In keeping with our goal of bringing you important medical issues for yourself and your family this week’s health tip addresses Obstructive Sleep Apnea, stay awake long enough to read it!
 
Our Wealth Tip addresses protecting your investments in these volatile times with collars that can be implemented to limit losses by also putting a reasonable cap on profits at zero net cost.

Jump around or read the entire issue.  Is any of this important to you?  We need to know if our efforts are worthwhile or should be re-directed.  We don’t really expect that every article will be of interest to every reader but there ought to be at least one important article in each issue that presses some of your ON BUTTONS.  Let us know if we are wasting electrons!!

Our intent is to publish smaller newsletters twice a month starting with this issue. Be sure to be in touch with Richard Gray, Editor, at rgray@fjmc.org with your articles, comments, appreciation and critiques. Each issue is brought to you by your editorial staff that includes:

• Richard Gray (Editor in Chief)
• Steven Mandel MD (Medical Editor)
• Gary Smith (Wealth Editor)
• Mark Druy (Publisher)

This HWR was sent out on , at approximately 11:15 AM (Eastern and prior to Shabbat).

HEALTH TIPS

Obstructive Sleep Apnea A common disorder to treat seriously…and seriously treat

By

Ruben Cohen, D.D.S.

You’ve probably heard of sleep apnea, and if you haven’t already, chances are you will.  Sleep apnea is a common disorder that affects one in five adults, afflicting more men than women.  What many don’t realize is that sleep apnea can lead to serious health issues, even death, if left undiagnosed and untreated.

What is sleep apnea and how could it affect my health?

Simply put, sleep apnea is a disorder that affects breathing during sleep.  The condition is characterized by abnormal pauses in breathing (apneas) or abnormally low breathing during sleep. The pauses can last anywhere from ten to thirty seconds and upward to as many as four hundred per night or more, in those with severe sleep apnea. 

Sleep apnea has many possible causes. The most common type of apnea, called Obstructive Sleep Apnea (OSA), occurs when there is a physical blockage of airflow.  People who are overweight are at an increased risk of OSA, often caused by physical obstructions in the mouth and throat. During sleep, when your soft palate and tongue muscles are more relaxed, this soft tissue can collapse and cause the airway to become blocked.
 
If left untreated, OSA can cause serious long term health issues including:

• High blood pressure.  If you already have high blood pressure, sleep apnea can make it worse. When you wake up often during the night, your body gets stressed. That makes your hormones go into overdrive, which boosts your blood pressure levels. Also, the level of oxygen in your blood drops when you can’t breathe well, which may add to the problem.

• Heart disease.  People with OSA are more likely to have heart attacks.  The causes may be low oxygen or the stress of waking up often. Strokes and atrial fibrillation -- a fast, fluttering heartbeat -- are also linked with the condition. Sleep apnea disrupts how your body takes in oxygen, which makes it hard for your brain to control how blood flows in your arteries and the brain itself.  People with sleep apnea aren’t just sleep deprived; they’re also oxygen deprived.

• Weight gain.  Extra weight increases your chances of getting sleep apnea, and the condition also makes it harder to slim down.  OSA can also make your body release more of a hormone called ghrelin, which makes you crave carbs and sweets.  When you're tired all the time, you might not be able to turn the food you eat into energy as efficiently, which can lead to weight gain. 

• Type 2 diabetes.  Sleep apnea is common among people with Type 2 diabetes.  Untreated OSA results in increased levels of cortisol, the hormones that are released in response to stress.  Prolonged exposure to elevated levels of cortisol leads to hyperglycemia or elevated blood sugar levels.  OSA has also been linked to insulin resistance, a precursor to diabetes.

• Depression and anxiety.  When your body releases large amounts of stress hormones such as cortisol and adrenaline while asleep, this can cause or exacerbate conditions such as depression and anxiety.

What are the symptoms of sleep apnea?

Individuals with OSA are rarely aware of having difficulty breathing. In fact, the problem is often recognized by the person’s significant other. Patients suffering from OSA frequently feel fatigued during the day and report daytime sleepiness. Additional symptoms of sleep apnea may include:

• Loud snoring
• Waking up with a sore or dry throat
• Occasionally waking up with a choking or gasping sensation
• Sleepiness while driving or sitting as a passenger in a car
• Morning headaches
• Restless sleep
• Forgetfulness, mood changes, and a decreased interest in sex
• Recurrent awakenings or insomnia

How is sleep apnea diagnosed? A polysomnogram is the most common sleep study for diagnosing sleep apnea.  This study records data such as brain activity, hear rate, oxygen concentration in your blood, air movement, snoring level, blood pressure, and eye movement. While traditionally this required patients to spend the night in a sleep center to undergo a sleep study, today many patients are able to undergo a home sleep test, in their own home, in the comfort of their own bed.  The results are then reviewed by a sleep specialist, who will review the data collected during the sleep study and make a diagnosis.

What are the treatment options for sleep apnea? Treatment options for those suffering from OSA vary a great deal, from conservative to invasive surgical treatment. If you’re overweight, the best place to start is a lifestyle change including healthier eating habits and daily exercise. If you are not overweight or weight loss alone doesn’t help resolve your condition, your physician may recommend any of the following treatments:

• Continuous Positive Airway Pressure device (CPAP).  This is a machine that keeps your airway open during sleep by delivering a continuous flow of pressurized air into the throat.  CPAP requires the use of a mask that is connected to the actual machine.  If you use CPAP to treat your OSA, you must use it every night.  If you don’t, your symptoms will return right away. Many use CPAP with great results, but others can’t get used to wearing a mask while sleeping, even after making adjustments or changing to a different style of mask. Also, using CPAP means you must travel with it on trips or any overnight excursions.  For these reasons, many prefer an alternative treatment solution.
• Custom oral appliance.  A custom-fit oral sleep appliance is an effective treatment option for OSA and snoring.  Worn only during sleep, the oral appliance fits like a sports mouth guard or an orthodontic retainer and supports the lower jaw in a forward position to help maintain an open airway. Many patients prefer oral appliances because they are effective, non-invasive, comfortable, quiet, portable, convenient for travel, and easy to maintain.  If you and your doctor decide that an oral appliance is your best option, a qualified dentist can create the appliance for you.
• Surgery.  When other treatments have failed or you decide not to use other treatments such as CPAP or a custom appliance, your doctor may recommend surgery. There are many surgical options for the treatment of OSA, such as uvulopalatopharyngoplasty (UPPP), genioglossus advancement, hyoid suspension, and jaw surgery. The goal of all these procedures is to allow air to move through the throat more easily when you breathe, thereby reducing the severity of OSA.  Although typically a last resort to treat sleep apnea, surgery can offer a long-term solution and with a high success rate. 

Who should you see for the diagnosis and treatment of sleep apnea?

In most case, it’s your primary care doctor (i.e. internist) who will recognize the symptoms and refer you to a sleep specialist for a sleep study and diagnosis.  For treatment, most sleep specialists will provide you with a CPAP machine. If you prefer an oral appliance, a sleep specialist may have you see a dentist or an oral surgeon they work with.

Another option for treatment after you receive your diagnosis is to see an oral surgeon who has experience treating OSA.  While an oral surgeon does not usually prescribe or sell CPAP machines, they do specialize in the mouth, head, neck and facial bones, so they are well-versed in treating OSA with custom oral appliances or surgery.  So, if your preference for treatment is an oral appliance or surgery, a reputable and board-certified oral & maxillofacial surgeon is a good place to turn.

Is sleep apnea treatment covered by medical insurance?

The short answer is YES -- both sleep studies and treatment are covered by almost all insurance plans.  However, as with any health-related matter, some insurance plans have different guidelines. You should always check to see your plan’s requirements and criteria.

Don’t let sleep apnea ruin your life!

With insurance coverage readily available for diagnosis and treatment, there’s every reason to see your doctor and start to sleep soundly and wake up healthy, happy and refreshed!

Ruben Cohen, D.D.S. is a Diplomate of the American Board of Oral and Maxillofacial Surgery.  Dr. Cohen is the founder of Park Avenue Oral & Facial Surgery, P.C., located in the Upper East Side of New York City.  He was named in 2017 by The New York Times Magazineas one of the top 20 oral surgeons and “Super Specialists” in New York City – selected by his peers.  For more information on Dr. Cohen’s sleep apnea treatment options, including custom oral appliances and surgery, please visit his website at www.ParkAvenueFaces.com.

WEALTH TIPS

COLLARS - Collar Your Stocks To Limit Losses For No Cost

By

Richard Gray and Gary Smith

• Are you sitting on significant capital in stocks and etf’s?
• Are you concerned about a potential 40% drop in the market and your assets?
• Do you not want so sell your stocks because of taxes and the chance that you would miss the upside potential of your well picked stocks?
• Are you willing to challenge your financial advisor or broker to limit your potential losses using put and call options in a “collar”?

Buying a put and selling a call on a stock or ETF that you own is a classic way to limit your risk of loss in a market crash with a reasonable cap to profits at a net cost of near zero.  It takes some effort to implement and is best when set up for a 1 to 2 month period and then re-evaluated.  You also may be forced to sell your stock, take profits and pay taxes if it goes up too much.
 
If your investments are managed by a broker or financial advisor you will need to specifically ask them to do this for you as it takes time and attention on their part – once a month or so.  The reason that most financial professionals justify not doing this is probably that they espouse a belief in the recovery of markets in the long term.  However, there is a lot of discomfort when your assets drop 20 to 40% or more in the short term. 
 
This is why I am much happier to be controlling some of my risk of loss in today’s volatile market.
There are many websites that describe the details of picking the puts and calls to buy / sell.  Search “Writing Stock Collars” and enjoy the exploration.  Once you get some understanding ask your broker or financial advisor about it.

An example of an actual collar done on March 13, 2018 in a taxable no-trading-fee brokerage advisory account is: (It is important to be aware of trading fees for puts and calls as they can be substantial and can be on both the opening and closing transactions.  They can also be small or included in an account for which you pay an advisory fee.) 

Each contract below is for 100 shares of Oracle common stock.

On March 13 Oracle Corp (ORCL) was trading at (about) between $52.20 and $53.40 a share – an average price of $52.80.

• 10 contracts of $55 calls expiring April 20, 2018 were sold for $740, 3% to 5% above the price that day.  Note this is a covered call as you must own the stock you are selling the call on.
• 10 contracts of $50 puts expiring April 20, 2018 were bought for $740, 4% to 6% below the price that day.
• A net cost of zero dollars.

Let’s explore the coverage of this collar and possible outcomes:

1. If on April 20 the stock is between $50 and $55 a share the options expire and coverage ends with no additional fees.  You still own your stock, and you slept easy for a month.
2. If the stock goes significantly above $55 a share before April 20 it may be exercised and you would have to provide the stock from your account at $55 a share. You would have to pay taxes but could immediately buy the stock back at its current price – say $57 .  At any time you could buy the options back at the current price.  You have sold your stock after a 5% gain in a month, not too shabby.&nbsp
3. If the stock is above $55 a share on April 20 you have a choice of buying the options back at the current price or (automatically) delivering your stock at the end of the trading day.
4. If the stock is below $50 at any time before April 20 you could sell your put at a profit, ending your downside protection and keeping your call in place and keeping your stock.
5. If the stock is below $50 at the end of the trading day on April 20 you would automatically receive the difference between the current price, say $45 and $50 per share.  You would keep your stock and the payment would reflect the drop in price.  At $45 for 10 options you would receive $5000 in coverage. 
6. All option transactions are short term capital gains or losses, fully taxable in taxable accounts and not taxed in retirement accounts.&nbsp
7. If the stock doubles because it is being taken private, you only make 5%. Sorry. 

April 20 you would decide whether to open a new collar at the then current price.
If you are new to options this may sound a bit daunting. However, you can start with small amounts of coverage.  Also your broker or planner should have people to call upon to make sure it is done right.  I think this is a good test of your professional’s commitment to your risk tolerance and to protecting your assets in these volatile times.  Also you may find out the limitations of your relationship and become aware of where you incur added trading costs. 
 
Please note that this article was not written by a financial professional.  It is most important that you do your own research and consult with your financial professional. 

And here is a comment from a Financial Professional reviewer

I am very well aware of the collar strategy, and I share the anxiety about the possibility of a sharp market drop. As your friend notes, the significant question for the potential employment of this strategy is tolerance for risk.  At the age of 75, I have no tolerance for risk. I am a conservative investor who harvested all my tax losses and invested heavily in the FANG stocks when the bottom fell out of the market in the late winter of 2015, keeping a large cash reserve.  I now have raised another cash reserve that I hope to expend on puts expiring just before the November election.

I love ETFs. They are a cornerstone of my core-and-satellite. Collar your stocks to limit losses for a no cost strategy.  I am looking at sectors like small cap stocks that I think are the most vulnerable in this environment.  This would be the centerpiece of my bearish strategy, but I wouldn’t be averse to using collars as well.

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