Cleveland Clininc

Box Breathing for Stress, and the Ancients’ Code to Becoming a Hero

 
 

Listen Instead of Reading

 

This week, you'll learn that breathing is only part of the solution, along with the ancient (and quite unexpected) secret to becoming a hero.

Enjoy!

 
 
 
 

4 Thoughts


1. Breathing as the XX% Solution

“Consider what life would be like if we gave up the idea of healthy or sick, zero versus one, and replaced it with the idea of multiple continuum. One minute, for example, we might score 60% on one health dimension, 30% on another, and perhaps 85% on yet a third. How would that change our lived experience?”

- Dr. Ellen Langer, Counterclockwise

I love this idea from Dr. Langer. It encourages us to forget “all or nothing” approaches and instead consider everything on a continuum. This perspective also provides a new way of finding solutions to our health problems.

Let’s say I only sleep 5 hours a night. Then, I start mouth taping and begin sleeping 6.5. That’s a 30% improvement. But let’s say you’re already sleeping 7 hours, and mouth tape gets you to 7.5. That’s only a 7% increase. But, that 7% might be all you need to feel your absolute best.

The point is that we’re all unique, and we’re all on different spots on the health continuum. My 80% solution might be your 30% one, and vice-versa.

So, instead of wondering what breathing (or the latest diet, the sauna, etc.) can fix for you, perhaps consider what percentage of the solution it is. “How would that change your lived experience?”

***

Related Quote: “The people I distrust most are those who want to improve our lives but have only one course of action.” - Frank Herbert

2. Test Like a Pro

“You may feel your anxiety turning to panic. … To tackle this, watch your breathing. Just before you might go into panic mode, put your hand on your belly and try to draw air so deeply into your lungs that your hand moves up and down. This deep breathing can allow you to grow calmer and steadier.”

- Dr. Barbara Oakley and Olav Schewe, Learn Like a Pro

Last week, we discovered that to learn like a pro, we need to sleep like a pro. This week, Dr. Oakley and Olav Schewe give us their advice for testing like a pro: slow deep breathing.

This technique isn’t just for school tests, either. This is for any big event you’re facing. Of course, sometimes anxiety is good (see Kelly McGonigal’s amazing book, The Upside of Stress). But, in moments when you’re panicking, and it’s hampering your performance, here’s the perfect trick.

Place one hand on your belly and use your breathing to make it move. This activates the calming parasympathetic nervous system, helping you relax and gain mental focus. It’s free, available anytime, anywhere.

Here’s to approaching whatever tests life throws at us like pros, today.

***

Related: A better state-of-mind: deep breathing reduces state anxiety and enhances test performance through regulating test cognitions in children (Check out the last two sentences of the abstract)

Related: This 2-Minute Breathing Exercise Can Help You Make Better Decisions, According to a New Study

3. From the Cleveland Clinic: “How Box Breathing Can Help You Destress”

“Box breathing’s simplicity is its greatest strength”

- Melissa Young, MD, How Box Breathing Can Help You Destress

The Cleveland Clinic is one of the most respected hospitals and research centers worldwide. So, it was awesome to see them release an article on box breathing this past week.

It’s a quick yet comprehensive guide on box breathing. Enjoy!

4. The Ancients’ Secret to Becoming a Hero (it’s not what you might think)

“True heroism, as the ancients understood, isn’t about strength, or boldness, or even courage. It’s about compassion.”

- Christopher McDougall, Natural Born Heroes

Heroes are compassionate. In fact, the word hero itself actually means “protector” in Greek, not “strength” or “courage.” That’s why we call our parents, big brothers and sisters, military, police, firefighters, doctors, nurses, and especially our dogs, heroes. They protect us.

And these heroes don’t just rely on boldness or brute strength, like movies and the news might make us believe. They rely on empathy and compassion for those they are protecting. As McDougall puts it:

“Empathy, the Greeks believed, was a source of strength, not softness; the more you recognized yourself in others and connected with their distress, the more endurance, wisdom, cunning, and determination you could tap into.”

Thus, we can all be heroes because we can all develop these traits. Sitting and breathing, meditating, or doing some yoga will increase your compassion and awareness for yourself and those around you. That’s how heroes are made.

So who can you show compassion and empathy for this week? You might just become their hero.

 
 
 
 

1 Quote

“In a crunch situation, I recommend you collapse your concentration to your breathing while maintaining relaxed awareness of the surroundings. Breathing deeply will greatly reduce the stress, slow your heart rate, and bring your nervous system back into balance.”

- Mark Divine, Retired Navy SEAL Commander

 
 
 
 

1 Answer

Category: Word Etymology

Answer: The word “breath” is derived from the Old English “brǣth,” which has this meaning.

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(Cue the Jeopardy! music.)

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Question: What is ‘smell or scent’?

P.S. Thus, the word breath itself is related to the nose : )

In good breath,

Nick Heath, T1D, PhD
“Breathing is the compound interest of health & wellness.”

P.S. wow, respect to these teen parents

 
 
 

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Each Monday, I curate and synthesize information from scientific journals, books, articles, and podcasts to share 4 thoughts, 1 quote, and 1 answer (like "Jeopardy!") related to breathing. It’s a fun way to learn something new each week.

 
 

The Lesser-Known Benefits of Nasal Breathing, Designed for Diabetes

 

As a person with type 1 diabetes, my experience with nasal breathing has been nothing short of miraculous.  It's been such a simple change, yet its impacts on my energy and blood sugars have been profound. I feel it would be irresponsible not to share it with other people with diabetes.

Luckily, people much brighter than me have become fascinated by the nose too.  Whole books have now been written on the topic.  It has been featured in popular sources such as Outside Magazine and the Cleveland Clinic.  An article published in Frontiers in Human Neuroscience even concluded that “nasal stimulation represents the fundamental link between slow breathing techniques, brain and autonomic activities and psychological/behavioral outputs.”

But after several years of research, I have come to realize that the reasons nose breathing is so helpful for diabetes go far beyond the “obvious ones.” 

Of course, the usual suspects are essential, such as the warming and humidifying of the incoming air and the natural slowing of the breath.  But to fully understand the benefits for diabetes requires a synthesis of research from different fields, such as diabetic complications, the metabolites of nitric oxide, chronic stress, and sleep.

Let’s start with diabetic complications.

Oxidative Stress and Inflammation Reduce Blood Flow

Over time, the oxidative stress and chronic inflammation associated with diabetes can damage blood vessels, resulting in poor circulation. 

Less blood flow means that less oxygen reaches the cells, tissues, and organs. 

As a result of this poor circulation (and other complications), people with diabetes have an increased incidence of retinopathy, kidney disease, and foot problems.

Nose breathing—specifically inhaling through the nose—immediately helps with this.  For example, one small study showed that just five minutes of inhaling through the nose and exhaling through the mouth increased tissue oxygenation by 10%.  This increase was due to nitric oxide.

Nitric oxide is continuously produced in the paranasal sinuses.  When you breathe in through your nose, nitric oxide is carried into the lungs, where it opens up the blood vessels and improves blood flow in the lungs.  This results in better gas exchange and better blood oxygenation.

But that’s only the beginning of NO’s benefits.

How Nitric Oxide Helps with Blood Flow and Oxygenation

Typically, the nitric oxide produced in your nose is treated separately from the nitric oxide produced throughout the rest of your body.  Although it is known that that inhaling nitric oxide has effects outside of the lungs, scientists have not known how. Researchers at the Cleveland Clinic have recently shed light on the issue.

In a 2019 study, they did something simple yet meaningful.  The researchers had participants inhale extra nitric oxide, and they measured what happened in the blood afterward.  If nitric oxide’s journey ended in the lungs, they wouldn’t see any signs of it in distant blood samples.

The results showed the opposite. 

They found that inhaling nitric oxide significantly increased circulating levels of a specific form of the molecule, SNO-Hb.  These findings matter because, in a separate study published in PNAS in 2015, a different group of researchers found that SNO-Hb played an essential role in whole-body oxygenation.  Without it, mice received less blood flow to the heart and even had smaller litter sizes.

Why This is Important to Diabetes

The complications of diabetes also impact nitric oxide.  Sustained high blood sugars alter how hemoglobin stores nitric oxide. 

The end result is that people with diabetes generally have less SNO-Hb. 

And, as we just learned, SNO-Hb is critical to blood flow and tissue oxygenation. 

So, putting it all together:

  • People with diabetes suffer from poor circulation and insufficient oxygen.

  • Our noses are a source of nitric oxide—breathing through our nose utilizes it.

  • Inhaling nitric oxide increases an essential form of NO called SNO-Hb.

  • SNO-Hb is critical to improving blood flow and increasing whole-body oxygenation.

Therefore, nose breathing could be especially helpful in diabetes by maintaining normal SNO-Hb levels and hence helping improve blood flow and oxygenation throughout the body.*  Mouth breathing would not provide these benefits.

How High Blood Sugars Reduce Oxygen Delivery

In addition to altering how nitric oxide is stored, high blood sugar also modifies the relationship between oxygen and hemoglobin.  Specifically, it tightens the bond between them.

As a result, less oxygen can be delivered to the places it is needed.  (For the breathing nerds out there, it causes a left shift in the oxyhemoglobin dissociation curve.)  This problem might be further exacerbated by stress.

Chronic Stress and Carbon Dioxide Alter Oxygen Availability

Diabetes also causes chronic stress—a less intense but sustained fight or flight stress response.  This stress causes people with diabetes to have anywhere from 14% to 20% more cases of anxiety than those without it.  Moreover, it has been reported that up to 40% of the diabetic population show symptoms of anxiety.  A 2013 meta-analysis, including over 12,000 people with diabetes, also found significant associations between diabetes and an increased probability of anxiety disorder or anxiety symptoms.

Chronic stress and anxiety, such as that experienced in diabetes, are often associated with overbreathing.  Overbreathing, or hyperventilation, simply refers to breathing more than your metabolic demands at any given moment, and is often associated with mouth breathing. Consequently, the body gets rid of too much carbon dioxide, which alters the pH of the blood.

This has a similar effect on oxygen and hemoglobin as high blood sugar. 

That is, it tightens the bond between them, reducing the amount of oxygen that can be delivered to the cells and tissues (this is known as the Bohr effect).

Together, we see that the high blood sugar and chronic stress associated with diabetes combine to reduce oxygen availability to the cells and tissues.

When we switch to nose breathing, the volume of each breath is naturally reduced.  This helps normalize carbon dioxide levels and restore blood pH to normal levels, which will improve oxygen delivery.** 

Combining this with the earlier discussion on nitric oxide, we see how this one simple change (nose breathing) helps offset some diabetic complications.

Nose Breathing, Sleep, and Diabetes: The Missing Link to Better Blood Sugar Control

If we breathe nasally during sleep, all of the benefits of nose breathing continue throughout the night. Of all the things nose breathing helps with, this might be the most critical for diabetes.

We have already discussed that diabetes causes chronic stress, which can lead to more rapid breathing.  Nose breathing helps naturally slow down the breath.  This will help you shift from a stressful sympathetic state to a calming parasympathetic state.  This shift is significant for people with diabetes who exhibit less parasympathetic tone at night than non-diabetics.  Thus, nasal breathing at night helps us increase parasympathetic tone and enjoy better sleep.

Receptors in your nose also act to maintain rhythmic breathing during sleep.  This might help explain why nose breathing reduces the risk of obstructive sleep apnea when compared to mouth breathing.  Diabetes is associated with a significantly increased risk of obstructive sleep apnea. So, if nasal breathing at night can help reduce this risk, it could be especially beneficial.

Lastly, we know that inadequate sleep causes insulin resistance.  By getting deeper, more restorative sleep, insulin sensitivity can be improved.  This could potentially lead to better morning blood sugars (that was my experience), setting you up for a better day of glucose control.

The More Subjective but Most Important Benefit of Nasal Breathing for Diabetes

Altogether, nasal breathing increases blood flow, improves tissue oxygenation, and appears to increase an essential form of bioactive nitric oxide that people with diabetes have less of.  It also improves sleep quality by helping us flip to a more calming state and by reducing the incidence of sleep apnea.  This can help improve insulin sensitivity.

When we combine all of these together, nasal breathing's net benefit can be simply stated as:

It gives you more energy. 

And it’s harder to objectively measure, but perhaps the best aspect of increased energy levels is more motivation to take care of your blood sugars. 

Diabetes is an exhausting full-time job that can lead to physical and emotional burnout.  Having more energy and enthusiasm to manage the disease could be the most valuable aspect of something as simple as breathing through your nose.

Footnotes:

*The levels of NO inhaled in the 2019 Cleveland Clinic study were greater than those produced in the nose.  But, the study validated that there is a mechanism by which NO that is introduced into the lungs can be transported throughout the body as SNO-Hb.  Thus, nasal breathing would only act to bring SNO-Hb up to normal physiological levels, whereas mouth breathing would rob the body of this important physiological process.

**This discussion is centered around the regular blood sugar fluctuations associated with diabetes and not diabetic ketoacidosis.

 
 

Patch Your Breath, and Wim Hof’s Slow Breathing Method?

 

Happy Monday, and welcome back to another issue of The Breathing 411. Here are four thoughts, one quote, and one answer for you to reflect on this week.

 
 
 
 

4 THOUGHTS

1. Instead of a Bigger Engine, Patch the Hole in Your Boat

If you have a hole in your boat, a bigger engine or better fuel might keep you afloat longer. A more aerodynamic design might help you temporarily go faster. But either way, you’ll still be slowly sinking until you patch the hole.

Your breathing is that hole. You can eat better, workout harder, and take more supplements, which will all be very helpful. But until you "patch" your breath, you’ll never see the true potential of your energy and performance.

2. Diaphragmatic Breathing from the Cleveland Clinic

"But keep at it, because with continued practice, diaphragmatic breathing will become easy and automatic."

- Diaphragmatic Breathing, Cleveland Clinic

Last week, we discussed how diaphragmatic breathing improves recovery. Here’s a brief article from The Cleveland Clinic (regarded as one of the best hospitals and research centers worldwide) on how to get started.

Enjoy!

3. Become a Breathing Flâneur

"The flâneur continuously—and, what is crucial, rationally—modifies his target as he acquires information."

- Nassim Taleb, Antifragile

I propose we become breathing flâneurs. Let’s not be rigid with our techniques, but rather be open to change as we get new information.

Importantly, let’s rationally modify our approach based on the best information we have and the circumstances we find ourselves in.

The best way to do this is to have many options to choose from (slow breathing, Oxygen Advantage, Wim Hof, and so on) and use them as needed.

4. Wim Hof’s Slow Breathing Method - A Thought on Statistics

Here’s a fun thought about the infamous Kox et al. (2013) study on the Wim Hof Method (WHM). This paper scientifically validated that the WHM can allow people to control their autonomic nervous system and innate immune system.

There is a plot (their Figure 2) showing about 10.8 minutes of data. In that time, participants did 3 rounds of hyperventilation, and 3 breath holds. Each hyperventilation session was ~30 breaths. So, over the 10.8 minutes, they took about 90 breaths. On average, that’s ~8.3 breaths/min.

Thus, from a statistical perspective, the Wim Hof Method is slow breathing.

Now consider how much different it is to "breathe at 8 breaths/min for 11 minutes" compared to "performing three rounds of the WHM." This is why we must always put statistics into context…

But it’s also just fun to ponder : )

 
 
 
 

1 QUOTE

"Facts are stubborn things, but statistics are more pliable."

- Mark Twain

 
 
 
 

1 ANSWER

Answer: About 50% of the oxygen you breathe originated from this location.

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(Cue the Jeopardy! music.)

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Question: What is the ocean?

In good breath,
Nick

P.S. A fun thought exercise.