On Excellent Scientific Statements and Being Reasonable with Breathing

Greetings,

Here are 4 thoughts, 1 quote, and 1 answer related to breathing. Enjoy!

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4 THOUGHTS

1. 18 Excellent Statements from Scientific Papers

"With breathing interventions being relatively rapid interventions to implement and also demonstrating a wide range of positive clinical outcomes, breathing interventions warrant closer consideration from healthcare professionals."

- Psychophysiology (2017)

Over the past few years, I have accumulated over 500 pages of notes on over 100 scientific articles on breathing. I’ve recently been going back through them as part of a project I’m working on.

In this post, I share 18 of the best "one-liners" I’ve come across. Enjoy!

2. Breathing, Autonomic Function, and Diabetes

One of the most significant benefits of slow breathing is its positive effects on autonomic function. This is typically measured by heart rate variability (HRV) and baroreflex sensitivity (BRS)—higher HRV and BRS indicate better function.

Perhaps unsurprisingly, people with diabetes generally suffer from lower HRV (Benichou et al. 2018; Kudat et al. 2006) and BRS (Bernardi et al. 2017; Esposito et al. 2016). This is due to many factors, such as fluctuating blood sugars and resting tissue hypoxia, which cause autonomic imbalance (Bianchi et al. 2017).

Encouragingly, slow breathing at a rate of 4-6 breaths per minute is an effective way of increasing HRV (Steffen et al. 2021; Russell et al. 2017; Tavares et al. 2017; Chen et al. 2016; Lin et al. 2014; Van Diest et al. 2014; Vaschillo et al. 2006) and BRS (Rosengård-Bärlund et al. 2011; Bernardi et al. 2011; Joseph et al. 2005).

Slow breathing improves these markers by stimulating the vagus nerve, which activates the calming parasympathetic nervous system (Gerritsen and Band 2018). This helps people with diabetes restore autonomic balance.

It is simple and immediately useful, seeming too good to be true. But alas, science agrees: “Slow breathing could be a simple beneficial intervention in diabetes.”

3. How Stuff Works: Why Breathing Through Your Nose Is Best

"But wait, there's more. Breathing through your nose also increases the amount of oxygen in your blood more than mouth breathing, which is essential to virtually every cell, organ and tissue in your body."

- How Stuff Works
Why Breathing Through Your Nose is Best

This excellent article succinctly summarizes the benefits of nose breathing. It’s short, sweet, and packed full of great information. Enjoy!

4. With Breathing, Be Reasonable Not Rational

"Do not aim to be coldly rational when making financial decisions. Aim to just be pretty reasonable. Reasonable is more realistic and you have a better chance of sticking with it for the long run, which is what matters most."

- Morgan Housel, The Psychology of Money

I find many parallels between health and wealth. Here is another. We often get too bogged down with doing everything rationally. "This study said 20 minutes of slow breathing is best" or "That one said three times a day is needed."

Rather than following scientific studies exactly, I believe it’s better to aim for being "pretty reasonable." Find the time of day that works best with your schedule. Find the method that works best for you. Two slow breaths are better than no slow breaths. Four minutes a day is still better than zero minutes a day.

With breathing, be reasonable, not rational.

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1 QUOTE

“But the nostrils, with their delicate and fibrous linings for purifying and warming the air in its passage, have been mysteriously constructed, and designed to stand guard over the lungs.”

– George Caitlin (1864), The Breath of Life

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1 ANSWER

Answer: The internal surface area of these organs can be a great a 100 sq. meters, about half the size of a tennis court.

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(Cue the Jeopardy! music.)

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Question: What are the lungs?

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In good breath,
Nick

P.S. No I need these

The Breathing 4.1.1. - Slow or Control? (+ Seneca on Walking & Breathing)

Happy Monday to you! Welcome to a new edition of The Breathing 4.1.1.

Below you’ll find 4 thoughts, 1 quote, and 1 answer (think "Jeopardy"). Enjoy!

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4 THOUGHTS

1. Breath Rate or Breath Control: Which is More Important?

Last week, we talked about a powerful evolutionary advantage: Rather than evolving to breathe slowly, we evolved the ability to control our breathing.

We know slow, controlled breathing is beneficial, but what about just the controlled aspect itself?

A study published in 2017 examined this by having participants perform controlled breathing at 12 breaths per minute. This rate is on the low end of average for spontaneous breathing.

They found that this practice reduced sympathetic activity. There was something about the act of consciously controlling the breath that helped promote autonomic balance, despite the rather ordinary rate.

Slow breathing provides a host of additional benefits. But let us not forget the power of simply controlling your body’s most important function: breathing.

2. While We’re on the Subject: Slow Breathing Restores Balance in COPD

People with COPD have similar complications to diabetics, such as increased sympathetic tone and reduced baroreflex sensitivity (BRS).

A study published in 2008 found that slow breathing at 6 breaths per minute for 4 minutes significantly reduced sympathetic activity and increased BRS in COPD patients. That is, it helped restore cardio-autonomic balance. 

Their words are always better than mine:

“In summary, patients with chronic obstructive pulmonary disease showed sympathetic excitation and depression of the baroreflex. Slow breathing counteracted these changes.” - Raupach et al.

3. Another Non-Breathing Tip: I Take This Every Morning

To build off of my #1 non-breathing tip (2-4 hours between dinner and bedtime), here’s another one I use every day: baking soda.

Baking soda has been shown to improve performance and even help with autoimmune conditions. From a breathing perspective, it has also been shown to increase breath-hold time (something I have anecdotally experienced).

Here’s how I take it every morning:

• 2 tablespoons of apple cider vinegar

• 1/2 teaspoon of baking soda

• Mix and "enjoy"

It sounds disgusting, but it’s actually not too bad. Apple cider vinegar might also help control blood sugars, so that’s an added bonus for us diabetics.

4. A Race for the Future

"Looking at the evidence, it’s hard not to conclude that our entire physiology was engineered to reward us for moving." - Kelly McGonigal, The Joy of Movement

I love Physiology First, its mission, and the people behind it. On August 15, they are holding a run/walk to collectively cover 1,000 miles. You can join virtually anywhere (my wife and I will be joining from here on the Space Coast of Florida).

It’s been a while since my 100-mile ruck, so this is a great reason to get out and move for a good cause. Every mile helps, and there is no minimum. I hope to "e-see" you there!

More Details:

A RACE FOR THE FUTURE
(We’re signing up for the "1000 Miler")

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1 QUOTE

Speaking of walking and breathing:

“We should take wandering outdoor walks, so that the mind might be nourished and refreshed by the open air and deep breathing.” —Seneca, On Tranquility of Mind

(I found this quote in Ryan Holiday’s Newsletter.)

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1 ANSWER

Answer: The number of oxygen molecules in each red blood cell.

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(Cue the Jeopardy music.)

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Question: What is 1 billion?

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In good breath,
Nick

P.S. Keeping Cool During COVID.

Breathing is the Compound Interest of Health

"He who labors diligently need never despair; for all things are accomplished by diligence and labor." - Menander (342 BC - 292 BC) 

Correct breathing synchronizes many systems in the body. This coherence compounds over time.

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Breathing improves your sleep [1,2]. Better sleep improves your cardiovascular system [3].

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Breathing improves your cardiovascular system [4,5]. This improves your sleep.

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Breathing restores autonomic balance [6]. Better autonomic control increases heart rate variability and baroreflex sensitivity [7,8].

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Correct breathing improves tissue oxygenation [9]. This improves autonomic balance [10]. And insulin sensitivity [11].

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The more control you have over your breathing, the more control you have over your emotions [12].

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The more control you have over your emotions, the more control you have over your breathing [13].

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The more control you have over your breathing, the more control you have over all the systems mentioned above [14].

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Thus, all of these benefits are not isolated but integrated. It would still be rather amazing if breathing helped just one or two of these systems (since it’s free and everything). But, it helps so many different aspects of health and these benefits aggregate and compound over time.

But Nothing Happens Overnight

Well, maybe it does, because my first night of sleeping with my mouth closed literally changed my life.

But just like in financial investing, we have to keep contributing small amounts to our health consistently. Over time, those contributions will grow into something great, without any additional effort.

In good breath,

Nick

P.S. Best part of quarantine: No airports.

References

[1] Mouth breathing during sleep significantly increases upper airway resistance and obstructive sleep apnea

[2] The many important roles of the nose during sleep

[3] Obstructive sleep apnea causes hypertension

[4] Meta-Analysis: Slow Breathing Reduces Systolic Blood Pressure by 5.62 mmHg

[5] Slow breathing improves blood pressure in hypertensive type II diabetics

[6] Two minutes of slow breathing restores autonomic and respiratory balance

[7] Slow breathing decreases blood pressure and increases heart rate variability in hypertensive diabetics

[8] Slow breathing improves autonomic function in type 1 diabetics

[9] Nitric oxide might outweigh all other benefits of nose breathing

[10] Treat & reverse the root cause of diabetic complications (tissue hypoxia) with slow breathing

[11] Hypoxia Decreases Insulin Signaling Pathways in Adipocytes

[12] Slow, controlled breathing improves anxiety independent of CO2

[13] Breathing center in brain has powerful effects on higher-order brain functions…calm yourself by breathing slowly

[14] How slow breathing improves physiological and psychological well-being (hint: it might be in your nose)

Breathing Restores Autonomic Control in Type-2 Diabetics with Complications

“Quit worrying about your health. It’ll go away.” - Robert Orben

As people with diabetes (type 1 or 2), we know our bodies are under extra stress. This is due to things like fluctuating blood sugars and chronic inflammation. These factors can gradually accumulate into nerve damage and a variety of other long-term complications.  

However, we have recently learned that some “long-term complications” are functional and reversible (at least in their early stages). One way to reverse them is slow breathing.

Slow breathing treats the root cause of many complications, tissue hypoxia, which then restores autonomic functioning. This has been proven in several studies involving people with type-1 diabetes. However, most participants had not yet developed severe complications.

Putting Slow Breathing to the Test

It seems reasonable to assume that slow breathing would have the same effects in type 2s. But, what if these people with type-2 diabetes have chronic kidney disease? With a severe complication such as this, could slow breathing still have the same benefits?

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Trained breathing-induced oxygenation acutely reverses cardiovascular autonomic dysfunction in patients with type 2 diabetes and renal disease

Published in Acta Diabetologica, 2016

Click Here to Read the Full Summary

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The Study Group and Breathing Protocol

This study had 26 type-2 diabetic patients, 12 of which had diabetic kidney disease, and 24 non-diabetic controls. The protocol was simple: They had the participants lay down and breathe normally for five minutes, followed by two minutes of slow breathing at 6 breaths per minute.

The primary outcome was a change in baroreflex sensitivity (BRS). BRS measures your body’s ability to quickly adjust blood pressure to meet the current demands of your situation. It is thought to be an overall measurement of autonomic and cardiovascular control. In general, diabetics have lower BRS scores than non-diabetics.

Slow Breathing Improves Autonomic Function in Diabetics With Kidney Disease

At baseline, the type-2 diabetics had a lower resting oxygen saturation and lower BRS. When they switched to breathing at 6 breaths per minute, their oxygen saturation and BRS both increased significantly. Their blood pressure also reduced.

Perhaps most importantly, these same changes were observed in the diabetics with kidney disease. Both sets of diabetics (kidney disease and no complications) showed similar increases in BRS and oxygen saturation.  This indicates that, even in diabetics with severe complications, slow breathing can acutely reverse autonomic dysfunction.

Getting Back to Tissue Hypoxia

The authors suggest that these improvements in autonomic function were due to increases in tissue oxygenation. Similar to the study we featured on type-1 diabetes, they indicate that by increasing tissue oxygen levels, sympathetic activity is reduced, and autonomic balance is restored.

A New Model of Diabetic Complications

These results again indicate that autonomic dysfunction is not an expression of nerve damage. Instead, it is a reversible phenomenon that might actually be the precursor to nerve damage.  This paradigm-shifting view opens the door to new opportunities for treating autonomic dysfunction in diabetics.

In good breath,

Nick

P.S. A Zoom Meeting I would Look Forward To.

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P.P.S. James Nestor’s new book, Breath: The New Science of a Lost Art, comes out tomorrow. I don’t know James, but from the podcast interviews I’ve heard so far, this sounds like a must-read if you’re into all this “breathing” stuff :)

And if you really want to geek out, James and Patrick McKeown got together for an hour long conversation on all things breathing. Watch/Listen Here.

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Lack of Oxygen Might be the Root Cause of Diabetic Complications

Since we cannot know all that there is to be known about anything, we ought to know a little about everything.” - Blaise Pascal

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People with diabetes are at an increased risk of cardiovascular and autonomic problems. Diabetics also display altered respiratory control, for example, showing depressed (or enhanced) chemoreflexes.

However, previous studies have never examined these two aspects in an integrated fashion.

Integration Over Isolation

The problem with separately studying these systems is that the results might not be independent. For example, if a study shows that diabetics have decreased respiratory control, it might conclude that this is from diabetic nerve damage.

Likewise, if a study shows that cardiovascular function is depressed, it might also conclude that this is due to diabetic nerve damage.

However, if we study them together, we might find that there is a reciprocal relationship. Maybe the respiratory problems are causing cardiovascular issues? Perhaps it’s the other way around?

This study takes that approach and has some pretty remarkable conclusions.

Integrated cardiovascular/respiratory control in type 1 diabetes evidences functional imbalance: Possible role of hypoxia

(Click Here to Read Full Summary — I don’t say this often, but please read this one if you have diabetes)

Published in the International Journal of Cardiology, 2017.

In forty-six type-1 diabetics and 103 age-matched controls, they measured baroreflex sensitivity (BRS) as a marker of cardiovascular function and chemoreflexes as a marker of respiratory control.

Chemoreflexes estimate how sensitive you are to increasing CO2 (hypercapnic chemoreflex) and decreasing O2 (hypoxic chemoreflex).

The Hypothesis: If BRS and chemoreflexes are reduced, this would suggest diabetic nerve damage. However, if some are reduced while others are elevated, this reciprocal relationship might be showing autonomic dysfunction instead of diabetic nerve damage.

This is such an important distinction. “Damage” implies that the damage is done. “Dysfunction” implies that we could make it functional again.

Diabetics Have Worsened Cardiovascular and Respiratory Control

The results showed that subjects with diabetes had a lower BRS than the controls. They also had a suppressed hypoxic chemoreflex. However, they had an elevated hypercapnic chemoreflex. (Remember their hypothesis: if it was nerve damage, both of these chemoreflexes would be reduced.)

Interestingly, the diabetics also showed a lower oxygen saturation. And, they also had relatively high HbA1c’s (an average of 8.19%). A high HbA1c will decrease oxygen delivery to the tissues and cells.

Tissue Hypoxia is at the Root of Diabetic Complications

The reduced oxygen saturation and high HbA1c suggest a resting state of tissue hypoxia in diabetes. Over time, we become “numb” to this, which explains the decreased hypoxic chemoreflex.

The body compensates with an up-regulated hypercapnic chemoreflex, which leads to chronic activation of the sympathetic nervous system (fight or flight).  Chronic sympathetic activation then suppresses our cardiovascular control.

It’s a vicious cycle with negative long-term implications:

Dysfunction, not Damage: A Silver Lining

“We show in the present study that what is normally called ‘autonomic neuropathy’ could be in many cases a functional condition of sympathetic activation, driven by many factors, one of which seems to be resting hypoxia.”


This is all actually good news.  Their results suggest that diabetic autonomic imbalance is mainly functional and not related to nerve damage.  In fact, the authors suggest that this imbalance likely leads to nerve damage, rather than being the result of it. Therefore, therapies targeting cardio-respiratory control could help reverse/prevent diabetic complications if caught early enough.

Break Out Your Slow Breathing Hammer

What are these therapies? One is slow breathing. Slow breathing will immediately improve cardiovascular and respiratory reflexes. It will also enhance oxygenation (when breathing through the nose).

I hate sounding like all I have is a “slow breathing hammer,” but it is just too important not to stress over and over again.

Here’s to taking the first step toward protecting our long-term health as diabetics.

In good breath,
Nick

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P.S. A great podcast was recently released with James Nestor, author of the soon-to-be-released book: “Breath - The New Science of a Lost Art”. (The book looks terrific, so I pre-ordered my copy about a week ago.)

You can basically learn everything you’ll ever need to know about breathing in this quick 35-minute interview. I loved it.

Listen to the podcast here.

The Best Way to Begin Slow Breathing

“The secret of making progress is to get started. The secret to starting is to divide your complex, overwhelming task into small, manageable tasks, and then start the first.” - Mark Twain

Slow breathing has many benefits. For example, it improves cardiovascular and autonomic functioning. However, as we mentioned last week, you can quickly get “lost in the crabgrass of details” if you’re not careful, which is basically what I do every day :)

For instance, there are several ways to breathe slowly. You can use equal inhales and exhales, extended exhales for more relaxation, or you can include ujjayi breathing if you’re a trained yogi.

The study I’m sharing this week examined some of these nuances to determine which is best for beginners.

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Cardiovascular and Respiratory Effect of Yogic Slow Breathing in the Yoga Beginner: What Is the Best Approach?

(Click Here to Read Full Summary)

Evidence-Based Complementary and Alternative Medicine, 2013

The study had seventeen non-yoga practitioners perform several different breathing protocols:

• Spontaneous breathing

• Controlled breathing at 15 breaths/min

• Slow breathing at 6 breaths/min, 5 sec inhale, 5 sec exhale (equal)

• Slow breathing at 6 breaths/min, 3 sec inhale, 7 sec exhale (extended)

• The above two slow breathing protocols, but with ujjayi

Measurements of baroreflex sensitivity (BRS), blood pressure, and several respiratory variables were taken during the experiment.

Most Improvements from Slow Breathing without Ujjayi

They found that slow breathing without ujjayi was the most effective at improving cardiovascular and autonomic function (as measured by BRS) and at reducing blood pressure.

However, keep in mind that these were not trained yogis. Therefore, the added effort of ujjayi likely dampened the parasympathetic response. The results would likely be different in a trained ujjayi practitioner.

Getting Started: Breathe at a Ratio That Is Comfortable For You

All of their results revealed that slow breathing with an equal inhale-to-exhale ratio performed best. However, the differences between the balanced and extended exhale techniques were small. Therefore, they concluded that “practitioners can engage in a ratio that is personally comfortable and achieve the same BRS benefit.”

For us, the take-home message is that slow breathing at a rate of 6 breaths/min improves cardiovascular and autonomic function. The best way to begin is to choose a ratio that is comfortable for you.

I suggest that you start with a 4 second inhale and a 6 second exhale and see how it feels. Begin with a five-minute session first thing in the morning and build up from there to reach three 5-minute sessions a day.

In good breath,
Nick

P.S. Me. Also me.

The One Percent Rule of Breathing (& Bravest Podcast Interview)

Craig Kasper invited me on his podcast, Bravest, to discuss all things breathing and diabetes. It should be released later today.

Craig is a type-1 diabetic and a genuinely good person. We had a lot of fun, and I hope you’ll give it a listen. 

Listen Here: Bravest

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The Pareto Principle, or 80/20 rule, states that 20% of your efforts get you 80% of your results. Twenty percent of your customers account for 80% of your profit. A small number of NBA teams hold a majority of the titles. This rule holds true in many fields of life (here is an excellent article about the 80/20 rule) [1].

For breathing, I believe we can take this even farther.

The One Percent Rule of Breathing

In “To Sell is Human,” [2] Dan Pink describes a lesson he received during law school that stuck with him the rest of his life:

“Don’t get lost in the crabgrass of details, he urged us. Instead, think about the essence of what you’re exploring—the one percent that gives life to the other ninety-nine.”

“The one percent that gives life to the other ninety-nine.” I love that exaggeration of the Pareto Principle. In breathing, that one percent is your nose.

So Simple - So Complex

Slow breathing is simple and takes minimal effort. But, if you get “lost in the crabgrass of details,” it can become extremely complex.

But none of it would matter without the nose. The nose is the hidden engine driving all the benefits of “breathing.” Whether it’s slow breathing, sleep, or exercise, simply using your nose is the 1% that allows the other ninety-nine to occur.

How breath-control can change your life: A systematic review on psycho-physiological correlates of slow breathing

(Click Here to Read Full Summary)

Slow breathing has many benefits, which we covered in the infographic last week. To name a few: it reduces blood pressure, increases heart rate variability, enhances baroreflex sensitivity, improves arterial function, and increases tissue oxygenation.

The paper above concluded that the nose is the link connecting slow breathing to these benefits. It’s not just slow breathing; it’s nose breathing.

In good breath,
Nick

P.S. Coffee at home for me.

References

[1] I cannot overstate how much I enjoy James Clear’s work.

[2] To Sell is Human

Are Long-Term Diabetic Complications Reversible?

As a person with type-1 diabetes, long-term complications are like the boogeyman. I hide under the covers, turn off the lights, and they can’t get me. I am healthy, after all. Right?

But the truth is, diabetic complications are more common than I would like to admit. There are, however, two pieces of good news.  

There is Always Good News

First, a popular study showed that for every 1% reduction in HbA1c, there was a significant reduction in the risk of many diabetic complications.  

For example, in type-2 diabetics, a 1% drop in HbA1c was associated with a 14% drop in heart attacks. Because we know that slow breathing can help reduce HbA1c, this is more motivation to be consistent with our breathing practice (and exercising, eating healthy, and sleeping more).

Second, the study I’m sharing this week found that some diabetic complications are reversible by slow deep breathing:

Deep breathing improves blunted baroreflex sensitivity even after 30 years of type 1 diabetes

(Click Here to Read Full Summary)

Journal: Diabetologia, Volume 54, Article number: 1862 (2011)

Baroreflex sensitivity (BRS) measures your heart’s ability to adjust your blood pressure in response to changing conditions. It’s also an early indicator of autonomic dysfunction. People with diabetes typically have reduced BRS, even before other complications show up.

This study found that slow breathing at six breaths/min restored BRS to normal levels, even in long-duration type-1 diabetics (>30 years). These results indicate that reduced BRS in diabetics is partially functional and hence partially reversible.

How did slow breathing do this? The authors showed that it increased heart rate variability and parasympathetic tone, leading to improved cardiovascular and autonomic functioning.

More Benefits of Slow Breathing for Diabetics

While getting this post ready, I was considering all of the research showing the benefits of slow breathing for diabetes. This inspired me to create this little graphic, which I think sums it up succinctly.

The earlier we address the adverse effects of diabetes, the better our chances are of avoiding complications.

In good breath,
Nick

P.S. That is trust.

P.P.S. My stats for this week:

Average BOLT Score: 30 sec (Min: 26 sec, Max: 36 sec)
Average CO2 Tolerance: 64 sec (Min: 54 sec, Max: 82 sec)
Average Blood Sugar: 102 mg/dL (Min: 47 mg/dL, Max: 230 mg/dL)