Slow Breathing & High Blood Pressure: What it Means for Diabetes and COVID-19

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“Trees and plants depend on the weather to flourish but I make my own weather, yea I transport it with me.” - Og Mandino

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Recent reports have shown that high blood pressure is associated with negative outcomes from COVID-19.  

As people with diabetes, we already knew we were at higher risk when it comes to COVID-19. But, anywhere from 40%-80% of diabetics suffer from hypertension. That, on top of our compromised immune systems, is why we have to be more vigilant than ever with our health and well-being.

Thus, keeping our blood pressure under control should be a primary focus during these uncertain times.

A 2019 Meta-Analysis Shows Significant Reductions in Blood Pressure

I say this often, but meta-analyses are my favorite studies to read. They synthesize findings from all of the scientific literature on a particular topic in an easy-to-follow format.  

The one I’m sharing this week looked at slow breathing and blood pressure:

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Device and non-device-guided slow breathing to reduce blood pressure: A systematic review and meta-analysis

Published in Complementary Therapies in Medicine, August 2019

(Click Here To Read The Full Summary)

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On average, they found that slow breathing reduced systolic blood pressure by 5.62 mmHg. Slow breathing reduced diastolic blood pressure by 2.67 mmHg.

Additionally, the longer participants practiced, the more significant the reduction in blood pressure. For example, in the studies where subjects practiced slow breathing for more than 200 minutes per week, the average drop in systolic blood pressure was 14 mmHg.

These improvements are significant. Blood pressure reductions of these magnitudes have been shown to reduce the overall risk of cardiovascular death. Obviously, there are no studies explicitly looking at COVID-19 yet. Still, it seems safe to assume that these reductions would be beneficial, especially if you have diabetes.

Breathing as a Complementary Therapy

Slow breathing is not a cure-all. As the name of this journal implies (Complementary Therapies in Medicine), it is complementary, not a replacement. But, slow breathing is free and has no adverse side effects, so why not use it as another way of controlling your blood pressure, stress, and anxiety during these unsettled times?

In good breath,
Nick

P.S. When Quarantine is Over.

P.P.S. Happy Mother’s Day to all of the amazing moms out there!

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)

Unlock Your Breathing "Combination Lock"

For each scientific paper I read, I ask myself,

“What practical takeaways can my readers and I apply in our lives today based on these results?”

I usually get similar answers: (1) Breathe slowly, (2) breathe through your nose, or (3) hold your breath. (This is how I discovered the three breathing principles.)

Feeling Like Bill Murray in Groundhog’s Day

These common answers can be frustrating because I often feel like a broken record. Each paper I read is full of awesome, nerdy information. But, from a practical perspective, it’s all really simple stuff.  

For example, the paper I’m sharing this week reviews the latest science on nasal nitric oxide (including two new things I hadn’t read anywhere before). But, the take-home message is simple: Breathe through your nose.

Let’s look at this excellent paper, and then I’ll explain how Jim Rohn helped me work out my frustration.

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Recent Advances on Nitric Oxide in the Upper Airways

(Click Here For Full Summary)

Journal: Current Medicinal Chemistry, Volume 23, Issue 24, 2016

Since we’ve reviewed the beneficial effects of nasal nitric oxide several times, let’s focus on the two new things from this paper:

1. Nitric Oxide Plays a Role in Warming Incoming Air

A study showed that increased nasal NO release was associated with increased temperature in the nasal airways. There precise mechanism for this was unclear, but interesting nonetheless.

(If this interests you, please send me an email and I’ll share some of my speculation as to what is happening.)

2. Nasal NO Enhances Cilia Functioning

Cilia are tiny little hairs in your upper and lower airways. They move back and forth to push inhaled particles out of your airways and back out through your nose. They are your lungs' main line of defense against inhaled pathogens.

Nasal nitric oxide enhances the functioning of these cilia, and low levels of NO have been associated with weakened cilia movement. Here is yet another way that NO defends us against airborne pathogens.

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Jim Rohn and His Combination Lock

Again, the take-home message from this paper is: breathe through your nose to harness the benefits of nasal nitric oxide. Which brings me to Jim Rohn’s wisdom:

“Ideas can change your life. And sometimes all you need is just one more good idea in a series of good ideas. It’s like dialing the numbers of a combination lock. After you’ve dialed five or six numbers, the lock may not come open. But you probably don’t need five or six more numbers. Maybe you need just one more number, one more idea.”

Although I feel like a broken record, this passage reminded me that broken records are necessary for learning.  

I hope the (repetitive) ideas shared here help you breathe through your nose more today.

In good breath,
Nick

P.S. Can’t wait for grandchildren.

Two Simple Ways to Improve Your Sleep Tonight

Charles Dickens just walked into a hotel room. The year is 1860. As arguably the most famous author alive, you might think he set up his writing station and poured a glass of Brandy. Instead, he pulled out his compass and rearranged the place [1].

Dickens’ Odd Fix for Insomnia

Dickens believed that sleeping with his head toward the north helped with his insomnia. This sounds funny but is probably more helpful than his previous solution, which was to walk all night, sometimes covering up to 30 miles [2].

Although Dickens’ sleeping habits were peculiar, it was his keen observations of others that changed sleep science.

Joe’s Snoring and Sleep Science

In 1836, Dickens began writing The Posthumous Papers of the Pickwick Club, also known as The Pickwick Papers. In it, Dickens’ character “Joe” displayed all of the classic characteristics of sleep apnea. Joe was always tired, he fell asleep during the day, and he snored loudly.

Sleep scientists credit this work as being the first accurate observations of sleep-disordered breathing [3], recording it 120 years before the science caught up.

Modern Sleep Science Catches Up

Today, estimates of sleep-disordered breathing are, well, breathtaking. The term “sleep-disordered breathing” itself is rather generic. It covers a wide range of issues related to sleep and breathing (most commonly, obstructive sleep apnea).

However, in 1996 a review study was published that sheds light on the mechanisms that cause sleep-disordered breathing. This research helps explain why it is so common and provides suggestions as to what we can do about it.

Sleep and Breathing State-of-the-Art Review: Sleep-Induced Breathing Instability

(Published in Sleep in 1996 — Click Here to Read Full Summary)

The main conclusion from this study is that your breathing system does not work the same during sleep as it does during wakefulness.  

For example, there is less input to the muscles that keep your upper airways open, which can narrow or collapse them. This narrowing of the upper airways also increases breathing resistance. Additionally, sleep dampens the chemoreflexes that usually keep blood pH in a tight range. 

Interestingly, this “State-of-the-Art Review” concluded that carbon dioxide (CO2) could potentially help with sleep-disordered breathing. CO2 could stimulate the chemoreflexes that keep breathing steady. Additionally, CO2 is a smooth muscle dilator, which would help increase blood flow to the muscles that keep the airways open.

Two Ways You Can Start Tonight

1. Tape Your Mouth

You can start adding CO2 to your breathing tonight by taping your mouth during sleep, which will reduce breathing volume and increase CO2.

Paradoxically, while nose breathing increases resistance during the day, it reduces upper airway resistance during sleep. This small change will help you breathe better during sleep and wake up feeling refreshed and energized.

2. Breathe Less During the Day

You can also practice light breathing during the day to train your body to tolerate more CO2. By doing this consistently, you can reset your baseline CO2 back to normal values and ultimately improve your breathing during sleep.  

In good breath,
Nick

P.S. I think we all need a smile like this right now.

References

[1] Source: https://www.pharmaceutical-journal.com/opinion/blogs/how-dickens-got-a-good-nights-sleep/11074673.blog (I made up the little hotel story to go with it…he might have in fact poured some Brandi too…)

[2] Source: https://academic.oup.com/sleep/article/15/3/264/2749285 

[3] Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3365094/

Breathing and COVID-19 (Plus 4.5 Ways to Increase Nitric Oxide)

I’ve stated previously that nitric oxide (NO) is my favorite gas. Recently, the breathing community has jumped on it for its antiviral effects. The thought is that nasal NO could serve as our first line of defense against COVID-19.

While I see how that argument makes sense, I don’t think anyone really believes nasal breathing alone will stop COVID-19. Yes, it might help, but to think it will stop it completely is rather naive. So, please, wash your hands AND breathe through your nose :)

But none of that is the point of this week’s post. We know nitric oxide has amazing benefits (it’s still my favorite!). But what if your blood sugars are stopping you from realizing its full potential?

Vasorelaxation by Red Blood Cells and Impairment in Diabetes. Reduced Nitric Oxide and Oxygen Delivery by Glycated Hemoglobin

(Click Here to Read the Full Summary)

I uploaded this paper to The Breathing Diabetic on December 11, 2018! I knew it was important, but re-reading my notes emphasized just how meaningful this research is.

Here are the important points:

• Diabetics suffer from a lack of bioavailable nitric oxide. Because bioavailable NO is critical for whole-body oxygenation, this could play a major role in diabetic complications.

• High blood sugar changes the configuration and binding properties of blood proteins. This changes how they store NO, explaining the lack of bioavailable NO stated above.

The net outcome is that sustained high blood sugar reduces oxygen delivery to the tissues.

I think you can immediately see the importance of this finding. Luckily, there are things we can do to increase our nitric oxide and oxygenation.

1. Control Your Blood Sugars

No surprise here, but you need to get your blood sugars in range. Breathing can help (I might be a little biased…).

There is also a positive feedback loop that speeds up the process. Better blood sugars will increase bioavailable NO and enhance blood flow, which will lead to better oxygenation, which will improve insulin sensitivity, and so on.

2. Breathe Through Your Nose 24/7

The second thing you can do is start breathing through your nose 24/7. The paranasal sinuses continuously release NO into the airways. That NO travels into your lungs, redistributes blood flow, and improves oxygen uptake. Nasal breathing is an easy and proven way to increase NO and whole-body oxygenation.

3. Start Humming

Humming can significantly increase nitric oxide. I haven’t dug into the papers yet (they’re on my list), but people I trust, like Patrick McKeown, have.

I now do 7-8 minutes of humming before bed every night. I set my breathing app to 4 breaths/min and hum on the exhale. Despite making me feel silly, humming has a mind-calming effect that I enjoy before falling asleep.

4. Supplement with Beetroot Powder

Finally, you can supplement to increase NO. I am a novice here, but I have tried BeetElite by Human after hearing Tim Ferriss recommend it. It seemed to give me a slight boost of energy while I was sitting in the sauna (which is another way [#4.5] to increase nitric oxide, but I’ll leave that science to Rhonda Patrick). As with any supplement, make sure you have no contraindications before taking it.

In good breath,
Nick

P.S. If you want to learn more about breathing, nitric oxide, and COVID-19, Patrick McKeown is holding a free 20-minute Zoom meeting to discuss the topic.

Here are the details:

Topic: Breathing Exercises to help defend against CoVid19
Time: Mar 26, 2020 05:00 PM Dublin (1:00 PM EDT)
https://zoom.us/j/542438957
Meeting ID: 542 438 957

Learn more here: https://www.instagram.com/p/B-ANbRfgE_v/

How Nasal Breathing is Imprinted on the Brain - And What it Means for You

It feels somewhat odd to send to write a post breathing right now. There are certainly bigger problems to worry about. But, I hope this can, at the very least, serve as a distraction. Stay healthy and stay safe!

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It makes sense that our brains have regions that “light up” when we smell something. But, what about the airflow itself? If there was no odor, would we still see effects on the brain?

That was the question this week’s paper answered.

Activity Patterns Elicited by Airflow in the Olfactory Bulb and Their Possible Functions

(Click Here to Read Full Summary)

It took me two days to enter all of my notes on this one. I felt almost neglectful distilling everything into one page for the summary.

Using fMRI, the authors examined how nasal airflow stimulated the olfactory bulb of mice and compared it to that of odor stimulation. The main difference: Nasal airflow lights up broad regions of the olfactory bulb, whereas odor stimulation is more localized.

Interestingly, the intensity of the nasal breathing signal only changed with total airflow. For example, if they increased the breathing frequency, but reduced the volume, intensities remained relatively constant. But, if they increased frequency and volume, things “lit up” even more.

Why is all of this important for you? The olfactory bulb influences the limbic system, which influences emotions and the autonomic nervous system. Therefore, if nasal breathing is imprinted on your brain in the olfactory bulb, this helps explain how it can easily influence your emotional and physiological state.

If you have done any breathing practices, you have likely experienced this. Here, we see one reason why.

So, we can conclude: Breathe through your nose to change your brain, change your emotions, and change your physiological state. Simple, yet profound.

In good breath,
Nick

P.S. Don’t worry about corona?

Can Breathing Improve Insulin Sensitivity? (+ 35 hours & 291 miles)

On Valentine’s Day, the CDC published a report documenting trends in diabetes incidence from 2002-2015. The take-home message: Rates of diabetes, both type-1 and type-2, are increasing in people less than 20 years old, especially in racial and ethnic minority populations.

Results like this make no-cost interventions more important than ever. (I will not get into the cost of diabetes here. But, I’m fortunate to have a job with great benefits, and I still feel the cost of diabetes daily.)

Which brings me to this week’s paper. It is a follow-on to the one I shared last week, which showed that relaxation breathing lowers blood sugar spikes.

Here, the same author published a review paper on breathing, glycemic response, and insulin sensitivity:

Review: Can yoga breathing exercises improve glycemic response and insulin sensitivity?

(Click Here to Read Full Summary)

Overall, this review concluded that slow breathing exercises can improve glycemic control and increase insulin sensitivity.

The glucose-lowering effect of slow breathing is likely due to reduced sympathetic activity and, subsequently, reduced glucose production by the liver.  That is, slow breathing reduces your body’s internal production of glucose.

The improved insulin sensitivity is likely related to reduced sympathetic output, but could also be due to improved tissue oxygenation.

These breathing techniques are so simple, yet they could be life-changing to diabetics.

If you feel inspired, please share the CDC study and this paper (or my summary of it) with someone you know with diabetes or pre-diabetes.

It’s a small, no-cost step in the right direction toward improving the lives of diabetics.

In good breath,
Nick

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P.S. 100 Mile Ruck Thank You!

Thank you all for the support during the 100-mile ruck! It was the hardest thing I’ve ever done, but I finished.

Overall, it took me 35 h 45 min to finish and I took approximately 225,000 steps to cover the 100 miles.

Including those who walked with me, we put in a combined 291 miles for chronic disease and raised ~$2K for HHPF! Simply amazing! THANK YOU!

Relaxation Breathing Reduces Blood Sugar Spikes

This week, I am sharing one of those amazing papers that I read and underline the whole thing. Despite having a small sample size, it hints at the incredible benefits of breathing for optimal blood sugars.

Relaxation Breathing Improves Human Glycemic Response

(Click Here to Read the Full Summary)

The study participants were randomized into a control group (n=13) and a relaxation breathing group (n=13). The relaxation breathing (RB) protocol used a constant inhale with a progressively longer exhale:

• Inhale 2 sec, exhale 1 sec.

• Inhale 2 sec, exhale 2 sec.

• Inhale 2 sec, exhale 3 sec.

• …

• Inhale 2 sec, exhale 10 sec.

The participants performed this exercise once every 10 minutes for 30 minutes prior to an oral glucose tolerance test. Then, they did it every 10 minutes for 90 minutes after the test. Overall, they did the RB technique 3 times before and 9 times after the test. The control group simply took the glucose tolerance test.

The results showed that the RB group had a significantly lower blood sugar (~37 mg/dL lower) thirty minutes after the glucose tolerance test.  After an hour, the two groups were approximately the same. Thus, relaxation breathing reduced the blood sugar spike associated with the glucose tolerance test.

Although the exact mechanisms are not clear, it seems likely that activation of the parasympathetic nervous system improved the insulin response of the RB group, and might have also improved insulin sensitivity.

This study provides another scientifically-validated breathing technique we can use to improve our blood sugars. After reading this paper, I started using it quite often.  I’ve found it’s nice to do while lying in bed before sleep.  I also find it helpful at the beginning of a breathing/meditation session just to calm everything down. 

And, with how simple it is, you do not need a watch or app. You can simply count in your head. It only takes ~75 seconds to complete one cycle and it will leave you feeling calm and relaxed (and potentially lower your blood sugar).

Give it a try before your next meditation or breathing session as a way to prepare you for relaxation.

In good breath,
Nick

P.S. I am finalizing this post on Friday, Feb. 28, and do not plan to look at it again before Monday (I am assuming my body/mind will not be in any capacity to do so). Hopefully I made through the 100 miles with no major issues. If you still want to donate, it’s not too late. HHPF is always accepting donations to further their mission. Thank you for your support!

Exercise and Hypoxia Increase Insulin Sensitivity (& 100 Mile Ruck Website)

There are many paradoxes in breathing. For example, breathing less air delivers more oxygen to your cells.

Here is another one. Many diabetic complications (for example, insulin resistance) are rooted in tissue hypoxia. Yet, the deliberate practice of intermittent hypoxia (IH) can improve insulin sensitivity, as shown by the study I’m sharing this week.

Acute hypoxia and exercise improve insulin sensitivity (Si2*) in individuals with type 2 diabetes

(Read the Full Summary)

This research examined four different protocols:

1. Rest at normal O2 levels for 60 min

2. Rest in hypoxia for 60 min

3. Exercise with normal O2 for 60 min

4. Exercise in hypoxia for 60 min

All participants were type 2 diabetics. Oxygen levels for the hypoxic group were maintained at ~14.6%, and the results showed that the participants’ SpO2 never fell below 88% (well within the therapeutic range).

Here were the main findings:

• Hypoxic rest increased insulin sensitivity more than rest at normal O2 levels

• Hypoxic exercise improved insulin sensitivity greater than exercise in normal O2 levels

Together, these results imply that exercise and hypoxia can be added together to improve insulin sensitivity.

However, before jumping in, we must remember that hypoxia does induce stress, and stress hormones increase the body’s production of glucose. Thus, the increased insulin sensitivity could just be the body’s preemptive response to the stress: It knows more sugar is coming, so it primes itself to use it.

We should keep this in mind as we practice intermittent hypoxia: It’s important to find our Goldilocks zone, where we’re experiencing hypoxia, but not inducing too much stress. I recommend starting slowly with walking breath holds. You get the benefits of exercise and hypoxia in a safe, easy-to-perform way.

Try adding 3-5 walking breath holds to your morning routine. They don’t have to be intense, just enough to feel it. And, make sure you can recover normal breathing within 3 breaths after the hold…this ensures you do not push too hard.

Give it a shot, and remember, consistency over intensity.

In good breath,
Nick

P.S. Here is the link to the 100 Mile Ruck fundraiser page:

https://www.hhp-foundation.org/donate

Please share the link with friends and family. And consider walking a mile or two with me virtually. Or, if you can, come out to Gleason Park in Indian Harbor Beach, FL between 8 AM - 10 PM on Feb. 29th to walk in person!

Obstructive Sleep Apnea Lowers Nitric Oxide (plus a big backpack)

The 100 Mile Ruck webpage is almost ready. The folks at HHPF plan to have it up by Wednesday. I’ll send you a super quick email when I hear it’s ready.

In the meantime, here is this week’s dose of breathing science.

Circulating nitric oxide is suppressed in obstructive sleep apnea and is reversed by nasal continuous positive airway pressure

(Read the Full Summary)

This study found that:

• Obstructive sleep apnea was inversely correlated with nitric oxide

• Meaning that, as OSA indices increased, NO decreased

• And as NO decreased, blood pressure increased

However, just one night of nasal CPAP restored NO to normal levels.

We know from previous studies that inhaled NO can have positive impacts throughout the whole body.  And we also know that the nasal cavity is warehouse for NO.  Together, these results suggest that the nasal CPAP machine might be restoring NO concentrations by simply encouraging nasal breathing during sleep.

Obviously, there is more to it than that, as CPAP machines do a lot more than just promote nasal breathing. But, I think a key take home message from this study is: Breathe through your nose at night.

Read the full summary to learn more.

In good breath,
Nick

P.S. How the rucksack will feel by mile 50:

I'm Rucking 100 Miles + Diaphragmatic Breathing Improves HbA1c

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Announcement:
I’m Rucking 100 Miles for Chronic Disease

On Leap Day, February 29th, I’m going to ruck 100 miles to raise money for the Health and Human Performance Foundation (HHPF).

If you’ve been following me for a little while, you know I’m a huge fan of their mission. They are an amazing nonprofit raising awareness around the benefits of breathing for chronic disease, stress, and anxiety.

Given the impacts breathing has had on my life, I wanted support their cause. What better way than a ridiculously long walk?

I am wearing a weighted rucksack to symbolize the extra weight we carry around as those living with chronic disease. Yet, despite that weight, we can still accomplish anything. In fact, that weight makes us stronger. I wholeheartedly believe diabetes has made stronger.

We are setting up a donations page on HHPF, which I’ll be sending out separately. If you feel so inspired, donate to help support their great mission. And please support me by telling others, sharing our posts on Instagram, and spreading the word about HHPF.

Thank you in advance for your support!

Now, on to the science.

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Last week, we learned that diaphragmatic breathing improved HRV and lowered HbA1c. This week’s research reveals that it also improves antioxidant status in type 2 diabetics.

Diaphragmatic Breathing Exercise as a Therapeutic Intervention for Control of Oxidative Stress in Type 2 Diabetes Mellitus

(Read the Full Summary)

This is one of the early papers I posted to The Breathing Diabetic. I often go back through important papers to reinforce the ideas and see if I notice new things I missed before.

This one did not disappoint. Just re-reading all of my notes on this one energized me (image below). I’m fascinated with breathing, but sometimes I need a paper like this to remind me how important it is to get this research out.

The Breathing Protocol

One hundred and twenty three type-2 diabetics participated in this study. Sixty were placed in the diaphragmatic breathing group, and 63 served as controls.

The participants were instructed to lie down, place one hand on their chest, one hand on their belly, and breathe deeply and slowly, only allowing the hand on their belly to move.

This protocol is almost identical to the Oxygen Advantage “Breathe Light Advanced” exercise.

They were asked to perform this procedure for 15-20 minutes, twice a day, for 3 months.

Breathing Improves Oxidative Stress and HbA1c

At the end of the 3 months, participants in the breathing group had significantly lowered their oxidative stress by increasing antioxidant levels.

Additionally, they decreased their HbA1c by 3%. Now, this isn’t 3% as in dropping from 9% down to 6% (like last week’s study). This was 3% of their original value. Not quite as significant, but still encouraging. And, remember the study from last week didn’t see major improvements in HbA1c until the 12 month follow-up.

In short, diaphragmatic breathing led to:

• Decreased oxidative stress

• Better blood sugars

In good breath,
Nick

P.S. Here’s the first page of my notes on this article. I was clearly excited the first time I read it too.

One year of slow breathing increases HRV and reduces HbA1c

It’s rare to find a long-duration breathing study. Typically, they examine effects lasting only minutes to hours. Then, it’s up to us to extrapolate the long-term benefits. This paper was different.

Effect Of Diaphragmatic Breathing On Heart Rate Variability In Ischemic Heart Disease With Diabetes

(Read Full Summary)

They asked participants to perform 10-15 minutes of slow deep breathing, twice a day, for one year. The researchers followed up with them at the 3 and 12 month marks.

(Side Note: This is basically what I have been doing for the past 2 years. I perform 15 minutes of slow breathing in the morning and ~5-10 in the evening before bed.)

The results were amazing.

• Heart rate variability (HRV) increased significantly at the 3 and 12 month marks.

• HbA1c dropped slightly at 3 months, and then significantly at 12 months.

The drop in HbA1c (3-month average blood sugar) was impressive, with one group experiencing a 2% decrease: They dropped from an average of 8.95% down to 6.95%. That’s like going from an average blood sugar of around 200 mg/dL down to 150 mg/dL. Even if you don’t have diabetes, you can appreciate the significance of these findings.

Participants who did not comply with the breathing protocol experienced a worsening of their HRV and HbA1c over time.

Of course, we need to take these results with a grain of salt. Over the course of the 1-year study, participants could have made other changes (diet, exercise, and so on) that would also influence the findings.

Nonetheless, this study is encouraging and corroborates the “N=1” experiment I have been performing on myself over the past few years.

The results also remind us that persistence is key. If they had stopped the study at 3 months, the improvements in HbA1c would not have been significant. It wasn’t until the 12 month follow-up that major improvements in blood sugars were observed.

Check out the full review to learn more.

In good breath,
Nick

P.S. Gonna need a bigger backpack.

What an Ancient Philosopher Can Teach Us About Breathing

I am clearly a big fan of theory. I love to read and learn how things work (especially breathing). And since you are reading this, I am guessing you do too.

Something I constantly struggle with is the balance between theory and practice. I get joy from reading, but everything I learn would be useless if I did not practice it.

Which begs the question: What is more important, theory or practice? Where do you draw the line between theorizing and practicing? Let’s go back a couple thousand years and see what a philosopher named Musonius Rufus can teach us (my bold for emphasis):

“Theory which teaches how one must act assists action and logically precedes the practice, for it is not possible for something good to be accomplished unless it is accomplished in accordance with theory. But as a matter of fact, practice is more important than theory because it more effectively leads humans to actions than theory does.”

So we need theory to guide our practice. We need sound principles and a foundation based on science. But practice requires action, and action is where we get results.

It’s easy to read a paper and tell you that slow breathing will do this or that. But what’s more important is that you practice and see for yourself. Theory is good, but practice is better.

Let’s use Musonius’ wisdom for inspiration this week. Not just with breathing, but with anything you learn. Use the theory to guide your practice, but focus on the practice.

“Likewise, the man who wants to be good must not only learn the lessons which pertain to virtue but train himself to follow them eagerly and rigorously.”

In good breath,
Nick

P.S. This idea was copied from another one of Brian Johnson’s +1’s. He is one of my favorite teachers. His wisdom helped get me through graduate school and boosted me into my career as a research meteorologist. He is a living embodiment of everything he teaches.

P.P.S. If you don’t know where to start with your breathing practice, I have a “Get Started” page that might help. Or even easier, just spend 5 minutes each morning breathing at 6 breaths/minute. Try it for 5 days and see how you feel.

Nasal Nitric Oxide is My New Favorite Gas

The nose warms and humidifies incoming air. We’ve heard that a lot.

However, when you dig into the scientific literature, you learn that nitric oxide (NO) might outweigh all other aspects of nasal breathing. It’s actually hard to overstate the benefits of nasal NO.

Which brings us to this week’s paper:

Nasal Nitric Oxide in Man

- Published in Thorax in 1999 (Read Full Summary Here)

This was a great overview of the many functions of nasal NO. Here are a few of my favorites. Check out the full summary for more.

The general consensus is that NO is continuously released in the paranasal sinuses. Because of this continuous release, a lower flow rate will result in higher concentrations. This could be yet another benefit of slow breathing: Increased nitric oxide delivery to the lungs.

Another amazing benefit of nasal NO is that it increases arterial oxygenation. For example, one study showed that nasal breathing increased tissue oxygenation 10% more than mouth breathing.

Finally, and this was my favorite part, a study showed that breathing humidified air through the mouth did not increase oxygenation; however, breathing supplemental NO through the mouth increased oxygenation similar to what is seen in nose breathing.

Although the warming and moistening effects are important, this suggests that nitric oxide might explain many of the benefits of nasal breathing.

I am continually amazed by everything nitric oxide does in the body.  I think it’s my new favorite gas (never thought I’d have one of those!).

In good breath,
Nick

P.S. Who Needs Gas?.

Breathing and Brushing Your Teeth

I’m pretty obsessive about my breathing practice and I tend to over-analyze every session. “Why did it feel harder today? Was I breathing light enough? I need to increase my CO2 more…” It goes on and on.

Recently, however, I heard something awesome in a “+1” from Brian Johnson. He quoted a great passage from Herbert Benson in The Relaxation Revolution:

“Most of us are concerned to one extent or another with dental hygiene, but we don’t dwell on the tooth-cleaning process. We just work away with that brush every day. Almost no one evaluates the brushing, to say, “That was a good brush!” or, “Too bad—that was a bad brush.” We simply do it!”

I love that. When is the last time you analyzed your tooth brushing skills? Probably never. Yet, we count on it for dental hygiene. We trust that it’s working, whether we brush “good” or not.

In some ways, that’s what we have to do with our breathing practice. (Or any integrative health practice, such as meditation, yoga, or physical exercise.)

We can’t spend too much time worrying if we did it exactly right. Instead, we just have to do it. Every day. And know that it’s working.

Of course, we want to start with the right principles and not jump foolishly into something. But, once we’ve committed, sometimes we just have to trust the process without over-analyzing it.

Here’s to treating our breath/meditation/yoga practice more like brushing our teeth.

In good breath,
Nick

P.S. Here’s another gem from Herbert Benson on the same topic (my bold for emphasis):

“Similarly, if you’re taking a pill your doctor has prescribed for your cholesterol or blood pressure, you probably don’t wonder, “Am I putting this pill in the proper side of my mouth? Am I swallowing it correctly? Is it really going to work?” Again, you just do it—and that should be your approach to mind body treatments.”

Nasal Nitric Oxide: Our Body's Answer to Gravity?

Gravity is pretty awesome. After all, it keeps us here on Earth. And when our bodies are not subject to gravity (say, if you’re an astronaut), some crazy things happen. For example,

• Astronauts lose 25% of their aerobic capacity in 7-14 days (it usually takes 10 years to lose 10% here on Earth)

• Bone density can decrease as fast as 5% a month (it’s usually about 1% a year on Earth)

Thus, our bodies are clearly meant to be under the influence of gravity. However, as we became upright mammals walking on two feet, gravity could have posed an issue.

Blood flow in our lungs is influenced by several factors, but one of the largest is gravity. Gravity acts to focus blood toward the base of the lungs.

Interestingly, in humans and other primates, the nasal airways produce a considerable amount of nitric oxide (NO). As we’ve learned before, NO is a potent vasodilator that is critical for whole-body oxygenation.

Maybe the NO produced in the nasal airways is an adaptation to walking upright and helps counter gravity’s effects on blood flow? That was the hypothesis of the study I’m sharing this week.

Nasal Nitric Oxide: Nature’s Answer to Gravity?

(Read Full Summary Here)

This research found that when participants breathed through their noses, blood flow in the lungs became more uniform and gas exchange was increased. Breathing through the mouth did not have these effects.

However, if subjects breathed through their mouths but were given supplemental NO, the blood flow in their lungs looked similar to nasal breathing.

This suggests that NO is responsible for making blood flow more uniform in the lungs.

The authors hypothesize that nasal NO might be an evolutionary adaptation to counter the effects of gravity on lung blood flow, allowing greater and more efficient gas exchange to occur.

We often praise nasal breathing for its warming and humidifying effects. But the more I learn, the more convinced I am that nitric oxide is the real hero.

In good breath,
Nick

P.S. Happy New Years Dance!

Breathing as an Integrated Approach to Health and Well-Being

I recently hit a plateau with breathing. I had been practicing my principles and reading everything I could find. I was doing everything “right.” However, my breath holds and CO2 tolerance had become stagnant. I felt good, but I had just stopped progressing. I thought, “this must be where I’m supposed to be.”

Then something awesome happened. And it had nothing to do with breathing.

I started adding a couple hours between dinner and bedtime. Eat dinner at 5:30 or 6:00 PM, then go to bed around 8:00 PM. Almost overnight my CO2 tolerance increased by ~20 seconds. My old “normal” seemed crazy. It wasn’t normal at all.

I share this story because I had a minor epiphany: everything is integrated. Obviously, that phrase seems pretty obvious. But, this experience gave it a whole new meaning for me.

I was so focused on using “breathing” to improve my breathing that I did not even consider other aspects of my life. But that’s exactly where I needed to look.

I do believe breathing is the foundation of good health. However, to achieve optimal results, it needs to be integrated with other aspects of our health, including things like nutrition, exercise, sleep, and work.

If you’re ignoring any of these, ask yourself how breathing might help out. On the flip side, if you’re ignoring breathing, consider how it might support you in achieving all of your other health-related goals.

You might also ask yourself if anything you think is “normal” right now might not be normal at all?

In good breath,
Nick

P.S. Sleep?