbicularis oris muscle here, because the tension is going in a bi-directional relationship to help activate that muscle and to change that habit. So for somebody who might be apprehensive about wearing tape, to realize that there is a way to tape without covering the mouth entirely, and it is my own product, so I'll say that out front, but it's relatively inexpensive, it's 25 for a three months' supply, and if it helps you to get a better night's sleep — I've been taping my mouth for 20 years, for me, as somebody with asthma and somebody with sleep disorder breathing, it was a game changer. And I really would say, you know, I think sleep should be the foundation in many instances of many different conditions, because if we're not getting that quality deep sleep, the body doesn't really have that chance of recovery, or at least to the same degree, because if the sleep is in a state where we're having apneas, or we're having hypopneas, or having heavy snoring, it's increasing sympathetic drive, it's putting the body into that stress response, and of course our day is going to be — we have difficulty concentrating and focusing and being productive, and that feeds back into stress, and then the implications that stress has in a condition such as type 1 and type 2 diabetes. So, in terms of a final couple of sentences, would you see the application of slow breathing, and nose breathing, and breathing light and breathing low, in terms of the breathing application, for both type 1 and type 2 diabetes?

Dr. Nick Heath
52:07

Yeah, it seems like — and that's what the studies have shown, I see a mix of type 1, type 2 — and although, like we said at the beginning, the way their onset is much different, the outcomes are very similar, in that you get a lot of the same complications. And so the autonomic dysfunction and things like this, that slow breathing can really help with almost immediately, and then some of the disturbances in blood gases and things like that, that nose breathing can help with, and help with circulation and stuff like that. So I think that the applications are going to be for both types, the results might be slightly different depending on which type, because if you're a type 2, you still do have the potential to produce insulin, or you're still creating some insulin, and so by stimulating the parasympathetic nervous system, you might increase your insulin production, or you might improve your insulin sensitivity, and that might help with your glucose control more. But for the complication side of it, it seems like slow breathing is a no-brainer for things like improving autonomic function, which is the big one with type 1 diabetes, and reducing stress, which is another big one with both types of diabetes. So it seems like it's a really easy application for both types, and that could really have some profound benefits.

Patrick McKeown
53:28

Yeah, and there's benefits even that go beyond diabetes as well, because in terms of reducing racing mind, improving sleep, just feeling better overall, as opposed to — as human beings, we're very often stuck in our head, you know, so there's added benefits there. Nick, if people are to find a little bit more about you, what's your website again?

Dr. Nick Heath
53:52

Yeah, so I have the breathingdiabetic.com, and I have a lot of the information we've talked about today, and lots of different stuff about breathing and diabetes on there. We also, if for Oxygen Advantage fans, my wife has a yoga studio called Black Sand Yoga, and we have a class that combines Oxygen Advantage and yoga, and so there's breath holds — that's one thing I find really nice, if I want to do some breath holds, they're short and they're easy, so it's less of a sympathetic response. And then I'm on Instagram and things like that, but I try not to look at those too much, so mainly the breathingdiabetic.com, and I love email, so if you email me from there, I'll reply. My email address is nick@thebreathingdiabetic.com.

Patrick McKeown
54:42

Okay, great. And as well, I have a new book, and I know this is a blatant plug, but it's called The Breathing Cure, and we did put a chapter on diabetes, because we felt it was very important, and it was after talking with Nick, maybe five years ago, or four years ago, when we first were in touch — I'm not sure if it's going back that far, but certainly going back a few years — and we included Nick's story, and we looked at the science and the papers, and I really feel this is something that could be helpful for people with diabetes, of course you have to proceed with some caution, because of the fluctuations in blood sugar levels. And as Nick said, at the very start — Nick, I'll put it back to you — for somebody who's just starting off, what would be the first couple of things that you would encourage them to do?

Dr. Nick Heath
55:37

Yeah, first and foremost, just switch to nose breathing throughout the day, and then if you can, at night — that's the big one. And then try some slow breathing exercises, get an app on your phone, make it as easy as you can on yourself, just do a minute or two minutes, just do something to feel it, so you can see how quickly you can shift to that relaxation response, and then maybe increase it. But yeah, nose breathing and slow breathing are the two most important things I think we can do.

Patrick McKeown
56:00

Great, well, it's been a pleasure, thanks very much.

Dr. Nick Heath
56:08

Thanks, yeah, thanks a lot, Patrick.