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Physician executive Carlos Nunez discusses his article “Why sleep is the missing pillar in modern health care,” emphasizing the urgent need to treat sleep as essential to overall wellness alongside diet and exercise. Carlos explains how poor sleep contributes to chronic conditions, highlights the scale of untreated sleep disorders like obstructive sleep apnea, and underscores the lifesaving benefits of timely diagnosis and CPAP therapy. He also outlines how digital health tools, wearable technology, home testing, and AI-driven platforms are transforming access to sleep care, making it more personalized and patient-centered. Listeners will take away actionable strategies for improving sleep health, embracing technology, and closing the gap between awareness and effective treatment.

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Today we welcome Carlos Nunez. He is a physician executive. Today’s KevinMD article is “Why sleep is the missing pillar in modern health care.” Carlos, welcome to the show.

Carlos Nunez: Thank you, Kevin. It is a pleasure to be here.

Kevin Pho: All right, so let us start by briefly sharing your story and then talking about the article and why you decided to write it.

Carlos Nunez: Sure. So, as you mentioned, I am a physician, but as an executive in the corporate world, I do not practice clinically anymore. I was in clinical practice. I am an anesthesiologist and intensivist, but if you look on my Discord profile, it will say, “Should have been an engineer, went to medical school instead.” I am super nerdy, always just enamored by technology, and eventually shifted into industry, started working for different medical technology companies, finding ways to use technology to improve clinical care for patients. The company I work for now, for which I am the chief medical officer, is a company called ResMed. We are the largest provider of respiratory and sleep technology that people use in their homes. And it is an amazing space to be in because, as you mentioned, sleep is such an important part of human health.

Kevin Pho: All right, so before we talk about your article, I just wanted to tap into that industry side. For physicians who may be interested in getting into that health tech industry, what would you say is the single biggest piece of advice for those doctors?

Carlos Nunez: Find something that you love that is adjacent to your practice of medicine. Find the career in industry that exploits that. If I was working as a research physician at a pharma company, I would probably do a good job, but I would not be happy because that is not my passion. My passion, as I said, was technology, so finding a role within that health tech, med-tech space has become extremely fulfilling for me. When I was practicing as an anesthesiologist, I could take care of one patient at a time. As an intensivist, I could take care of ten or twenty in the ICU. But I do things today, I may make a decision that can help millions of people breathe better, sleep better, and live happier, healthier lives.

It has become an extremely fulfilling career for me. I am still involved in clinical work. The medical affairs team that I lead does a significant amount of research with key opinion leaders around the world. I am the co-author of an article that was just published two days ago in The Lancet Respiratory Medicine. So I get the best of both worlds, and I get to have a job that allows my passion to really be my career. And when you love what you do the way I do, it does not feel like work. It feels more like a calling.

Kevin Pho: Your KevinMD article is titled, “Why sleep is the missing pillar in modern health care.” Tell us about that article for those who did not get a chance to read it.

Carlos Nunez: The article is so important to me personally, but I think to physicians and also to our patients because we have three basic pillars of human health: sleep, nutrition, and physical activity. We have, and forgive the term, but in society for the last several decades, fetishized things like diet and exercise. We talk about those all the time, but it feels like now, finally, sleep is having its moment. Of those three pillars, if you do not sleep well, you do not feel like going to the gym. You do not make the right choices to pick foods that are healthy for you. As one of my colleagues likes to say, “No one craves a salad at 3:00 a.m.” When you sleep well, you are giving your body a chance to heal and recover from the day, from the stress on the physical parts of your body, but also your mental wellbeing and your brain health.

We take it too much for granted. We wear it like a badge of honor. Physicians, for example, we are used to things like internship and residency. “Oh, I am always tired. No big deal. I learned to survive on three, four, or five hours of sleep.” Well, now we know that every night that you do that, you are damaging your body, you are harming your brain, and we understand that poor sleep leads to higher risks of things like cardiovascular disease, dementia, Alzheimer’s disease, and erectile dysfunction in men. So there is so much that we still do not appreciate about sleep, and we do not emphasize it enough in many of our clinical practices.

Kevin Pho: Now despite the greater awareness that we have about the harms of a lack of sleep, why do you think so many people still accept poor sleep rather than seek help about it?

Carlos Nunez: It is interesting. As I travel the world in my job, ResMed is a global company, and we do business in 140 countries. I have had the pleasure of visiting physicians and hospitals and health systems around the world, and I am struck by what they say. A lot of it is cultural. For example, a few months ago I was in India talking to physicians in Mumbai, and in society there, a good sleep is when you are snoring and it sounds like you are just deep in sleep. But actually, a lot of those folks who are snoring that way may be suffering from a sleep disorder like sleep apnea and not sleeping well. And again, then there is that society, that hustle culture where it is like, “No, sleep three, four hours,” or the joke, “You will sleep when you are dead.” Well, you might sleep when you are dead if you do not sleep well while you are alive, because again, it increases your risk for so many comorbidities.

Kevin Pho: So tell us some of the misinformation that people are seeing about sleep disorders. I am sure we have so many things on social media that patients come to me about, but from your travels and your experience, what is the biggest misconception that people have about their sleep or lack thereof?

Carlos Nunez: A couple of things. The first is that most sleeping problems people suffer from, you know, basic, simple bouts of insomnia a few nights a week or whatever, cannot be taken care of simply. The vast majority of people who have some trouble sleeping, if they just stick to basic sleep hygiene (go to bed at the same time more or less every day, wake up at the same time more or less every day, and make sure you are sleeping in a comfortable, dark, quiet space), those simple things help so many people.

However, because problems while you sleep, including sleep disorders like sleep apnea, happen while you are asleep, you do not know. So you should listen if you have a bed partner. Listen to your bed partner or listen to your body the next morning so that you can ask your physicians questions. Why am I always tired? Why do I wake up with headaches? Why do I wake up drenched in sweat? All those different signs and symptoms of different sleep disorders.

Our colleagues, physicians, need to learn a little more about sleep medicine than we typically do in medical school. The average U.S. physician only gets a few hours of sleep medicine training in school. So if you do not go into internal medicine or sleep medicine as a fellowship, you will not get much more training. So we need to learn how to speak to our patients when they ask, how we can respond, or what are the follow-up questions we should ask. The thing that bothers me the most is a condition that I deal with, sleep apnea. I have mentioned it a couple of times, but it is a condition that affects one billion (that is with a B) humans, but eighty-plus percent are undiagnosed and untreated. It is one of the most devastating sleep disorders because it completely fragments your sleep and also deprives your tissues, including your brain, of oxygen multiple times over and over every hour. It is a condition that it seems like we are not doing enough to find those patients because they deserve treatment. They deserve the different options that are out there.

Kevin Pho: Now let us get everyone on the same page. Tell us a little bit about what exactly sleep apnea is and the consequences of sleep apnea going untreated or undiagnosed.

Carlos Nunez: Sure. So I am going to do a little play-acting here. Sleep apnea is a condition that, as I mentioned, affects a billion people, and most are still untreated. What happens when we sleep, as we all know, is our muscles relax, including the muscles in our upper airway in the back of our throat. In one out of every eight people, those muscles will collapse to the point where they obstruct the airway. It is called a condition, not a disease, because it is multifactorial, and it is also a consequence of us being human. The fact that we evolved the capacity to speak, which makes our soft palate and our tongues more flexible, makes us more predisposed to snoring and obstruction.

When you obstruct, you may go from snoring to what sounds like gagging, choking, or gasping for air. So this is what my wife would hear before I was on therapy. I would be snoring… (imitates snoring and gasping). After about ten seconds, as your oxygen saturation starts to drop, your brain has a little freakout moment. “Hey, maybe we are suffocating.” It sends a little rush of adrenaline through the body. You get that little spike of epinephrine, your heart rate jumps up, your blood pressure jumps up for a second, and you take a good deep breath. But it is not enough to wake you up most times. A sleep apnea patient like myself will stop breathing like that to where they start to desaturate multiple times an hour, every hour they sleep.

Now you asked about the consequences. Untreated sleep apnea is a very, very serious condition. There is really good research that has been published in just the last few years that shows that untreated sleep apnea increases the risk of all-cause mortality by thirty-five percent and cardiovascular mortality specifically by fifty-five percent. I alluded to things like erectile dysfunction in men, and the one that scares me the most is dementia. You can only imagine, someone with mild to moderate sleep apnea may stop breathing fifteen times an hour. That is considered mild; fifteen is when you get into the moderate range. That is a lot of suffocating. Can you imagine if every hour you sleep, every four minutes, you are suffocating? You would never tolerate that while you were awake. Imagine if you held your breath every few minutes until you turned blue and you had to live your day like that. Well, that is how you are living your night, and your brain is suffering because it is not getting as much oxygen. Then it is suffering those adrenaline rushes that spike your heart rate and spike your blood pressure over and over. It is literally just a barrage of physiologic insults that happen all night, every night. It happened to me until I was finally out of the denial phase. I was the typical doctor. “I am always tired. I can live on four or five hours of sleep.” And then my wife finally put her foot down. And yeah, so I have sleep apnea, and I sleep with a CPAP machine every night.

Kevin Pho: So how about in a primary care setting, which I practice in? Tell me the types of questions I should be asking or symptoms I need to recognize to make me suspect sleep apnea.

Carlos Nunez: So, it will never become a thing, but I always use these three letters to remind me of the three most important questions: QTS. It is the quality, the time, and the schedule. So ask patients just overall quality, “How is your sleep?” That is a good open-ended question. They will start to tell you where they think they may or may not have problems. The second, T, time: “How many hours on average do you sleep?” And then S, the schedule: “What time do you usually go to bed, and what time do you usually wake up?” It all refers back to that sleep hygiene that I mentioned earlier. That is the easiest way to help most people get back on track with their sleep.

But if you ask those questions and they deviate from typical sleep hygiene, or they mention that they are excessively tired, fall asleep at a red light, fall asleep watching TV every night, or can even fall asleep at work, those are signs. I mentioned waking up with headaches, waking up drenched in sweat, a dry throat, or a scratchy throat. Those sorts of things are all giveaways that you are not sleeping well. Maybe it is sleep apnea, maybe it is insomnia. But asking those questions, if we believe that sleep is so important and knowing in the primary care setting that time is so limited, should almost be some of the first questions that you ask. Sleep should be almost like a vital sign, if you will.

Kevin Pho: Now, way back when, whenever we suspected sleep apnea, we would do one of those overnight sleep studies in a sleep lab. But what is the standard of care now? I know that we have a lot of technology when it comes to diagnosing sleep apnea. So tell us some of the options that are available to patients today.

Carlos Nunez: Absolutely. So you are right, the in-lab overnight sleep test still exists, and it is still often used for very complicated cases where people might have a sleep disorder that is not just obstructive sleep apnea but may be mixed with central sleep apnea, or maybe they have narcolepsy. There are all sorts of reasons. But for suspected obstructive sleep apnea, the most common form, the rise of the home sleep test has been quite impressive over the last couple of decades. More than half of tests in the U.S. now are done at home. The smallest home sleep test devices are about as big as a piece of chewing gum. It is something that will sit on the end of your finger, you wrap a little Band-Aid-looking piece of tape, sleep with it for a couple of nights, throw it away when you are done, and your doctor gets all the data through the cloud and can make the diagnosis.

We also see that some of the big tech players, Apple and Samsung in particular, have announced that their smartwatches can detect sleep apnea. It is not considered a formal diagnosis, but similar to the AFib detection that we see on some wearables, it is enough of a screening and detection device to raise it with your physician. Funny anecdote: my mother, who I know has had sleep apnea for decades and refused to listen to me (because who knows, I am just the doctor that she paid for all that medical school), got an Apple Watch last year for the fall detection because she is elderly. It told her she had sleep apnea, and now she has got an appointment with her primary care physician to get a sleep test. So she did not want to listen to me, but boy, she did listen to her Apple Watch.

Kevin Pho: Now, once someone is diagnosed with sleep apnea, you mentioned a CPAP machine. Is that the only option? Do we have other modalities other than CPAP machines?

Carlos Nunez: There are multiple options. CPAP still is the gold standard. It is the one therapy that works for almost everybody every time, and it alleviates the apnea immediately. The good thing about a CPAP device, for those who think about them, you probably think about your father’s or your grandfather’s generation of CPAP devices. The new ones are much smaller, quieter, comfortable, connected to the cloud, have apps, and all of that great stuff.

But there are other options. Some people do not tolerate CPAP. There are what are called mandibular advancement devices, where they reposition the mandible forward to try and pull the tongue off of the back of the throat, the back of the upper airway. That works for some people, especially in milder cases. It is not without complications. It can cause tooth movement and jaw pain. There are implants; there are hypoglossal nerve stimulators that are implanted like pacemakers that are also an option for some people. They are expensive, and there are a lot of insurance qualifications, as you can imagine, to get a surgical procedure, but they do work for some folks. So those are sort of niche alternative therapies.

There is also a lot of discussion around GLP-1s. There is no GLP-1 with an indication for obstructive sleep apnea and obesity, but obesity is associated with a higher incidence of obstructive sleep apnea. It is not the majority, however. It is a misconception to think that most people with sleep apnea have it because they are overweight. Some do have worse sleep apnea because they carry extra pounds, but a GLP-1 can be useful to help manage weight. If you do lose weight, your sleep apnea can become less severe, and then it is easier to treat with something like a CPAP or another therapy.

Kevin Pho: Now for patients, in terms of what they should be looking out for, you mentioned sometimes their partner may describe that they may be snoring or gasping for air at night. Now what about things like daytime sleepiness, because that is a proverbial symptom that brings people in for sleep apnea? What do you think about that or any other symptoms they should be looking out for?

Carlos Nunez: Yeah, daytime somnolence and being sleepy in an unnatural way is what you really want to look out for because the good thing about people who have that symptom is that they see almost immediate relief from CPAP therapy. It is easier for someone to stay on therapy when they notice a difference. If someone is actually asymptomatic, which does happen, you can have sleep apnea for years and live with it just fine, or at least you think you do. It is harder because you are like, “OK, I have this therapy, I am sleeping with this device, or I have this mouthpiece, or we went through the surgery, but I do not feel different.” It is harder for patients to understand the benefit when they do not feel a difference.

Daytime somnolence is a really important indicator. But then I mentioned some of the others. Waking up with a scratchy throat is a sign of strong snoring and potential obstruction. Waking up with headaches, waking up drenched in sweat—that was mine. I never understood why sometimes I would just wake up completely drenched in sweat, and that was the symptom. That and, well, the bruising from my wife hitting me with her elbow, saying, “You are snoring.”

Kevin Pho: We are talking with Carlos Nunez. He is a physician executive, and today’s KevinMD article is “Why sleep is the missing pillar in modern health care.” Carlos, let us end with some take-home messages that you want to leave with the KevinMD audience.

Carlos Nunez: I think the most important one is do not sleep on sleep. Understand how important it is. Do a little bit of research if you are not familiar with the basics of sleep medicine so that when your patients ask questions, or more importantly when they do not ask questions, and you need to get to the bottom of why they might be feeling the way they do, you understand how important sleep is.

The second thing I would say is that obstructive sleep apnea is a really significant condition that is way underdiagnosed, and the misconceptions about therapy and adherence to therapy are decades old. Do not be afraid to ask the questions about sleep apnea. You do not have to send someone for an overnight sleep test anymore. They can actually, in the comfort of their own home, get a real diagnosis.

Kevin Pho: Carlos, thank you so much for sharing your perspective and insight, and thanks again for coming on the show.

Carlos Nunez: Thank you, Kevin. It is always a pleasure to hear you, and now I am on the show, so it will be a pleasure to say that I got to be a part of what is such an important resource for physicians around the world.

Kevin Pho: Thank you so much, Carlos. Take care.