Sleep Apnea 101: Symptoms, Risks & Solutions with Aparna Bhat, MD

Podcast Transcript

John Horton:

Welcome to another Health Essentials Podcast. I'm John Horton, your host.

Have you ever woken up in the middle of the night, gasping for air like you're choking or drowning in your sleep? It's unsettling, to say the least, and it happens to far more people than you might expect. This frightening moment is a telltale sign of a very common condition known as sleep apnea. Today, we're going to learn a little more about this condition and why it's so important to address. Sleep medicine specialist Aparna Bhat is with us to break it all down. Dr. Bhat is one of the many experts at Cleveland Clinic who bring their knowledge and expertise to our weekly chats. So with that, let's find out why we sometimes struggle to breathe in our sleep. The answer might help us rest a little easier tonight.

Welcome to the podcast, Dr. Bhat. I am so glad that we were able to get you on the guest list.

Dr. Aparna Bhat:

Thank you so much for having me.

John Horton:

So when it comes to sleep apnea, the stats are pretty eye-opening. I read a study where researchers estimated that there are nearly 1 billion people around the world — 1 billion — that have the condition. It's no wonder that some people refer to sleep apnea as an epidemic.

Dr. Aparna Bhat:

No, you're absolutely right. It's staggering. The number is nearly a billion people worldwide. And in the U.S., it's actually estimated to be about 83-84 million adults over the age of 20 with obstructive sleep apnea. So to put things into perspective, it's 1 in 5 individuals with at least mild sleep apnea and 1 in 15 with moderate to severe.

John Horton:

And I'm guessing that a lot of people who have it don't even realize it.

Dr. Aparna Bhat:

Yeah. Like you said, it's like an epidemic, and it's a highly prevalent issue, but it's definitely underdiagnosed and under-recognized even.

John Horton:

All right. Well, we're going to recognize it a little bit more today. That's why you're here. So I guess for starters, can you walk us through what sleep apnea is and what's happening in our bodies when we have these symptoms at night?

Dr. Aparna Bhat:

Sure. So obstructive sleep apnea is something that happens at nighttime, of course, when you're sleeping, and it's repeated pauses in your breathing while you sleep. And they're either called apneas or hypopneas. Basically, that means blocking or narrowing of the upper airway or the windpipe. So basically, this part of the body that we're worried about when you're sleeping.

John Horton:

Is it because of how you're lying? Does it just kind of kink it a little bit?

Dr. Aparna Bhat:

Yeah. So essentially, when we sleep, especially when we sleep on your back, gravity plays a role, and all of our muscles kind of relax. And when we're awake, that doesn't matter. It doesn't make a difference. All of our muscles are activated and fully functional. When we're sleeping, our body's meant to relax, and in that process, it results in the airway either narrowing or blocking completely.

John Horton:

Yeah. That seems like a design flaw.

Dr. Aparna Bhat:

And so why we worry about that is because not only do you get unrefreshing sleep — because when your airway blocks off, you repeatedly wake up throughout the night and they may not be conscious awakenings — but really what concerns us is the oxygen levels dropping, carbon dioxide levels rising, your blood pressure rising as well. So a lot of heart health consequences and mental health consequences, too.

John Horton:

Now, I know we always talk about sleep apnea as kind of like it's one thing, but there are different types of sleep apnea that people deal with, correct?

Dr. Aparna Bhat:

Yeah. Typically, we think of obstructive sleep apnea, which is the upper airway and the windpipe, again. And the other type of sleep apnea that we can see is something called central sleep apnea. And this is the way our brain reacts to changes in carbon dioxide, oxygen and the pH in the body. And not everyone has this type of central sleep apnea, and there are several different types of them as well, but these are the major two types of sleep apnea that we see.

John Horton:

All right. And it sounds like obstructive sleep apnea is the main one. When most people talk about it, that's what they're kind of referring.

Dr. Aparna Bhat:

That's what they're referring to. Yeah, exactly.

John Horton:

Now, in the opening, we kind of mentioned how sleep apnea can wake you up pretty suddenly at night, and you're gasping for breath and all that, which is a pretty dramatic symptom. What are some other signs of the condition that people might notice?

Dr. Aparna Bhat:

Yeah. So as you said, the most dramatic symptom is snoring. The other ones that people typically come in with are waking up choking or gasping for breath.

John Horton:

Yeah, that's a big one it seems like.

Dr. Aparna Bhat:

Yeah. Witnessed apneas or witnessed pauses in breathing. And this is typically a loved one mentioning that, "Hey, John, you stop breathing in your sleep."

John Horton:

I've heard this. I'm thinking I have some sleep apnea going on.

Dr. Aparna Bhat:

The other thing is, people can wake up with their heart racing or pounding as well in the middle of the night. So those are the most dramatic symptoms. But the other ones that people can experience are insomnia. So patients can have trouble falling asleep or staying asleep. They can have multiple awakenings. Frequent urination is another one that patients don't realize as well. Mood changes. So mental health can really be impacted. If you're not sleeping well, anxiety, depression can be worse, and then anxiety, depression can make sleeping trouble worse, too.

John Horton:

I'd imagine just being fatigued all the time, too. If you're getting your seven to nine hours of sleep at night and you wake up and you just don't feel refreshed, it could be a sign that maybe you're not taking in enough oxygen all night.

Dr. Aparna Bhat:

Yeah. And you're just not getting good quality sleep through the different stages of sleep.

The other things that we might consider, our pain can be poorly controlled. So chronic pain patients, or headaches, migraines, can also be impacted as well. So a lot of different symptoms. And then of course, daytime sleepiness. If you're sleepy throughout the day, then your quality of life is impacted as well. So patients can feel really drowsy and sleepy, falling asleep during a meeting or falling asleep in the waiting room. These are all questions that we ask patients while we're assessing them for possible sleep apnea.

John Horton:

And just going over that list, it makes you realize why people might not realize they have sleep apnea because most of those symptoms you just brought up can all be related to other things. I mean, they're really pretty benign. So you don't necessarily just tie them to, "Oh, I'm having trouble breathing while I sleep."

Dr. Aparna Bhat:

Right, exactly. And so as a sleep physician or a sleep provider, we tend to do a little bit of investigative-like work. We're trying to figure out how is the individual's mood, what else is going on in their life? Could there be an organic cause for this, such as vitamin D deficiency or thyroid dysfunction? So it is a little bit of investigative work because there are a lot of things that can present with daytime sleepiness and fatigue and trouble with their breathing at nighttime, such as asthma, even.

John Horton:

Now, we've kind of gone over a lot of these symptoms, and they seem a little more kind of on the edges, like you're fatigued, you're a little moody, things like that, but there can be some pretty serious health consequences that come out of sleep apnea, too.

Dr. Aparna Bhat:

Yes, yes, absolutely. And it makes sense, right? Sleep, and good quality sleep, is such an integral part of our lives. It's no wonder that it's going to have heart-health consequences or cardiovascular consequences as well. And so that's what we really, truly worry about. Patients with sleep apnea can have an increased risk of heart attacks, strokes, irregular heart rhythms, such as atrial fibrillation, and it can also impact blood pressure control for patients, and it can control blood sugar control for patients as well.

John Horton:

Wow. I would not have thought that. The other ones I was kind of, OK, yeah, that all makes sense. How does it affect blood sugar?

Dr. Aparna Bhat:

So it just increases insulin resistance essentially. And so not only does that impact diabetes, but it also impacts hypertension through different pathways. So really, you need good sleep.

John Horton:

And I think sleep is one of those things that we all overlook. And the reality is, we spend about a third of our day sleeping. So how you're doing it is really pretty important.

Dr. Aparna Bhat:

Absolutely. No, yeah, I think that in this day and age, too, everyone is always keeping busy and not prioritizing sleep, but it's really important. Like you said, a third of our lives are spent sleeping. We might as well do it with good rest as a result.

John Horton:

All right. When we're looking at sleep apnea then, what are the causes? I mean, I know it's not just happening in a vacuum. So what are some of the things that might trigger this?

Dr. Aparna Bhat:

Yeah. So when we think about sleep apnea, again, we're thinking about this oral-facial area, as well as the upper airway or the windpipe. So what we see is that the muscles at the back of the throat and in the mouth just relax and they fall down and collapse the airway either completely or partially. Some of the things that impact that are the oral-facial factors. So a smaller jaw size called retrognathia, maybe a smaller mouth cavity with a narrow hard palate or roof of the mouth. Then, we think about a larger tongue size, and we also think about tonsils, but more so in pediatric patients, and we think about neck size or neck circumference. So we know that for men, a neck circumference of 17 inches and greater, and for women, 16 inches and greater, can increase the risk of obstructive sleep apnea. So if you think about it, obesity can also impact sleep apnea, but so can genetic or things that we are getting from our parents.

So hereditary factors, such as the shape of our jaw, the shape of our face, those are all going to impact the risk for sleep apnea.

John Horton:

I always like knowing I can blame the folks for stuff every now and then.

Dr. Aparna Bhat:

It makes sense. Genes make us who we are, so it only makes sense that those factors are also going to impact sleep apnea.

John Horton:

Obviously, there's not much you can do about the way your jaw is aligned or things like that. It seems like that's just something it's kind of luck of the draw. I read somewhere, too, that if you have certain medical conditions, if you have high blood pressure, things like that, that may make you more prone to sleep apnea?

Dr. Aparna Bhat:

One of the things we think about is uncontrolled blood pressure and the way that it impacts fluid buildup in the body. And so when that happens, especially when we sleep and lie flat on our back, the fluid kind of shifts, and it can shift to increase the swelling in this area. And so if you're increasing the swelling in the tissues in the airway, then that narrowing or the blockage only gets worse. So absolutely, like uncontrolled blood pressure, sometimes secondary causes of hypertension or high blood pressure with high aldosterone levels can also contribute to that swelling.

John Horton:

There's so much going on in the body.

Dr. Aparna Bhat:

There's so much going on, yeah. There's so much interplay.

The other thing that we think about is stroke. So patients who do have a history of stroke with parts of the brain that are impacted, like with swallowing and the breathing muscles and the throat muscles, those are also patients who might have an increased risk of sleep apnea as well.

John Horton:

So it sounds like, I mean, there's a whole bunch of factors that can kind of come into play and make you maybe more likely to have sleep apnea.

Dr. Aparna Bhat:

Yes, absolutely. Yeah.

John Horton:

Well, clearly nobody wants to stop breathing at night. I mean, we kind of need that oxygen going in and out. It's kind of essential for the whole living thing. So what can we do about sleep apnea so that way, we don't have to worry when we close our eyes at night?

Dr. Aparna Bhat:

Yeah. And there's a lot to cover here. I think the first thing is to establish that you have symptoms and establish that you have the diagnosis. So we can test for sleep apnea with two modalities, one being a home sleep study or an in-lab study that's called a polysomnogram. And more typically, we order the home sleep study, especially when we have this high suspicion of obstructive sleep apnea. We know that it can tend to underestimate the severity of sleep apnea, but it's a more accessible test. It's easy to do in the comfort of your home. And essentially, it's a type of nasal cannula or tubing that detects the flow of air. Then, you have a chest and a belly belt that assesses breathing efforts and assesses positioning as well. And of course, a pulse ox or an oximeter that measures your oxygen levels when these episodes of sleep apnea are happening.

John Horton:

Is that just one night you wear that or is that something that-

Dr. Aparna Bhat:

...typically, it's one night. There are some places that might do two nights and get an average of those, but typically, it is a one-night study, and you send it right back by mail.

The second option is an in-lab sleep study called a polysomnogram, and this is a little bit more involved. You have a lot of EEG leads, and these are leads that are placed on the scalp so that we can detect whether your brain is awake or asleep. We have EMG or muscle detection around the eyes, around the chin, and around the arms, sometimes, the knees as well. And then, of course, the chest and the belly belt, which is the same as the home sleep study. And then, the nasal cannula type of tubing device that detects the flow of air in and out.

John Horton:

So all of that then can kind of tell us whether or not we have sleep apnea or maybe how serious it is because you can see then the oxygen flow and everything that's coming in and out. Once we get that answer... Yeah, oh, go ahead.

Dr. Aparna Bhat:

Yeah, no, I was going to say, and when it comes to treatment, I think assessing or considering the severity of sleep apnea and then the burden of symptoms and the health effects is the next step.

John Horton:

Well, let's start walking through some of that, how we might be able to address it, how we can maybe tamp those symptoms down so we can sleep a little better. So what would you recommend for folks?

Dr. Aparna Bhat:

Yeah. So I want to just recap that, interestingly enough, the severity of sleep apnea does not always correlate with the severity of symptoms. OK. Treatment of sleep apnea is really dependent on symptoms. And typically, when we think about treating mild sleep apnea, which is five to 15 episodes an hour, we consider the patient's clinical setting. So are they having daytime sleepiness? Are they having troubles falling asleep or staying asleep? Are they having any mood issues or anxiety, depression? We also consider, do they have hypertension or high blood pressure? Do they have atrial fibrillation, a history of a stroke? These are all important things to consider when initiating treatment for sleep apnea.

John Horton:

I'm stuck on that 15 episodes an hour. It makes you realize how detrimental it really is to sleep.

Dr. Aparna Bhat:

Yeah. It's repeated episodes, which, really, yeah, it makes a huge difference.

And so positional therapy is one of the kinds of easier treatments for patients, and it's essentially, you are adjusting your sleep positions so you don't sleep on your back.

John Horton:

OK. Positional therapy sounded fancy, so just sleep a little different.

Dr. Aparna Bhat:

And really, it's using a sleep pillow or a sleep trainer, or some people even use a tennis ball to prevent themselves from sleeping on their back, and they just sleep only on their side.

John Horton:

So if you have sleep apnea, you don't want to sleep on your back because, I know, often, it seems like sleeping on your back is usually a recommended way to sleep, but it sounds like, if you have sleep apnea, it could constantly-

Dr. Aparna Bhat:

…you might avoid it. Yeah. You might avoid it. Absolutely. So there are ways to treat with positional sleep apnea, and for some patients I might recommend this.

John Horton:

Is one side better than the other? Because it sounds like you should sleep on your side.

Dr. Aparna Bhat:

No. Yeah, any side. Sometimes, sleeping on your stomach could be an option as well. And the next one is weight loss. So like I mentioned, there is a correlation, or association, between obesity and sleep apnea. And we know that with 10% weight gain, there's an associated sixfold increase of sleep apnea risk. So it only makes sense that losing weight is going to reduce the overall sleep apnea index. It also reduces the blood pressure and can improve overall quality of life. So the estimates are: Losing 10% of weight can improve sleep apnea by about 25%, 30% or so.

John Horton:

Oh, wow. That's a pretty dramatic effect.

Dr. Aparna Bhat:

And what happens is, when you lose weight, you lose weight around your neck as well and inside the windpipe. And so typically, what this does is it may not completely get rid of the sleep apnea, but it might reduce the severity down to a more mild to moderate range.

John Horton:

Well, because it sounds like, I mean, we're dealing with a very narrow area anyway. So anything you can do to keep that expanded and keep that air flowing is going to help.

Dr. Aparna Bhat:

Correct. Yeah, exactly. And the landscape of weight loss has really changed with the GLP-1s on the market. So we can't talk about weight loss and sleep apnea without talking about Zepbound® or tirzepatide. And so this is one of the newer GLP-1 receptor agonists. I can't say new, but it was FDA-approved in 2024 for the treatment of moderate to severe sleep apnea. So that's 15 episodes of sleep apnea an hour or greater and obesity. So the original studies really showed that Zepbound or tirzepatide resulted in roughly a 20% weight loss, and that's what reduced the sleep apnea severity. So the treatment approval was based on weight loss essentially, and how weight loss helps with the sleep apnea severity.

John Horton:

So it sounds like GLP-1s can be prescribed because of sleep apnea?

Dr. Aparna Bhat:

Correct. Yeah. So Zepbound, especially, it's the only one that is approved for both obesity and sleep apnea together.

John Horton:

Wow. See, I would not have thought that, but then, that link is there. So it does make sense, where if you can address that, some excessive weight issues, you can just sleep better, get rid of sleep apnea, and then hopefully, everything else mellows out, too.

Dr. Aparna Bhat:

Correct.

The next one is actually an oral appliance therapy or mandibular advancement device. Essentially, it's a bulkier version of a retainer or an Invisalign®. So a custom-fitted retainer, you could say, that is created by a sleep dentist for you. And when it's worn at nighttime, it juts the lower jaw forward so that it opens up the windpipe or the airway while you're sleeping. And so when it opens up the airway, you prevent the episodes of sleep apnea. So I do offer this as a first-line treatment for patients who have mild to moderate sleep apnea, and there is still good data for the heart-health benefits and improvement in daytime sleepiness. So this is something that's a good option for patients who have anywhere between five to 30 episodes of sleep apnea.

John Horton:

And it sounds like this mouthpiece then, it addresses some of those structural issues that you were talking about with maybe how your jaw is just ... how it formed, how it is and just kind of keeps everything lined up to keep the windpipe open.

Dr. Aparna Bhat:

The limitation is your TMJ. So you can't treat very severe sleep apnea, which is why we typically recommend it for mild to moderate because we know there's that physical limitation of pushing the jaw forward or jutting it forward.

John Horton:

That seems like a pretty simple way to go about it and an easy way to kind of get a fix.

Dr. Aparna Bhat:

Yeah. I would recommend seeing a specialized sleep dentist. It can take a couple of months to get adjusted, and you want to be mindful of your alignment of your bite, as well as TMJ pain.

John Horton:

Right. This isn't where you're just running to the store and getting that mouthpiece we all used to get for football. You need something pretty specialized.

Dr. Aparna Bhat:

Yeah, absolutely. Yeah. No.

John Horton:

I know the one thing we're all kind of familiar with, or we've heard about, are kind of those CPAP machines or things like that. How do those kind of work their magic at night to keep the breathing going?

Dr. Aparna Bhat:

So positive airway pressure or PAP therapy, there's two major types of devices that we think about: continuous positive airway pressure or bilevel positive airway pressure. And colloquially, it's CPAP or BiPAP. It is the gold standard of treatment for sleep apnea, and that's for two reasons: A, it gets to the root issue, right? Your windpipe is blocking off or trying to close off and the positive airway that's applied is stenting this airway open so that it doesn't have a chance to collapse.

John Horton:

So it's just pushing air in to keep everything going.

Dr. Aparna Bhat:

Dented open. Yeah.

John Horton:

Like blowing in a balloon.

Dr. Aparna Bhat:

Blowing in a balloon, exactly. Yeah. And it has the most data regarding the heart health benefits. So PAP therapy or CPAP, BiPAP, it pushes pressured air, not oxygen, to stent the airway or windpipe open. And by doing so, it normalizes the oxygen. It improves the carbon dioxide levels as well, improves blood pressure and limits the nighttime awakening. So really good symptom benefit.

John Horton:

How bulky are those machines? Because I have an image in my head and I don't know if that is like a dated image or something that just came out of sitcoms or whatever, but what does that look like when you're using it at night?

Dr. Aparna Bhat:

Yeah. I mean, the smaller travel ones might be about this big.

John Horton:

So that's pretty small. The size you're doing is what roughly ... I mean, that's smaller than a loaf of bread.

Dr. Aparna Bhat:

Yeah, about this big. So about 10 inches and the height is about five inches tall, not terribly big.

John Horton:

Now, what's on your face? Because I always think there's a lot on your face.

Dr. Aparna Bhat:

Yeah. So masks are always the bane of existence for patients, but really, there are four major categories that we think about for masks. One is over the nose, so covering the entire nose or just under the nasal. That's called the nasal mask. The one under the nose that go into the nostrils is called a nasal pillow. There are full face masks. Those are the traditional ones that people think about, and they get this worry that it can be claustrophobic that's going over the bridge of the nose and under the mouth.

John Horton:

Seems pretty intense. Yeah.

Dr. Aparna Bhat:

And then there are hybrid full face masks that go under the nose and over the mouth.

John Horton:

So you can probably find one that's going to fit you pretty well and you're comfortable with.

Dr. Aparna Bhat:

Exactly. Within those four categories, there are many different options from different companies that I always counsel patients that it takes a trial of two to three masks before finding just the right fit.

John Horton:

Yeah, I'd imagine. And then, just because anything that is on you at night, it can feel uncomfortable. So I'd imagine it does take a little getting used to.

Dr. Aparna Bhat:

Yeah. It does take a little getting used to, but you'd be surprised. I have some patients that, in the end, tell me, "I can't sleep without this thing, and I will not have a good night of sleep at all if I don't wear my CPAP."

John Horton:

Yeah. Now we went over the GLP-1s. Are there any other medications that kind of come into play?

Dr. Aparna Bhat:

Yeah, there are some medications, but nothing in the market just yet. They're still under research at the moment. So nothing that's on the market, that I'm aware of at least. There are some medications that we might use for daytime sleepiness such as modafinil or armodafinil or some of the amphetamine, like Ritalin® or Adderall®.

John Horton:

And it sounds like as a last case scenario, if things are really bad, there are surgical options?

Dr. Aparna Bhat:

Yes. Yeah. So there are two surgical options that we associate with sleep apnea, and this is for adults. One is an upper airway surgery called a UPPP or a uvulopalatopharyngoplasty. And essentially, you're removing the excess tissue in the throat in order to keep the airway open and prevent any extra tissue in there from falling back and closing off. Unfortunately, the results are fairly inconsistent. So the treatment has fallen out of favor.

The second one that a lot of people see on TV or ads about are the hypoglossal nerve stimulator or Inspire™. And this is a surgically implanted pacemaker that's placed under the skin about this big.

John Horton:

OK, small. Yeah, like a deck of cards, it looks like. Yeah.

Dr. Aparna Bhat:

Yeah. It's maybe even smaller than a deck of cards, and one wire that comes from the pacemaker that detects each breath, and it's connected to the muscles between the ribs. There's another electrode or electrical wire that goes to the hypoglossal nerve, and that's the nerve or the electrical supply to your tongue. So when the device is turned on at nighttime, each breath that is detected results in your tongue jutting forward or pushing forward. And when that happens, it's effectively opened up the airway.

John Horton:

That is wild. I did not realize my tongue had an electrical supply.

Dr. Aparna Bhat:

Well, all muscles have electrical supply, including your heart. So it's interesting, and there are adjustments that are made to it. So we increase the voltage in order to increase the strength of the muscle or tongue muscle pushing forward.

John Horton:

Such fascinating stuff.

Dr. Aparna Bhat:

Yeah. I will say the data that we have right now is that we know it helps with the sleepiness of sleep apnea, but the studies regarding heart-health benefits are still pending.

John Horton:

And it sounds like with those last options we just went over, that's pretty much after you've exhausted a lot of those other things we had talked about and they're just not working.

Dr. Aparna Bhat:

Yeah. Inspire or hypoglossal nerve stimulation is not first-line. And so there is a process, in terms of individuals, have to have a trial of CPAP. They have to, at least for three months, they have to not have a lot of central sleep apnea as part of their diagnosis. And they have to undergo something called the DISE, or a DISE procedure, that's a drug-induced sleep endoscopy where an ENT physician looks at how the airway collapses while you're sleeping. So it is a process before individuals can proceed with having the Inspire implanted.

John Horton:

Wow. Well, I got to tell you, we've covered a lot of information here, Dr. Bhat. And to be honest, I know I've heard enough here to go, I may have some mild sleep apnea. My wife might argue it's a little more than mild, but I'm guessing other people might feel the same way after hearing some of this information. If you're seeing yourself in this and you want to do something, how do you go about getting help? What's the first step you should take?

Dr. Aparna Bhat:

Yeah. So most importantly, good quality sleep is important. So kind of listen to your body. If you're feeling tired or sleepy, dig deeper. Try to understand why that could be happening. Could it be your sleep schedule? Are you getting insufficient sleep? Could it be snoring or gasping awake like sleep apnea? Could it be restless leg syndrome that's affecting your ability to fall asleep? Could it be chronic insomnia related to undertreated anxiety, depression, life stressors? So sleep is such an interesting topic. It's multifaceted. It really takes a while to understand an individual's sleep.

And then go to your primary care provider and voice these concerns that you have, and they're able to order home sleep studies or in-lab sleep studies.

Or you can always see a sleep medicine provider or physician and we're more than happy to dig deeper and try to get you the best sleep.

John Horton:

Well, it sounds like answers are out there if people go searching for them. So that's always a good place to be.

Dr. Aparna Bhat:

Yes, absolutely.

John Horton:

Well, Dr. Bhat, I can't thank you enough for coming in today. This is just, like I said, a fascinating discussion. I know I learned a lot just about what's going on while you sleep and all these little things that can influence your breathing at night. So really appreciate you coming in, and look forward to having you back.

Dr. Aparna Bhat:

Thank you. Thank you so much for having me, John.

John Horton:

Sleep apnea is extremely common, but it's not something that should be ignored, given the health risks that come with it. Talk with your healthcare provider about your options so that you can sleep tight tonight.

If you liked what you heard today, please hit the subscribe button and leave a comment to share your thoughts. Until next time, be well.

Speaker 3:

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