Feel Better, Live More with Dr Rangan Chatterjee - #242 How To Sleep Better and Reduce Inflammation with Dr Roger Seheult

Episode Date: March 2, 2022

This week, I welcome Dr Roger Seheult back to the podcast. Roger is a medical doctor who is quadruple board certified in internal medicine, pulmonary diseases, critical care medicine and sleep medicine. As well as his clinical practice, he is passionate about teaching doctors and the public via his teaching company MedCram and his YouTube channel. In this conversation, I was keen to focus on the topic of inflammation. Inflammation is a natural and necessary biological response to injury or infection, but thanks to our modern lifestyles, it’s become a response that doesn’t always go away when it should. Chronic unresolved inflammation in the body lies at the heart of conditions such as heart disease, stroke, cancer, depression, obesity, diabetes and dementia. And in this conversation, we look at some of the best things that you can do on a daily basis to reduce inappropriate inflammation and increase your chances of staying fit and healthy. We begin by talking about sleep, and Roger explains why quantity, as well as quality, is so important. We discuss the impact that a lack of sleep can have on inflammation and what we now know about sleep deprivation and our risk of disease. Of course, if you’re someone who struggles to sleep, this knowledge can just make you more anxious and this is something that Roger and I discuss. We share some practical tips for shift-workers, new parents and insomniacs. Roger explains the connection between stress and inflammation and he shares the type of exercise that studies show is most effective in lowering stress, anxiety and fear. Finally, we discuss why it’s not what we eat but when we eat that’s key to reducing inflammation. We’re not designed to be constantly digesting food, and Roger explains why practising time-restricted eating can result in amazing improvements in inflammation, metabolism and more. This conversation is full of actionable information to empower you to take control of your health. Roger has a brilliant way of simplifying complex ideas to motivate each and every one of us into action. I think you’ll really enjoy this conversation. Thanks to our sponsors: https://www.calm.com/livemore http://www.athleticgreens.com/livemore https://www.vivobarefoot.com/livemore Order Dr Chatterjee's new book Happy Mind, Happy Life: UK version and US & Canada version Show notes available at https://drchatterjee.com/242 Support the podcast and enjoy Ad-Free episodes. Try FREE for 7 days on Apple Podcasts https://apple.co/3oAKmxi. For other podcast platforms go to https://fblm.supercast.com. DISCLAIMER: The content in the podcast and on this webpage is not intended to constitute or be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your doctor or other qualified health care provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have heard on the podcast or on my website.

We are just now finding out in the last 20, 30 years now, in terms of research, it's very solid that if people don't get enough sleep, the processes in their body are just not going to be completed that need to happen. So we talked about metabolic, we talked about cancer fighting, we talked about Alzheimer's disease. All of these things seem to be tied to a lack of sleep. Hi, my name is Rangan Chastji. Welcome to Feel Better, Live More.

Today's guest is someone who is making their second appearance on my podcast, the wonderful Dr. Roger Schwelt. Now, Roger is someone who has impeccable qualifications. He is a medical doctor who is quadruple board certified in internal medicine, pulmonary diseases, critical care medicine, and sleep medicine. And as well as his clinical practice, Roger is really passionate about teaching doctors and the public via his teaching company, MedCram, and the videos that he regularly releases on his YouTube channel. Some of you may remember Roger from episode 206,

when he came on the show to talk about our immune systems and the simple things that we can all do to improve its function. And we talked about all kinds of things, including vitamin D, food, sleep, cold therapy, saunas, and so much more. If you've not heard the episode yet, I highly recommend you take a listen at some point when you have a little bit of time. Now, feedback to that episode was absolutely fantastic. So I decided to invite Roger back for a second conversation. And this time, I was keen to focus on the topic of inflammation. Now, inflammation is a natural and necessary biological

response to injury or infection. But thanks to our modern lifestyles, it's now become a response that doesn't always go away when it should. You see, chronic unresolved inflammation in the body lies at the heart of all kinds of different conditions, such as heart disease, stroke, cancer, depression, obesity, type 2 diabetes, and dementia. And in today's conversation, we look at some of the very best things that you can do on a daily basis to reduce inappropriate inflammation and increase your chances of staying fit and healthy. We spent the first part of the conversation talking about sleep and I think you will really enjoy hearing Roger's perspective on this topic and what kinds

of things he has found to work with his patients. We talk about light exposure, the potential problems with going to bed at a time that is not aligned with our own circadian rhythm, and why we need to think about the quantity of our sleep as well as the quality. We also talk about the impacts that a lack of sleep can have on inflammation, and what we now know about sleep deprivation and our risk of disease. The one thing I was really keen to address in this episode is the potential problem doctors like Roger and I face when trying to raise awareness of the importance of sleep. That we can sometimes unintentionally leave people who struggle with their sleep

feeling anxious and worried, which in turn makes sleep even harder to come by. Roger and I do talk about this and we share some practical tips for shift workers, new parents and insomniacs. We also talk about the connection between stress and inflammation, the types of exercise that studies show are most effective in lowering stress, anxiety and fear and we finish off talking about why the timing of our food intake is really important when it comes to reducing inflammation and improving our health. The truth is that we are simply not designed to be constantly digesting foods and Roger explains why practicing time restricted eating can result in amazing improvements in inflammation, metabolism and more. I have to say that I really enjoyed talking to Roger for a second time.

This conversation is full of nuggets of wisdom and actionable information and I think that one of Roger's great strengths is his ability to communicate complex ideas with a beautiful simplicity. If you are someone who is interested in health, I am quite certain that you will enjoy listening to our conversation and that it will leave you feeling motivated, empowered and inspired. And now, my conversation with Dr. Roger Schwelt. conversation with Dr. Roger Schwelt. I think many people realize that inflammation is at the heart of many of the different conditions that we struggle with these days. Heart disease, cancer, depression, strokes, Alzheimer's, whatever whatever it is we know that inflammation often

sits at the heart and i wanted to go through with you today roger you know some simple things that people can do to try and address that that don't cost a lot of money either which i know we're both passionate about how to make health accessible to everyone but right at the start of this conversation i wonder if you could explain to people, you know, how do you see inflammation? What is it? And why is it so important? Yeah, I think probably the best way to put it in terms that a lot of people, a lot of many people can grasp what inflammation is. Inflammation, I see it as, imagine you're building a house, or imagine you're constructing a road. Inflammation in terms of that and the processes that are going on inside your body is simply the construction.

It's the hassle. It's the materials. It's all of those things that are associated with the processes that are going on in the body. Of course, it's a lot more complicated than that. But the point I want to make there is that inflammation is simply a sign that something is going on, something is a process is occurring in the body, whether it's fighting a an infection. And if that infection is not being cleared up, then that inflammation will be chronic. Imagine, imagine construction, I live in Southern California, and it seems as though there's always road construction going on here in Southern California all the time. And that's how it

feels. It feels like there's always congestion because there's blockage of the roads. If I put it in terms of the body, whether or not there's an infection, there's inflammation. Whether or not there are cells that are damaged, and those cells are being repaired by your immune system, there's going to be inflammation. And so inflammation is sort of you have this love-hate relationship with inflammation because inflammation is necessary to get things done. But you don't want to have it excessively. You don't want to have it more than you need to have. And so it's, it's a tricky situation. You want to have the inflammation that you need to have to do the things that you want to do. Like if you want to build a house, you have to have construction, something that goes along with it. But on the other hand, as soon as you

don't need it, you want it gone. And, and, and that's really important. And there are processes that we're going to talk about in this, in this podcast that are going to show how we can have these processes occur and have the inflammation go away when we don't need it so that it doesn't lead to these diseases. It just is. It's a response. As you say, it's a signal. I guess it depends. What is the context of that inflammation? What is the dose of that inflammation? And does that inflammation go away once it's done the necessary repair job? And I think often we think of these things as either good or bad. You know, I don't want inflammation in my body. It's a bad thing. It causes heart disease, cancer, Alzheimer's, strokes. But it's not that, is it? It's much more nuanced and complex than that. It's exactly right. You know, it's not this on-off switch. It's not good or bad. It's not like, this is bad. We need to get rid of it. I mean, a number of years ago,

we talked about lipids and fats and everything fat and lipids was bad but we're starting to learn now of course and we've known for a long time that certain lipids omega-3s omega-6s these are are you know essential fatty acids you need them in moderation so it's you're right it's much more nuanced in terms of the lifestyle things that we can try and focus on to help reduce inappropriate inflammation in our bodies. A framework I often use is what I call my four pillars of health, food, movement, sleep, and relaxation. Four core aspects of health that I think not only have the most impact on how we feel and how we're able to operate in the world. There are also four things that we have quite a high degree of control over. Not everyone, of course, but a lot of us do. So I thought those

four pillars might be a good way to try and look through the lens of what we can do to help reduce inflammation. I thought we might start with sleep because sleep is something you have a great deal of expertise on. How do you see the relationship between sleep and inflammation? Yeah, this is really big. So I'm a sleep certified physician in the United States. We're boarded in sleep medicine and I did some extra training to do that. I'm also a pulmonary and critical care specialist and boarded internal medicine. I have a practice to do that. I'm also a pulmonary and critical care specialist and boarded internal medicine. I have a practice, a clinic, I work in the hospital.

And so I actually see patients and treat them and they come to me with all sorts of problems with sleep. You know, sleep is, it's this sort of pigeonholed corner of medicine, but let's face it, you do this for, you know, a good eight hours a night, hopefully. And people have all sorts of problems with sleep. So where do we start with sleep? I think there are problems with sleep in terms of quantity. And there are problems with sleep in terms of quality.

And people who don't get enough sleep, it may be that they want to sleep and they're just not getting enough time. I think probably the most common problem that we see in the Western world is that people that want to sleep, but they just aren't getting enough of it. And it's because they choose not to. And, of course, there's people that will be listening to this and say, well, what about me? I want to sleep more, but I just can't fall asleep. And those are people we call insomniacs. And we can talk about ways to handle that as well, but it's complicated. So let's talk about probably the lowest hanging fruit, as I like to call it, with sleep. So sleep is a very important process. We are just now finding out in the last 20,

30 years now, in terms of research, it's very solid that if people don't get enough sleep, the processes in their body are just not going to be completed that need to happen. There are certain times of the day for each individual person that are best for sleep. And that's based on something called the circadian rhythm. Circadian rhythms is something that's controlled in the brain in a tiny little nucleus called the suprachiasmatic nucleus that controls all of the little clocks in all of the cells of your body. It's sort of the master clock. Now, we could get into some, a lot of details and a lot of specifics about how to measure where each person's clock is, But let's just start off with

the very basis. If your clock is not aligned with your body and what you're doing on a daily basis, you're going to have problems where you're going to want to try to go to sleep, but your body is not going to be ready for sleep. Now, let me tell you what probably the most common problem is with circadian rhythms. Circadian rhythms, which as I mentioned, are regulated in this superchiasmatic nucleus of the brain, get inputs from various different aspects of your life. These are what we call zeitgebers. This is a term that I don't want to use too much because it really just doesn't lead anywhere. But there are things that that are you do in your life that tell your brain what part of the day it is. And this could be, you know, just food, it could be social interaction. But the most, the most powerful input to your brain is light. And nothing has changed

probably more dramatically in the human being in the last 100, 200 years is the input of light into the human body with the advent of electricity, light bulbs, media, screens, all of these sorts of things. We have dramatically changed the amount of light coming into our eyes at specific parts of the day. It used to be that if you wanted to have light in your eyes after sunset, you had to light a candle or you have to start a fire. These were things that were, you know, pretty involved. Now it's just a flip of a switch. It's turning on the television. And the problem is, is that because of our culture, we're getting a lot of light exposure in our eyes. And as a result of that, and we can get into the details, but what this is doing is

it's telling our brain when we're seeing bright light at night, that it's actually still day. And so what that does is it delays, it pushes back, it causes our circadian rhythm to think that it's actually earlier in the day, and therefore we won't sleep until later on. And so instead of going to sleep, perhaps maybe at nine or 10 or eight or nine, because we're exposing our eyes to bright light, we're now not ready for sleep until much later in the evening. Now, of course, it would be great if we could just sleep in later. But the demands of our culture, the demands of the day require us to get up at a certain set point on an alarm clock. And so one of the first things that I would mention at low hanging fruit is that many people's circadian rhythms are delayed. And as a result of that, they're trying to go to bed and not going to bed late. And as a result of that,

is we're seeing that sleep time. So we're talking about quantity right now, sleep time is sufficiently or severely reduced. If you were to go to the United Kingdom's Sleep Association, I know in the United States where I work, we have the American Academy of Sleep Medicine. And it will show you for specific ages, what is the recommended number of hours of sleep that you should get. And for adults, it's seven to eight hours at the minimum of sleep per night. And so one of the first things we'll talk about, Rangan, is the number and amount of hours of sleep that you should get if you're able to get this. And the lowest hanging fruit there is getting at least seven hours of sleep. Now, we can talk about why that is and what's going on in the brain

and what's going on in the body, but that's the first thing that I would tee up. Yeah, well, let's do that. I mean, why is that number so important? And what is going on in the body when we get that amount? Yeah, so there are several processes that are occurring. Scientists don't know why it is exactly why we sleep in general, but we certainly are becoming much more aware of why or what happens if we don't get that sleep. So let's put it that way. There was a study that was done a number of years ago, and it always seems to be done, these kind of studies on college students, because I think they're the ones willing to do this. But what they did was they, exactly, exactly.

So what they did was they had them do something that they probably are already doing anyway, right? They're in college. So they measured hundreds of different proteins and blood tests and things of that nature after they did this, quote unquote, all-nighter. And it's very interesting because the circadian rhythm that I'm talking about is not only something that regulates sleep, but as I mentioned, it's in basically every cell of your body and tells your body when to produce things and when not to produce things. And generally, proteins have this circadian rhythm of production. And what was amazing is proteins that were not just regular proteins that are involved in the everyday aspect of your life. Some of them were, but some of them were very, very important. Glucose regulation that may have an impact on diabetes. Immune proteins that are involved with fighting cancer. All of these things were completely put out of whack by just pulling

one all-nighter. And so the question is, is that this is happening on a regular basis? Are there effects downstream? And we already know the answers to these questions. We know that people who are night shift workers over many, many years can need seven hours of sleep? I can't tell you aesthetically, philosophically why we need seven hours, but I can certainly tell you what happens if you don't have it. And when you don't have it, we see increases in perturbations in these proteins, for one. There was another study that was done that looked at what we believe is the cause of Alzheimer's disease. It's the buildup of these proteins in the brain. So when your brain is working and doing things, there's sort of toxins and byproducts, if you will, of that use during the day. And what happens at night is that these proteins and these things need to get taken away. It's kind of like you're working in a workspace, and at the end of the day, you've got to clean up. Otherwise, you're going to come back the next day to a mess. What that cleanup is, kind of like janitorial at night, is sleep. It's an interesting aspect, but if you don't get enough sleep, researchers showed

that these beta-pleated sheets, which are what these proteins were that were building up in patients just as a normal run of the day, if you didn't get enough sleep, there was a 5% reduction in the amount of clearance of these beta pleated sheets. You can imagine over a long period of time, if you're not getting enough sleep, what this is going to do to various different aspects of your body. We talked about metabolic, we talked about cancer fighting, we talked about Alzheimer's disease, all of these things seem to be tied to a lack of sleep, among other things as well. But But these are the aspects that we're talking about. And I guess a lot of that will be mediated through inflammation, because when we haven't slept well, the next day, if we measure the blood, we can see all kinds of inflammatory

markers going up, can't we? Absolutely. Yeah. So, you know, IL-6, tumor necrosis factor, these are, you'll hear these be mentioned again and again, these are surrogates for inflammation. So I don't want you to think that these markers or these inflammatory markers are innately bad. They have a role, they have a job to do. But when you see them elevated chronically over a long period of time, that's a surrogate or a signal that this is not a good situation.

Yeah. And I guess the whole, you know, the underlying theme of this conversation is inflammation. How do we prevent chronic unresolved inflammation going on in the body, which in turn is going to help reduce the likelihood that we're going to get sick as we get older. And what you're beautifully demonstrating is that a lack of sleep is going to make you more inflamed the following day. And I guess

at this point, Roger, I think it's worth just really pausing on two points because something I've learned over the past few years of trying to promote the importance of sleep is sometimes when we do this, without realizing it, we can induce anxiety in people, which I know has happened in the past. Young mothers, young parents who are unable to sleep because their kids are up, they often hear things like this and they get really panicked. Or as you say, shift workers, shift workers might hear that and go, are you saying that my job's going to increase the risk of me getting cancer? So I think if we just take a slight aside there to try and address some of those things, because we want to share information, we want people to prioritize their

sleep, lower their inflammatory burden. But at the same time, we've got to be careful, don't we, that we don't stress people who can't sleep out. Oh, I can't agree with you more. In fact, this is exactly where I was going to go next. And it seems like our minds are melded here. So 90% of what I deal with when patients come in with insomnia, and this is exactly right, is the problem of anxiety about the fact that they can't sleep. And so this is a huge problem.

So I set the groundwork and we did it very well of showing that you need sleep. But 90% of what I see with patients that come in, in the clinic with insomnia is trying to deconstruct their anxiety about their lack of sleep. Because one of the worst things that you can have when you can't sleep is to have anxiety about not being able to sleep. What happens, and we call this the three Ps in insomnia for those that can't sleep is the precipitating, or I should say the predisposing factors. So this is type A personality. Then there is the precipitating factor, which is whatever it was that caused them not to sleep, whether it was a wedding or a divorce or a gaining of a job or a loss of a job. All of these can precipitate you not being able to sleep because of stress. And then, but here's the key.

The key point are perpetuating factors. What is it that people are doing in their sleep that is making them continue not to be able to sleep? Well, one of those perpetuating factors is related to anxiety. In fact, we call it psychophysiological insomnia, meaning it's their brain. It's what they're actually trying to think. I'll give you an example. Imagine you were asked to go onto stage at Carnegie Hall.

I guess in Great Britain, it would be the Royal Albert Hall. Imagine you're about to go onto Royal Albert Hall and you're being asked to play a Beethoven sonata. Imagine the stress involved with that. It's on television. You're there. Perhaps even the queen is there listening. The stress. Now, instead of a piano, instead we put a bed and we ask you to do the very same thing except go and sleep in this bed. It's not going to happen. And this is exactly what a lot of people are having to do. And I see this all the

time, practically speaking, in patients that come to see me. They say, Doc, I'm in the kitchen. I feel sleepy. I feel like I'm ready to go to bed. I say, wonderful. I'm ready to go to bed. And what they do is they go down the hall and they go into their bedroom and now they can't fall asleep. They're wide awake, they're activated. And what's happened is they've associated everything in that bedroom with the anxiety of the struggle of that battle that they take with them every night of trying to go to bed. So the last thing I want to do is make that anxiety worse. So what we typically do is we decatastrophize. We say, look, you haven't been sleeping for years. You're still alive. You're doing okay. You're probably going to be okay. This is not going to be a disaster for you. And then what we start to do is we start to show them where the behaviors in their

life have actually caused them to not be able to get a good night's sleep. And then what's happened is they've catastrophized it to the point where they've built up this perpetuating situation where they'll never be able to get good sleep unless we actually deconstruct some of those things. And what are some of those things? Very briefly, it would be things like, oh, no, I need to get more sleep. And what do I need to do? I know what I'm going to do. I'm going to go to bed early tonight. And I'm going to try to get as much sleep as I possibly can. And, you know, their circadian rhythm is not ready for them to go to bed until 10 or 11 o'clock at night, because that's what they've been used to.

And they get in bed at eight o'clock. Now, what are they going to do? What are you what's going to happen to the human body? If you go to bed at eight o'clock, and your body's not ready to sleep till 11? Well, you're going to be awake for three hours. And's going to cause more anxiety and you're going to be even more awake and you're going to associate with your bedroom. And Reagan, this is just one example of the things that we do that build up bad behaviors that cause insomnia. And so what my job is as a sleep physician is to listen to the patient, listen

to what they're doing, try to find cues, and then try to deconstruct what's happened and reverse those bad behaviors so that they can get some sleep. And once they start to get a confidence that they can go to sleep, the anxiety level comes way down. And then they're able to go to bed, go to sleep, and then sleep for those seven or eight hours eventually. There's a number of things that we do called sleep restriction therapy, decatastrophization. It's all included under something called cognitive behavioral therapy for insomnia or CBTI. A lot of people can do this. Psychologists can do it, sleep physicians. I'm glad that you bring that up because that's, as I said, 90% of what can do this. Psychologists can do it, sleep physicians. But I'm glad that

you bring that up because that's, as I said, 90% of what I do as a clinician is try to deconstruct that anxiety. I guess when people come to see you as a sleep physician, is it fair to say that a lot of the more, I guess, simple measures that people can adopt have already been tried. So let's take caffeine for example. We can talk about caffeine and its effect on sleep for sure but many people understand that although it's very individual that caffeine can absolutely make us alert if we have it too late in the day it can keep us up. So when people come to your door, have they usually tried reducing coffee and tea, or even eliminating it? Are they already at the point where, hey, doc, I've tried everything. I've listened to every podcast, I've read every book, I've tried everything that people

have recommended. Is that what tends to happen? It's a wide range. I have some people that have not done this and it all depends on the referral, uh, uh, the referral, uh, patterns that you see. As you know, you have some, uh, physicians that will refer very early. You'll have some physicians that will work on things. Um, and I, but I have seen very, very difficult patients where I've, I've sat down and I've gone through it and, and, uh, the referring physician has done everything that I would have tried. And there's just a few tools left that I have. And those are some of these tough cases that I have to deal with sometimes. But other times, no, they really haven't done much.

I think probably one of the best things to do for those people out there that have difficulty with sleep, there's a handout or a sheet, in other words, that you can find on the American Academy of Sleep Medicine. It's also probably there in the UK and in Europe and in any country that they're in. It's basically called a sleep hygiene handout or sleep hygiene document. And it has a list of about maybe 15 to 20 different recommendations. And it goes over some of the things that we've talked about, like avoiding coffee in the afternoon, making sure that you only go to bed when you're sleepy, making sure that you're never in bed longer than 15 minutes without going to sleep, get out of bed, get out of the bedroom. So you're not associating these insomniac issues with the

bedroom. But there's a lot more of those there and we can go over those, but that's basically the low hanging fruit. Yeah. I mean, I think certainly if I share my experience here, I've often found that simple things can make a huge difference for sleep for some people. And often it's not just doing one. If we take the Swiss cheese model that you mentioned the first time you came on my show, I really feel that applies to sleep as well. Some people will try one thing, won't they? They'll try, oh, I tried the caffeine thing, didn't make a difference. I'm going to go back to my usual caffeine intake. Now I'm going to try not looking at screens for an hour before bed. Oh, it's not that. Now I'm going to try and bring my

evening meal earlier. But I find with sleep, possibly more than anything else that I see, it's about small things in a number of different areas. Would you agree with that? Is that sort of the approach that you adopt as well? Just taking a quick break to give a shout out to AG1, one of the sponsors of today's show. Now, if you're looking for something at this time of year to kickstart your health, I'd highly recommend that you consider AG1. AG1 has been in my own life for over five years now. It's a science-driven daily health drink with over 70 essential nutrients to support your overall health. It contains vitamin C and zinc, which helps support a healthy immune system, something that is really important, especially at this time of year. It also contains prebiotics and digestive enzymes

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packs to 10. And these packs are perfect for keeping in your backpack, office, or car. If you want to take advantage of this limited time offer, all you have to do is go to drinkag1.com forward slash live more. That's drinkag1.com forward slash live more. livemore.com forward slash live more. Absolutely. Yeah, this is exactly the situation I tell I tell my patients, I say, look, we're going to be making a lot of changes here. And I don't want you to get discouraged about the number of changes that we're making, because all of these things are adding up. In fact, it may be more of a gestalt where the sum of the products is greater than the products themselves here. So realize that if we get on track, that some of these things may not need to be there for 100% of the time forever. But getting you back on track, one of the major things that we think about here

in sleep medicine is what we've just talked about, where anxiety, being anxious, being not being worried about sleep. Those people that are worried about sleep that make mountains out of molehills. Once we can give them the confidence to get back to bed and going back to sleep, we have just brought those perpetuating factors below the threshold. And now a lot of those

things that they were doing before that were not causing the problem, they could even in some cases go back to and not cause the problem with sleep. So yes, trying to give them the confidence of going to sleep is really important. I remember early on in my career, Roger, a few patients would come in telling me that they were struggling to sleep in their bedrooms. But on further sort of investigating, it was clear that if they were in front of the television in the evening in their living room, they could easily doze off in front of their favorite soap or whatever they were watching. And I thought, well, this is interesting. They can't sleep in their bedroom, yet they can sleep when they don't want to in front of the television. And I just remember that early on thinking there's something else at play here, because clearly they can sleep, but for whatever reason, the environment is not allowing them to.

but for whatever reason the environment is not allowing them to yeah this is this is the amazing stuff i mean there is there is a whole sea of subconscious that we are not even realizing um when you go into the bedroom i have this talk with with many of my patients um and it's and it's kind of geared to the way we live in the West. This may not be geared to a lot of people. I mean, here we're talking about a bedroom and we're talking about a kitchen. There's billions of people on this planet that don't have kitchens and bedrooms. They live in one room houses and they seem to get along fine, probably better because they don't have a lot of the stresses that we have in the West. But for those who do live in the West and we have a room dedicated to where we sleep. What I hate to see in patients who have different different difficulties with

sleep, are a television in there is is their work in their their laptop in their reading, I know a lot of people like to read, and they find it helps them to go to sleep, that's fine. What I'm talking about are those that have difficulty falling asleep, I tell them to go to sleep that's fine what i'm talking about are those that have difficulty falling asleep i tell them to get everything out of that bedroom that has nothing to do with sleep because i want there to be a very strong signal when you go into that bedroom your body understands that you're there for one thing and one thing only uh well maybe two things and if you if you don't get one of those you get the other at least. It's a win-win, right? But the point is that I don't want your brain confused that it's time to work. I don't want your brain confused that it's time to watch television.

And let's face it, late night television is probably the worst thing for being able to sleep. You're either watching the news, the disaster is happening. This is just going to increase anxiety. No, it's better to shut all of that off and go to bed. Yeah. Completely agree. It's what people do before they go to bed. Really, really interesting. I had another thought, and it was based on what you said about people around the world and how, you know, in the West, we have a room dedicated to sleeping. And for the first time in my life, I just thought, wow, that's quite a lot of pressure as well, isn't it? Actually, we've dedicated a room in our apartment or our house where we are going to sleep. Whereas, you know, for hundreds of thousands of years, we probably didn't have a particular bedroom, did we, where we put all the pressure on.

So there's that kind of subconscious pressure that builds up, even if we're not really thinking about it. Yeah, it's true. It certainly could lead ourselves to having these disadvantages. to having these disadvantages. But I see there are some advantages there in terms of people who, for instance, and this is changing the subject a little bit, people who, as you mentioned before, sleep in the day and work at night. It allows them to, the term I like to use is winterize, but it's not winterizing like we do when it gets cold. It's nocturnalizing, if you will, their room so they can make sure that no light is getting in. And so there are some advantages with having a room dedicated to that because then you can do things

that you need to do for sleep. But it's a very interesting point. Yeah, no, I completely agree. Lots and lots of advantages. How do you cope with this yourself? Because from what I gather from our email contact, you have quite different schedules from week to week, depending on what your job requires of you. So as a sleep physician, as someone who knows the importance of sleep, how is your sleep and how easy do you find it to practice when your schedule is changing all the time? Well, I think our audience would be happy to know that I am no bastion of sleep efficacy here. You know, for those that aren't aware, Rangan, what we, you and I, and hundreds of thousands of other physicians around the world have to go through to get where we are. There's medical school, and then there's residency.

to get where we are. There's medical school, and then there's residency. And as a critical care physician, I spent probably the better portion of my 20s staying up late into the night and getting up very early in the morning to take care of very sick patients. And so I got used to very quickly going through the barriers of sleep and having to do that sort of stuff. I have no idea what kind of effect that had on my body, I guess I'll find out later in life. But this is what we have to do as physicians to take care of very sick patients. And as a critical care physician, that sort of comes part and parcel. That we weren't really taught at the time what the consequences were of that, but I think we're starting to find out more and more. That's not to say that now, you know, being now I'm out of training, and I am able to

take probably better care of that. What I've what I found myself doing, at the end of all of that is still going to bed, you know, pretty late around 11 o'clock, I probably should go to bed earlier. But on days when I can get those six, seven hours, at least seven hours of sleep, that's what I aim to do. And that's just we're just talking about quantity. We haven't talked about quality of that sleep. As yet, we haven't talked about the stages of sleep. We haven't talked about sleep apnea, which is a huge problem in terms of quality of sleep as well. But yeah, it's something that we could all work on. Well, we're going to talk about those things because there's a lot of people who

struggle with them. I'm genuinely interested as a fellow physician working in a different country, do you have any moments that you recall that sleep deprivation really hit you? And why I'm asking it is because as you were describing residency there, I was taken right back to this moment where, you know, we were doing, well, I started work on that particular, well, the day before I started work at eight in the morning, I was covering a renal ward, a kidney wards, and I was on call. So I remember it was one of those nights where it didn't stop all night. You know, you hope for a little hour or two where you can get away and just put your head down. It just went all night. And then the following morning, you know,

it hits 8am. So you've been there for 24 hours now. And I was quite junior thinking, oh, maybe my senior is going to let me go a bit early today because I am really tired. There was nothing like that. I remember that afternoon about 4, 4.30 p.m. I just remember I was on the motorway, the M60 around Manchester. It's the ring road around Manchester in the northwest of England. And there was horns everywhere. And basically we were in a traffic jam.

I must have, whilst in that traffic jam. I must have, whilst in that traffic jam, I must have been so tired that I just actually fell asleep. And then suddenly, all the cars are moving, and everyone's horning me. And I remember having the living daylight scared out of me. I was so scared. What has just happened? Could that happen again? So I'm interested for you, do you have any moments like that you remember where sleep deprivation could have been really, really serious? I was kind of lucky in that I live pretty close to the hospital that I generally was at. But I do remember some, and it's very similar to your experience where we would come in at seven o'clock

or we come in at five o'clock in the morning to pre-round. We'd stay the whole day and the whole night and then through the next day till about four or five rounding on patients and making sure they were they had the workups in place. And then going home and realizing sometimes where when I got home that I don't remember actually driving home. It was sort of auto mechanical. But but there was this story that I did hear about in residency from another resident. This was a surgical resident. And they had both come in, they were so tired. And the resident and the attending, the resident was the one in training, the attending, of course, is the supervising physician. They were leaving at night. And I

think they left at the same time. And the, uh, the residents at a stoplight kind of rear-ended the, uh, the attending in front of her. And I think that was a wake-up call. Uh, it wasn't, it wasn't a, a severe accident, fortunately, but it was kind of a, um, a fender bender, we call it. Um, but no, this, this is the sort of the stuff that would happen. Um, and we would just, the, in the United would just, in the United States, they actually had to implement back in around 2003, something called an 80 hour work week. And you're thinking 80 hours, that's like double the amount of time that you're supposed to be, that a full time person would be working. They have to actually limit, they actually have to put in place rules that would make sure that residents were not working more than 80 hours in a particular week to limit how much they were working. And a lot of people don't realize that that's the issue that goes on in medicine. But that's exactly what we have to go through. And of course, we look back and we are sort of laughing a little bit,

but that is in some ways underplaying just how serious those things could have been for me, for your colleagues, for you. I mean, this is really quite serious. And this is actually probably what is still going on, although the hours have come down. There's many people who work shifts, who work, you know, regularly changing shifts. Perhaps we could talk about that in relation to circadian rhythms, because, you know, if you were on night shifts permanently, that would be one thing. But if, you know, one week you're on days, the next week you shift forward by four hours for your shifts, then the week after you're on night shifts. It's very, very hard to adapt, isn't it? Especially if you have friends and family and then so who are

not on those shifts. So in order for you to interact with them and exist with them and have some form of life, you probably have to live slightly outside your new circadian rhythm. So, you know, any sort of things you can share there for people at all? Well, there's no question. So we have enough trouble with people who have daytime jobs. That gets multiplied when we have people that do the nocturnal shift. And I have to tell them very specifically that if they're working the nocturnal shift, they really have to turn their night into day and their day into night. The problem that you bring up is just when you throw a monkey wrench into the whole

thing and say that, you know, one day you're going to be working the day shift and then you'll be working the night shift. The first thing I tell them is see if there's another way that you can do this scheduling because this type of scheduling we know is the hardest to adapt. I would say if you couldn't change the scheduling, probably the next best thing to do would be to make sure that as the shift progresses, that the shift gets later and later, because it's easier for our circadian rhythm to become later and later in the day. But it's still very, very difficult. Does that mean if you're on a day shift, let's say an 8am till 5pm, let's say, are you saying that if you can,

and you have to change shift, then the following week, maybe see if you can go then to a 10am till a 7pm. And then the week after a midday to a night. So pushing it that way is easier for us to adapt to. It is. And the reason why it is, is because we have a circadian rhythm, which literally means about a day, it's literally means about a day. It's actually longer than a day. And so that's why we find it so much easier to do things later as we progress than it is to do things earlier as we progress. So that would be the one thing I would say, if you really can't change it, you're really dependent on that job financially to do that.

That's what I would do. But it's better if you can arrange it with your supervisors, your boss, your employer, to have it consistent. And really, that's the underlying pinning of a theme of a lot of what we're talking about, which is inflammation. But also, there's a lot of processes that we'll talk about today that have to do with simply the fact it's not what you're doing. It's not what you're eating. It's not whether you're sleeping or not or how long, although we've talked about that. It's when you're doing it. And we're starting to find more and more that when you do something has almost as much impact, if not the same as what it is that you're doing and so that can that's really a big issue

yeah that is something i think what i guess about seven years ago now when i started to become aware of the research that sachin panda was doing in the salk institute around time-restricted eating it really got my attention thinking oh this, this is fascinating. This is really, really interesting that we can get all kinds of benefits when people don't change what they eat, they simply change when they eat. And yeah, there's a lot of research coming out. And we will definitely get to that. So I know you're very passionate about this as well, Roger. But in terms of circadian rhythms, you mentioned earlier on in this conversation that there is a way that you guys can measure where our clock is. So what does that look like for people?

Is that something they do in a specialist sleep clinic or is that something that is kind of accessible to them, you know, privately, for example? Yeah, it can be done. It's based on temperature because temperature is one of the ways that we can measure. It's based on temperature because temperature is one of the ways that we can measure. There is a temperature, I should mention the circadian rhythm can affect body temperature, although it's not as clean as other measurements like melatonin and things, and a lot more research-driven types of tests that they would do in a research lab. But for an everyday person, taking their temperature could do it if you were able to measure it. I think probably one of the best things to do is simply just try to measure when you feel tired. When you start to

feel tired is generally speaking what we call the dim light melatonin onset. And usually seven or eight hours from there is when you would wake up and maybe about instead of seven or eight hours, maybe about five, about five hours would be when we would expect the temperature nadir. So let me give you some times here. Let's say that you feel tired at around 11 o'clock at night, and you would normally wake up if you didn't have to get up for work. Let's say at around seven or eight o'clock in the morning, your dim light melatonin onset would be, or sorry, your temperature nadir, which is the lowest that your temperature is, would be around five or six. And that's how we would pin down where your circadian rhythm is. In college students, again, we mentioned college

students, they would actually put a rectal probe in when they're doing this and continuously measure their core body temperature as a way of trying to figure out where their circadian rhythm is, is how we kind of do it in the sleep research. But there are more sophisticated ways of doing it that are probably not available to your listeners on a regular basis. So trying to figure out where that is, is important. And you'll probably if you can nail it down to within an hour or two, I think that's a reasonable thing to do. Well, I guess the take-home there for me is, let's say you are someone with a relatively stable work routine

and a stable lifestyle, relatively predictable from week to week, then I can see real benefit in knowing, you know, what is that time where melatonin starts to rise? What is that time where I start to feel sleepy? Because once you're empowered with that knowledge, instead of fighting it, you can start to go, well, maybe I can just shift my lifestyle around it and sort of start to live in harmony with it. You can, or you can actually shift it and move it. I think that may be, well, let's think of a scenario here. Let's take probably a very common scenario where somebody goes to bed at 11 o'clock at night, but they've got to get up at six in the morning because they've got to get to work and they've got a traffic to take care of, and they've got to be to work by seven or eight o'clock in the morning. So they go to bed at 11. Maybe they don't fall asleep till about 1130 or so. And so they're getting up at six, they're getting less than the seven hours of sleep on a regular basis. How is it what what

could they do to make sure that they are going to bed at 10? Well, we already know that if they go to bed at 10, and their circadian rhythm is not ready for sleep till 1130, they're going to be spending an hour and a half in bed, concerned about their insomnia, getting anxiety, and it may turn into a bigger problem, as we've just mentioned. So why can't we just simply tell the clock and turn the clock back, if you will, from 11 o'clock to 10 o'clock? There are things that we can do to actually shift that circadian rhythm. And a lot of that involves light. And this is really a major area of research is how light affects not only chronobiology or the circadian rhythm, but also affects our well-being, our mood, all sorts of

things. Yeah. So what does that look like when a patient comes in to see you and you want to change their light exposure, or you want to alter it a little bit to help shift their rhythm? You mentioned, I think in our last conversation, we spoke about light in the morning, you know, and I guess at the moment we, as humans, we don't get enough light in the daytime, we're inside and we get too much in the daytime, we're inside, and we get too much in the evening. So what are some of those sort of practical things that you say to your patients to help them change that? Well, and this is exactly the point. So most, as we'll see, most patients that I see in my clinic don't have a problem with falling asleep

too early. They have a problem with falling asleep too late. And the reason is, as you mentioned, is we get far too much light in the evening and not enough light in the morning. And that's important because light in the morning advances the circadian rhythm, meaning that you'll go to bed earlier. You'll feel like you want to go to bed earlier. You'll feel like you'll want to go to bed at 10

as opposed to 11 because your circadian rhythm is becoming more advanced. It's coming earlier in the day, whereas night or exposure of light at night is going to do the opposite. It's going to delay your circadian rhythm. Think about this from a teleological standpoint. If your brain is seeing light late at night, you're telling your brain it's still daytime. I need to adjust my rhythm later because it's still day here at night.

Whereas the other is if you're seeing light in the day early, you're saying, oh, wow, the day has already started. I need to advance my circadian rhythm so I can be in sync with the day. This is already wired into your brain. All you need to do is just apply the appropriate stimulus. So what does this mean? This means getting up in the morning. The first thing that you want to do when you get up in the morning is turn on the lights as brightly as you can. Any lights in the house, anywhere where you are, make sure that things are bright. Make sure the curtains are

open. If you can even go outside, even if it's a cloudy day, even a cloudy day, anyone who knows photography and F stops and apertures will know that even on a cloudy day, there's probably more light outside than there is inside the house. And so going outside, exposing your eyes to bright light. I know that some of us who live at higher latitudes this time of year may not have a lot of light and that's still going outside. If it's dark outside, then turning on the lights inside the house in that situation would be important. The converse is also true. So when you get home at night, turning down the lights, using that option of having dimmers is really nice. And turning down the lights as low as you

can while still being safe is going to help move your circadian rhythm in a number of ways to make it earlier. And so you're going to bed earlier at night, you're getting more sleep, and you're still able to get up in the morning, get to your job and have a productive day. Yeah, no, I love it, Roger. So, so clear, so practical. And I think it really highlights something that many people don't think about, the idea that what you do first thing in the morning can absolutely influence the quality of your sleep that night, when you're going to feel sleepy that night. Often we think about sleep purely in those one or two hours before bed, don't we? Whereas this is beautifully demonstrating that a good night's sleep starts the minute you wake up.

Exactly. And so let's sort of work backwards and look at a full case here, just briefly. Imagine somebody that has no idea about what's going on, has no idea about this. They're just basically going along with what the societal pressures are. They have a job and they are under a lot of stress. This describes a lot of people today. They have to get up at six o'clock in the morning. They've got to get to work. They go to work. They come home. They have kids they have to do their homework with. They've got bills they have to pay. They may have some work to do from work that they are still working on. And so they leave the lights on. It's bright at night,

and they are doing their work. They're getting up to about 10 or 11. They do this for a number of weeks. And what's happened during that time is they've shifted their circadian rhythm later as a result of this. So now they don't feel tired until 11 or 12 o'clock at night. They start to fall asleep at 11 or 12 o'clock at night. And they're getting up at six in the morning. They're not getting enough sleep. They feel tired. And they say, you know what? I'm not getting enough sleep. I need to go to bed earlier. So they make a point of trying to go to bed at nine or 10 at night. But because their circadian rhythm is not in link with that, they've now caused the situation where they're going to bed. They're not able to fall asleep. They're becoming more anxious about it. Their anxiety levels go up and they can't fall asleep.

And this is sort of a self-fulfilling prophecy. And so what we have to do, this is what I do as a sleep physician is I look at all of this and I say, okay, this is what we're going to do. You're not going to go to bed until 11 o'clock at night because that's when you're going to sleep. I decatastrophize, I take away the anxiety. And then I asked them to do this light stimulation where they're exposing their eyes to bright light in the morning. They're not exposing their eyes to bright light at night. We shift the circadian rhythm back. Now they're getting plenty of sleep. They feel better. They have more, they're more productive. And we've just basically done stuff that they had no idea that they were doing this to themselves.

But if we follow some very simple rules of making sure that we're not exposing our eyes to bright light at night, making sure that we're shutting down, making sure we're doing the opposite in the morning, you can see that by consciously pushing back against the societal pressures and making sure that we're protecting those areas, we can maintain homeostasis and high productivity and having good sleep. Yeah. I think what a lot of people appreciate about you, I mean, you have a great way of explaining things, simplifying things for doctors and for the public. But you always give a very balanced viewpoint, which I've always really warmed to,

which is, well, this is what the science says, this is what I would recommend. But I understand that life gets in the way sometimes. And you know, if you can't do it always, don't beat yourself up. Yeah. Exactly. Exactly. you know if you can't do it always don't beat yourself up yeah exactly exactly and for me that just speaks to someone who has got an incredible amount of clinical experience because that is real life isn't it that's not just looking at the science it's also converting that science into something practical for people that they can actually use to improve the way that they feel? Because that's what it's all about, isn't it? It's about how do we take that science and convert it into practical action? Right. Otherwise, we're just basically, I don't know, we're putting the process as the goal

instead of using the process as to getting to a goal. And the goal is having a healthy life with good quality. And that's the key. And if we take these rules and make them the goal, then that's not a good quality of life. Nobody wants to live strictly according to rules for no particular reason. I mean, we're using these as tools. The tools aren't what we're trying to do. The tools are just ways of getting there. Well, I definitely want to get to stress. I definitely want to get to the timing of our food intake. But before we leave sleep, you mentioned a couple of things before, the different phases of sleep, which we've not discussed, and sleep apnea. So we've spoken about these rhythms. How do they play into these different phases of sleep? And why are these different phases so important?

sleep and why these different phases so important. Before we get back to this week's episode, I just wanted to let you know that I am doing my very first national UK theatre tour. I am planning a really special evening where I share how you can break free from the habits that are holding you back and make meaningful changes in your life that truly last. It is called the Thrive Tour. Be the architect of your health and happiness. So many people tell me that health feels really complicated, but it really doesn't need to be. In my live event, I'm going to simplify health, and together we're going to learn the skill of happiness, the secrets to optimal health, how to break free from the habits that are holding you back in your life.

And I'm going to teach you how to make changes that actually last. Sound good? All you have to do is go to drchatterjee.com forward slash tour. I can't wait to see you there. This episode is also brought to you by the Three Question Journal, the journal that I designed and created in partnership with Intelligent Change. Now, journaling is something that I've been recommending to my patients for years. It can help improve sleep, lead to better decision-making, and reduce symptoms of anxiety and depression. decision making and reduce symptoms of anxiety and depression. It's also been shown to decrease emotional stress, make it easier to turn new behaviours into long-term habits and improve our relationships. There are of course many different ways to journal and as with most things it's important that you find the method that works best for you. One method that you may want to consider is the one

that I outline in the three question journal. In it, you will find a really simple and structured way of answering the three most impactful questions I believe that we can all ask ourselves every morning and every evening. Answering these questions will take you less than five minutes, but the practice of answering them regularly will be transformative. Since the journal was published in January, I have received hundreds of messages from people telling me how much it has helped them and how much more in control of their lives they now feel. Now, if you already have a journal or you don't actually want to buy a journal, that is completely fine.

I go through in detail all of the questions within the three-question journal completely free on episode 413 of this podcast. But if you are keen to check it out, all you have to do is go to drchatterjee.com forward slash journal or click on the link in your podcast app. So if you look at sleep, it's not just on-off switch. There are different waves that we see in the brain, and we've named these parts of sleep based on these waves. There are very slow, high amplitude waves that we see early on in the night, particularly we call this delta wave sleep or slow wave sleep. And then we see this part of sleep later on where it's very irregular, the respirations are very irregular and the body becomes paralyzed. And we call that rapid eye movement sleep or REM sleep. And we feel that these two

types of sleep, REM sleep toward the end of the night and slow wave sleep toward the beginning of the night have completely different purposes and they do completely different things. Slow wave sleep is very physically restorative. It's associated with growth hormone secretion. This is a very interesting aspect of this particular type of sleep because growth hormone for many years was considered to be the fountain of youth in terms of what it did. It did so many things in our body that was associated with feeling young and vibrant and having physical prowess that it's this early sleep that's really important. A lot of research has been going into this aspect of sleep, which is slow wave sleep. And if you want to get this type of sleep,

it's available to you, generally speaking, early on in the night. So again, being able to get to bed early, being able to get to bed early, and able to get to bed early and have your circadian rhythm ready for you to go to bed early. I think that if a lot of people in our audience all of a sudden decided to go to bed early, they wouldn't be getting that benefit because what they need to do is simultaneously shift their circadian rhythm back. Unless of course they're experiencing sleepiness at 10 o'clock at night and just not taking advantage of it. Taking advantage of sleep early in the night is very important. Now, REM sleep, on the other hand, has potentially completely different aspects. We're a little bit less clear on that,

but we do know that this is where we dream. How many people in the audience, first of all, dream, number one. Number two, it's usually when you're dreaming, it's right before you wake up in the morning. And that goes along with what we know, which is REM sleep toward the end of the night. It's felt that REM sleep is not physically restorative like delta wave or slow wave sleep, but in fact, is mentally restorative. It's a way of repackaging the memories of the day before. You may notice that sometimes you dream about things that happened to you the day before or that day. And that could very well be what it is that's going on. These all have purpose. They're doing something. We don't know exactly what happens if we don't have it. But we do know that as we get older, the natural tendency for people as

they get older is that slow wave sleep kind of gets less and less, and REM sleep kind of gets less and less. And what we're left with is this kind of generic sleep we call stage two sleep, which is okay. It's just not going to be as purposeful as we used to get when we were infants. You've heard the term sleep like a baby, right? These babies can sleep like the dead. It's because they're either in slow wave sleep or in REM sleep, one or the other. And as we get older, it's natural for that to happen. We also have less sleep efficiency as we get older. These are things that normally happen that we can talk about. But the point is, is that, yes, we need good quantity of sleep, as we talked about, seven

hours at least. And by the way, that goes up for school-aged children, nine, 10 hours of sleep in some cases. We could talk about secondary education and how that's impacting sleep, but that's a different topic. We need quantity of sleep, but we also need quality sleep as well. And so making sure that we get the full spectrum and making sure that we're getting slow wave sleep and REM sleep and allowing for that to happen. Now, the other thing that you

mentioned that we can talk about is sleep apnea, which is, you know, of all of the things that I see in sleep medicine, the majority of my time is spent on obstructive sleep apnea. We could spend a whole hour talking about it, but let me just give you a little bit of a brief synopsis. Sleep apnea is where when you go to sleep, your airway muscles go to sleep. And when your airway muscles go to sleep, they can contract, they can get smaller so that your airway gets smaller. When you're breathing in, the pressure in the lumen of your airway, the hole that you're breathing through can sometimes become negative pressure. And that's because you're sucking air in and that can sometimes bring the airway so close that it actually touches each other, in which case you'll have snoring, or it'll completely collapse so that no air gets down into your lungs. Obviously, you can imagine if no air is getting into your lungs for an extended period of time, your oxygen levels in your body will drop. That

will wake up your brain and the brainstem, which monitors oxygen. That will then send a signal up to the upper part of your brain to say, hey, we've got a problem here. Oxygen levels are dropping. That will then cause your brain to arouse out of its sleep and send a very strong sympathetic nervous system to your body to wake up in some sense so that your airway muscles open up, air starts to move in again, oxygen levels go back up, and your body settles down for another cycle of sleep. Then the cycle happens again and again, over and over and over again. The treatment of this is to keep that airway open. There are several ways of doing that now. We have CPAP machines that can open that up, masks, dental devices that advance the tongue forward

because it's a dental device that moves your jaw forward. And because your tongue is attached to your jaw, that moves forward. There's many different ways of treating this. You should do this with a physician. But the point is, is that there's many people out there that don't realize that they have sleep apnea, the signs of which could be,

they're getting enough sleep numerically, seven hours of sleep, but they still feel tired in the morning. They may have morning headaches. They generally are obese, but they don't have to be. They can also have high blood pressure that's treated with multiple medications and still the blood pressure is not coming down. These are all sort of underlying signs that sleep apnea may be there. There's emerging evidence, pretty sound evidence that sleep apnea is associated with a bunch of outcomes that we don't like, heart attacks, strokes, hypertension, all sorts of things. That treating the sleep apnea may actually be beneficial at reducing those things in those patients. I put this out there because it's a

very common thing and people may have it. They may not think that they, they may say, oh, I don't snore. I'm not having those problems. And so therefore I don't need to worry about it. I would say that if you have daytime, excessive daytime sleepiness, falling asleep very easily, just sitting and watching television. If you're having morning headaches, when you get up in the morning, if someone tells you that you stop breathing at night, that's pretty sure. If you're having issues with snoring, if you're overweight, these are all signs put together that you may have obstructive sleep apnea. Yeah, I really appreciate you sharing that because it may be that someone listening or watching this goes, wait a minute, that sounds like me. Maybe I should make an appointment with my doctor, go to a sleep clinic, or it may be that they recognize it in a family

member or a friend who's struggling. And I think the information you just shared will allow someone to sort of potentially help someone else in their life. As you say, it's really, really common. So yeah, thank you for that. What do you know, in sleep apnea, in obstructive sleep apnea, are particular phases of sleep affected more than others? Or is it quite variable depending on the patients? Good question. So the issue with the different phases, because we are depending on the tonicity of the airway to try to keep it open, because during REM sleep, all of these skeletal muscles become very relaxed, we typically see the worst sleep apnea during REM sleep.

And as a result of that, we will see that there are major drops in oxygen saturation towards the end of the night when we do these sleep studies. As a result, they don't last in REM sleep very long. What's very interesting, and I see this all the time, is we'll have a patient for years and years have very bad sleep apnea. Then we'll make the diagnosis and we'll put them on treatment. It's amazing. What you see is it's as if the brain was asking for REM sleep for years and years and years. And it's almost like you haven't had your favorite meal in years. And then you get to sit down and you eat that. And literally the entire night of somebody getting treatment for

the first time, I've seen basically just REM sleep. It's like they've been lacking it for years and it's now just making up for it. And I've had patients come back and see me after that. And they say, wow, that was the most amazing night of sleep I've had in years. It's not for everybody, but it certainly happens. I can tell you personally that even though my BMI, body mass index, is in the normal range, I have sleep apnea myself. And I'm not obese. That's just the way my neck was designed.

It's just my anatomy. I have the genetics that I inherited that make me susceptible to getting sleep apnea. So I wear a CPAP mask, and it's helped me in talking to my patients as well, that I can relate to them, they can relate to me, and I'm not doing something to them that I wouldn't do to myself. So it's something that I deal with as well. Yeah, well, thank you for sharing that. What is your view on trackers? Because they're all the rage these days, aren't they? Whether it's on your phone or on your ring or on your wrist, what is your view? Have you got much

experience with them? And are they helpful for most people or are they unhelpful and anxiety inducing, would you say? It's exactly the question that I have for these trackers. I think the trackers are actually numerically and they're very accurate. I don't have any doubts about their ability to measure what they're saying that they're measuring. I think they do a very good job at measuring activity at the different types of sleep because they can measure this. And the data that I've seen has shown that they work very well. But the question is really in your question. And that's what we've discussed about here is we can talk about how you need sleep, how you need to make sure that you're getting enough sleep. But the flip side of that is, is it anxiety provoking? Do you become fixated

on these numbers? And if you're not meeting these numbers, does it cause anxiety and cause you to have problems falling asleep? The type of person that would go out and buy a tracker, someone that would look at and seeing whether or not they're sleeping is the type of person who's actually worried about their sleeping. And so I have the same concern I think that you do in that if you're out there and you're placing too much emphasis on the numbers, you can miss the forest for the trees, increase anxiety, and as a result of that, actually be counterproductive. Yeah, I agree. And it reminds me a bit of blood pressure monitors, because I find with my patients who ask me, doctor, should I get a home blood pressure monitor? Well, for some patients, it's the best thing in the world. They do it once a week or twice a week. It motivates them to

stay on board with their lifestyle changes when it starts to creep up. But for the other half, they're looking at it four times a day and they're getting anxious each time and that's sending their blood pressure up and making them even worse. And so i kind of feel it depends on the individual because some people probably can use it in a very helpful way um so but i but i think it's a i think it's a point that we need to be discussing a lot more across medicine across society you know how good are these trackers are they helpful or are they unhelpful? Yeah, it's true. And another example I can say on a continuum is these trackers that can measure your heart's rhythm. And for most people, they can look at that heart rhythm,

they wouldn't know a P wave from a T wave, which is probably good because there's a little bit of distance. But for those that want to know, I think that's fine. Where I think it's a great idea is it can detect atrial fibrillation, which of course is a risk factor for stroke, and alert the patient to that as well. So I think it depends on how it's done. If there's a lot of numbers that you can get wrapped up in, it may not be a good thing because you get fixated on of numbers that you can get wrapped up in, it may not be a good thing, because you get fixated on these numbers that by themselves may not have the clinical meaning that that that you might think they do. Well, we've spent a lot of time discussing sleep and its role in inflammation, I really want to move on now to stress if, if that's okay, because stress is this big catch-all term, isn't it? We know that many

people are feeling incredibly stressed. They were actually, even in 2018, 2019, even back then, the World Health Organization called stress the health epidemic of the 21st century. Of course, since then, there has been another event which has taken over the world. So when we're looking at inflammation, how does stress fit into that? What does the science tell us? Oh, the connection is very tight, unfortunately. So stress, as we mentioned, is, or inflammation, as I'm sorry, as we mentioned, is this kind of this smoke or this fire or this construction that has to happen, whether or not, you know, has to happen in our bodies to make sure that we're doing the processes that we're doing, but we don't want it for longer than that. If we look at stress and see its effects with inflammation, it becomes very apparent very quickly.

So there's a number of researchers, to give you an example here, in Pittsburgh, that looked at stress and inflammation and the immunity specifically, how this affects immunity, because I think that's a big thing as well. We all know about cortisol. Cortisol is a hormone in the body that gets released during stressful situations. It's a stress hormone. And I want to make sure that I'm using the word stress here appropriately. There is stress that we feel mentally, and there is stress that's going on in the body. And I want to make sure that when we talk about stress, we're talking about that specifically. So when there is stress in the body physically, there is that stress hormone, cortisol, which is released from the adrenal gland. And one of the physiological downstream

effects of cortisol they found was a way that it shifts the number of white blood cells. There's different types of white blood cells, not to get too technical. number of white blood cells. There's different types of white blood cells, not to get too technical. There are white blood cells called neutrophils, and there are white blood cells called lymphocytes. And the ratio of these two, to give you an example, changes when cortisol levels go up. There's supposed to be more neutrophils when cortisol levels go up. And this is a natural response that is mediated through the cortisol receptor. So cortisol hits the receptor. This receptor then causes this downstream effect of neutrophils going up and lymphocytes going down. What they found, these researchers, was that

when this happened, if the subject was under a lot of mental stress, so stress from every day, stress from a wedding, a divorce, a loss of a job, a gain of a job, it doesn't matter, any kind of stress, that they no longer saw neutrophils going up and lymphocytes going down. There was a completely blunted response. And what they determined was determined was that the receptor was no longer transmitting the signal of that cortisol binding to it. In other words, this was known as cortisol receptor resistance. This receptor resistance was the result of stress. result of stress. And not only were there effects from stress in that situation, but there was also issues in terms of infection. So what they did was they took these subjects that had a blunted response, and then they subjected them to rhinovirus, which is basically

a common virus that causes the common cold. And what they found was that cold symptoms appeared more commonly in those patients that had this blunted response. In other words, this cortisol receptor resistance. So here is direct evidence that people, something that we know all the time, we know this innately. We know that if you're under stress, you're more likely to get infected, but we can actually see now the results of where cortisol is supposed to have a downstream effect. This downstream effect is gotten rid of, and it's exactly in these patients who have stress that gets rid of this downstream effect because of receptor resistance that causes these people to have more symptoms of the rhinovirus infection. So here's an example where inflammation, stress, immunity all sort of come together and cause this

kind of interaction. Yeah, super fascinating. And I guess for many people, they are becoming more and more familiar with this idea of insulin resistance, that this hormone that does many things, including keeping your blood sugar stable. If we insult the body, you know, year after year with highly processed foods, pro-inflammatory foods, all kinds of things, then actually the body becomes resistant to that hormone. But the way you just described that study is it's sort of saying, But the way you just described our study is it's sort of saying it's the same thing for stress. We can become resistant to stress hormone or the receptor.

It just doesn't work as well. So if we're exposing ourselves to too much stress, then the response in the body starts to get blunted. response and the body starts to get blunted. And I think that's something that's not commonly known because many of us think we can get away with pushing it every single day, every single week, month after month. But you're showing with just that one study, and I know there are many others, that it has a direct response on your immune system, a direct response on how inflamed you are. So managing stress is clearly another key strategy at trying to keep our inflammation levels down. Exactly. And let me just add to that, because we think of it in terms of infections, things from coming from the outside to infect our bodies and how to fight those things from the

outside. There are other things that our immune system has to deal with on a daily basis. It has to deal with basically the garbage that our cells make. In fact, cells become damaged and those cells that become damaged have to be dealt with. And if they're not dealt with, these damaged cells accumulate and our body starts to look like a trash dump. If our immune system is not taking away the trash, taking away the dead cells so that new cells can replace it, we have a problem there as well.

So imagine somebody with chronic stress, imagine someone who's not allowing their immune system to do the things that it needs to do. Our body's cells, instead of being brand new, ready to go off the assembly line, we're dealing with last year's version, version 1.0, because our immune system hasn't dealt with these damaged cells. And so this is something that goes on all the time in our body. And our body sets certain times, we'll talk more

about this when we talk about time-restricted feeding, there are certain times that are scheduled in our body for these processes to occur. Their body sets aside time based on these clocks that are in every cell that is run by the suprachiasmatic nucleus that says, okay, we're awake, we're doing stuff. This is not the time to put out the trash. This is not the time to have janitorial coming in after business hours. We need to work, work, work, work. But then when the time comes to allow janitorial to come in, to allow. We need to work, work, work, work. But then when the time comes to allow

janitorial to come in, to allow our immune system to go in and see what needs to be taken down and broken down so that new things can take their place, if we're not allowing that to happen, why would we believe that those things are going to go away on their own? They don't. And we need to have that time to be able to do that. What about a different kind of stress, fear? Fear itself is not necessarily a helpful thing for your immune system to work well. So are you familiar with any research on fear and how that plays into our immune system? Oh, yeah. I'm reminded of a really interesting study that was done by Jennifer Heiss at the McMaster University, where she took students that were in the last six weeks of their term.

And boy, if you want to incite fear, think about this. Here you're a college student, you're at the end of the term, six weeks to go, you have your major exams, your career is based on getting a good grade in college, and your good grade in college is based on doing well, there's fear there. There is anxiety, there's no question about it. And what they did was they randomized these students at McMaster University to three different groups. There was one group where they did nothing. It was just do whatever you want to do and study for your exams. The second group was a low intensity exercise or moderate intensity exercise group where they exercised three times a week. They got their heart rate up to about 75% of their maximum predicted heart rate. For those that don't know, your maximum their heart rate up to about 75% of their maximum predicted heart rate. For those

that don't know, your maximum predicted heart rate is 220 minus your age. If you take that number, multiply it by 0.75, that's where they would get their heart rates up to. They did it for about 20 minutes a day, three times a week for six weeks, the last six weeks of the term. Then in the third group, they did the same thing as they did in the second group, except instead of moderate exercise, they did high-intensity exercise, still 20 minutes a day, still three times a week, except they got their heart rates almost close to about 100% of their heart rate, so very intense exercise. And then what they did was they looked at depression scores. So the Beck Inventory Depression Score 2, which is a very well validated

inventory depression score. And they also looked at cytokines. So they looked at IL-6, they looked at tumor necrosis factor alpha, and they measured these in these three groups. So what do you think happened? The first thing that was really interesting to me in this study was when they looked at the control group. The control group went from about, well, there was a change of about six points in the Beck inventory depression scale score. What does that tell you? That tells you that after six weeks of immersing yourself in a stressful situation where your career, where your livelihood is

dependent on a score, you can quickly become depressed in that kind of a situation just in six weeks. Now we're headed into our second year of this pandemic. And so it should be no surprise to people that all of the things just with just the coronavirus itself, family members, also what's going on with at the government level, internationally, politics, all of this sort of stuff, that we're going to have some major issues with depression as a result of fear and anxiety. There's a well-established connection between fear, anxiety, leading to depression. And we saw that very clearly in this study. In terms of in this control group, there was also increases in tumor necrosis factor, and there was also a drop in IL-6, which is one of the cytokines that's involved with fighting infections. But let's look at the other two groups, moderate intensity and severe intensity or a high intensity exercise. Which one of those two

do you believe did better in terms of mitigating the effects of fear and anxiety? Well, it was the moderate intensity group. The moderate intensity group not only did not have an increase in depression, they actually had a reduction in depression, actually went in the other direction. In other words, in the moderate intensity exercise group, actually also in the high intensity exercise group, they had a reduction in their Beck Depression Inventory Scale Score. So what do we learn? We learn that exercise is really important in situations where you have chronic fear and anxiety. It can do a tremendous amount in terms of your mental well-being and also your physical well-being. But in terms of anxiety and perceived stress,

so when you asked the subject, do you feel like you're under stress? The moderate intensity exercise group actually did better than the high intensity exercise group. And that was actually the same for the cytokines. The reduction in tumor necrosis factor alpha was greatest in the moderate intensity exercise group. And what Jennifer Heiss showed here in this study is something that we have known for years in the high athlete population. So the elite athlete population, the population of athletes that go to the Olympics,

we've known this for a very long time. And that is this, that people with high intensity exercise have actually higher levels of stress, have higher levels of inflammation, have higher levels of stress hormones than those in the low and moderate intensity groups. And so as a result of this, there has been a number of papers of research that has been published on how to mitigate the infection risks in these high intensity athletes. Think about this. This is not political. There's no agenda here. The only agenda is that these governments want to send their athletes to the Olympics

to win the gold medal. And when a hundredth of a second can make the difference between a gold medal and not even getting on the podium, they're going to stick with the science. And what the science says is that you've got to make sure that everything is well-timed, everything is well-versed. You have to make sure that you have time for rest. We could go over the studies and the recommendations, but many, many papers have looked at this very stressful group, these high-intensity athletes. What you'll see is the recommendations there are the same recommendations that we've given so far on this podcast in terms

of sleep, in terms of making sure that we avoid infections, in terms of making sure that we're getting enough nutrition, diets, all of these sorts of things. But the point here that I want to make about getting back to your first question, which is about fear and anxiety, is one of the major prescriptions that I would advocate for everybody at this point is to get out and to exercise. There's this J hook, this J curve, I should say, approach, whereas we're all, if you can imagine the letter J, okay? And we're at the very beginning of that letter J, we're all couch potatoes sitting on our couch, watching television, watching the news channels talk about how everything is going downhill. That's not a good place to be. As soon as you get off the couch and start exercising and start doing something 20 minutes

a day, three times a week, you're going to go down. The J goes down. As a result of that, J goes down. Okay. And as a result of that, your inflammation goes down, your well-being improves, your Beck inventory depression scale scores start to improve. As it reaches a certain point though, that if you start to do more intense exercise, you could actually get some reversal of that improvement where it goes back up and even higher, as you would see in these high intensity groups. Rangan, this explains why sometimes we hear about people being in the hospital from COVID. And we say, well, they were a marathon runner. I mean, marathon runners, yes, these are the people that are actually at most risk. Why? Because they have chronic inflammation going on in their body because they are exerting themselves so much. So the key here is what is a good recipe for fear and anxiety among other

things? Number one, moderate exercise. Don't feel like you've got this huge barrier that you've got to overcome and be like these elite athletes that you see on television. No, just getting up off the couch and having a regular routine is so important. Thank you for sharing all that because I think it's such a key point, isn't it? When we talk about movement and physical activity for health, it's like, well, how much do I need to run a marathon do I need to be hitting the gym high intensity you know for one hour sessions five times a week no the research that you're sharing is saying that actually you don't have to do that you just need to get up move go for a brisk walk maybe 20 30 minutes three times a week you can get a lot of the benefits from doing that so I hope that is

really empowering for people who may feel that they don't have time money inclination to go you know and really push it and I guess that really speaks to one of the wider problems we have now in terms of health messaging is you know for all the benefits social media does have in terms of sharing health information, sometimes we can feel as though we're not doing enough or that, you know, a 20 minute walk three times a week is not enough because this influencer is killing it for an hour every single day. Right. So I think that really puts a bit of perspective for people. It really gives them encouragement. And I don't know how you found this, Roger. One thing I've always tried to do with my patients is help them understand what is the right dose of exercise for them to help them with their

physical health and mental health, reducing stress, reducing anxiety in the context of their lifestyle. You know, are they killing it at work? They're not getting enough sleep every night, yet they're still trying to push it really hard in the gym. Or, you know, because often I say, well, look, maybe you're much better off with yoga two or three times a week to help you balance all that excess stress that's in your life. Whereas someone else may be okay pushing it a bit harder because they don't have, let's say, a hugely stressful life or they have time to get eight hours of sleep a night. So it is quite nuanced, isn't it, really, when it comes down to each individual? It is. And I can tell you, being a physician, I see people all the time that

simply just can't walk for 20 minutes a day, either because they have joint problems, knee problems, or things of that nature. There are ways of getting around that. So if you can't walk, how about a stationary bicycle? You don't have to worry about balance. You don't have to worry about falling over. You get on the stationary bicycle if you can have access to one. A lot of on the stationary bicycle, if you can, if you can have access to one, a lot of, of, of places have access to gyms, if you, if you can do this and you can simply, you know, put your feet on those pedals and turn them for 20 minutes. You know, obviously if you have a heart condition, you want to make sure that you get cleared by your physician first before you do that. But, but there are a lot of things you can do. There's even, and I, you know, we probably don't have time to get into this too much. But I'm interested in looking at the cardiovascular equivalence of

perhaps even using a sauna or using a spa, but it's well known that when you get into these, into these hot tubs or into the sun is that that raises the heart rate and it raises circulation, it may have the same benefits in terms of that for those people that can't exercise. Yeah, fascinating. We'll save that for another time, because that sounds really, really interesting. So, so far, we've talked about sleep. You've given some practical advice on sleep. We've mentioned stress and fear. You've mentioned how moderate exercise can absolutely massively reduce your risk of getting infections, improve how your immune system functions, improve your well-being.

Before we get on to food then to finish off, what other things can people do or do you recommend to help them reduce that stress in their life, which of course can be very, very hard? Yeah, I mean, so the question is, is why do we have fear in the in the first place and if you you know and i'm i'm informed a little bit by by my upbringing as well is is being able to have a place to put those kinds of burdens so there's the spiritual aspect which is well known in medicine um and and what we do and and having that ability to rest. So as a Seventh-day Adventist, I take a day off a week where I basically disconnect from all of the worries of work and all of these sorts of things. And I can't see why anyone wouldn't do that. I mean, a lot of times

we have to do things. There's stuff that has to be done outside. And that list never goes away. There's never a point in my life where my work queue is zero. And I can say, I'm done, I can go away. And so if you're waiting for that period of time where your work queue is done, to be able to just relax and detach, guess what, you're never going to have that. You as a human being are going to have to take just relax and detach, guess what? You're never going to have that. You as a human being are going to have to take the initiative and say, here's a period of time during which I am not going to be working in my work queue. And I'm going to be able to disconnect from society and actually take care of myself and have a place where I can develop, you know, whether it's spirituality or religion, religiosity,

these sorts of things where I can improve my family relationships. These are so important. When when we look at the research, people who do well, people who live longer, if you look at the research that Dan Buettner has done, with the blue zones, I mean, there is there's always a connection of community. It's not just your immune system. It's not just your sleep. It's also your connection to people around you, knowing that there's a support system there,

knowing that there are people that can help you. This is so important. We are, you know, there's this expression, no man is an island unto himself. And so from this, we look at the community. We look at our connections to people outside of ourselves. We look at our parents, our children, our relatives, our, you know, our spiritual leaders, our God, whatever that is in each one of our lives and making sure that we have time for

that, that has a tremendous effect on our ability to process fear of being able to process, you know, anxiety. And actually, there are practical ways that that can be helpful. Obviously, if there's a specific problem that you don't know how to deal with, if you're part of a community, maybe that can be helpful in actually taking care of the problem. But if it can't, you know, we know that people who have diseases, they do better when they're in support groups with people with the same disease. So I think this is a huge area that for some people is obvious,

for others are not so obvious. And so I'm glad that you pointed that out and asked that question, because I think that there's a tremendous amount of benefit that can be gotten from that type of a program. The other thing that I would mention, we mentioned this last time as well, is this whole idea about circadian rhythms and our ability to make sure that we're doing what we're doing. We've talked about the circadian rhythm. There's also this, um, circa septum rhythm where we've talked about last time where, and scientists have looked at this, the biology where there is, whether it's our heart rate, whether it's our,

our body temperature, there is this seven day cycle that's sort of built into ourselves and built into our body. And we don't know why this is the fact. But for some reason, we seem to go every seven days. I mean, I have my ideas spiritually about why that's the case. But if you look in nature, there seems to be this need for every seven days to take a break, no matter what culture it is. I love that. So, so interesting. And I really appreciate you sharing your own upbringing and your own culture. because of course, culture plays into health massively in terms of our understanding, our practices, what we consider normal. And it again, speaks to society and how society is, in many ways, working against us. We've kind of had these periods of downtime eroded out of our lives. So it takes people like you to have a really strong upbringing and culture to fight against that. I remember as a kid that the supermarkets weren't open on a Sunday. You couldn't go and

buy your shopping on a Sunday. So everyone knew you had to get all the shopping done before Sunday was a family day, right? You're not out. And now we've got, I'm sure it's, you know, probably coming from America, but malls that are open 24 hours a day, seven days a week. You know, you can shop wherever you want any day. We don't have that natural downtime built in. So I think it's a great point.

I really appreciate you sharing that. And I think that fits nicely to the final sort of point of discussion, at least for this conversation, which is timing of food intake. Again, we're talking about inflammation. I guess the immune system is absolutely linked with inflammation. You shared some of your philosophy around diets last time, but instead of focusing on what we eat, I thought this time we could focus on when we're eating and what the benefits are when we eat in certain time periods. Yeah, this is probably more than anything we've talked about today, a game changer, because this is relatively new information, as you mentioned, some of the research that's been

coming out, and it goes along with exactly what we've been talking about. What we're about to talk about now is not what we're eating. We've talked about that. Many people have talked about that. It's simply when you're eating. That can have a tremendous impact. It goes again, what we're talking about, where there's certain times of the day, that your body is, quote, taking out the trash, if you want to put it specifically. And if you're doing something that never allows your body to take out the trash, why would we expect the trash to be taken out? What we're talking about here is a term that's been used, intermittent fasting. I prefer time-restricted feeding as an answer.

What we're really saying here is that are we allowing our bodies to be in an unfed state long enough to do what it needs to be doing? Let's talk a little bit about this. When you eat something, obviously you're eating, it takes you about maybe half an hour or an hour to eat. And then after you're done eating, the thing that you've got to understand is that your body is now completely different in terms of the metabolism, in terms of the proteins that are being activated than it was before you ate that food. And it will stay in that, quote, fed state for a good two, three, four hours until you stop eating. And then after about two or three,

four hours, it then starts to go back into its, quote, unfed state. And so you can think about this in terms of two states. Your body has a fed state and it has an unfed state. Obviously, we need to eat, we need to get calories, but if we spread the meals out in the day so that they're very far apart and we never allow our body to go into its unfed state, we extend the fed state of our 24 hours and we limit the unfed state. What we're finding out is that that has tremendous consequences. As we talked about before, when you eat, there are certain proteins, proteins that regulate glucose, proteins that regulate appetite, things that regulate metabolism, inflammation, obesity, fats, proteins, how all of these things are dealt with, blood flow to the stomach.

These are just some of the few things that we're talking about. When those things are constantly being left on, there are certain metabolic problems that occur. Imagine someone who grazes every day. They've got snacks out, and they eat, and they eat constantly. They've got this. They're constantly putting things in their mouth. They are essentially feeding the entire day. And the only time that they don't feed is when they're sleeping at night. So let's talk about, since we don't have a lot of time, let's talk about what are the things that is emerging? What is the emerging data? The emerging data is that having a restricted time of the day where you eat and outside of that,

where you don't eat any calories. So what could you do outside of that time? You could drink water because there's no calories in water. You could even put some lemon in the water if you wanted to. I think that's fine. But not eating any calories. As soon as you would have calories, you're breaking your fast. What we're noticing is that if we restrict that period of time to about eight or 10 hours a day, then we start to see some amazing things in terms of transformation of the body, in terms of metabolic improvement, in terms of improvement with inflammation, in terms of actually, according to a new study that came out of China, reducing even hemoglobin A1Cs in diabetes. So there's just tremendous amounts of information. You tell me where you want to go and what you want to talk about.

Well, I mean, that's super fascinating. I appreciate you sharing that. It's so simple, isn't it? Actually, at its core, what you're talking about there, it's like basically saying that we're not designed to constantly be digesting foods. That's kind of it in a nutshell, isn't it? Really, we need these periods of time where the body is

able to focus on other things rather than just digesting. Yet, it seems like such an alien concept in this modern culture where we, you know, eat so much so regularly, so late in the evening as well. And this is something actually, Roger, I've been utilising with my own patients for many years now. And, you know, initially there was only really animal studies there to suggest that this could work well. And with some patients, I thought, well, there seems to be a reasonable amount of evidence. I can't really see the harm here to try this with some of my patients. And I would see incredible improvements, whether it's in reducing weight, blood sugar control, sometimes sleep quality gets better sometimes when people are practicing time restricted eating. Irritable bowel syndrome symptoms can often get better. So

from a practical perspective, I've seen huge improvements, specifically around inflammation then, which is the sort of broad topic of this conversation although we have you know gone into quite a few different areas do you see value with time restricted eating specifically for inflammation and immune function as well oh yeah absolutely so um in terms of of inflammation let's look at the surrogates of diabetes, hemoglobin A1c, because that is one of the manifestations of inflammation. As I mentioned, this study that recently was just published out of China looked at a number of patients that were randomized. This was a randomized controlled trial and they tried to blind it as much as they possibly could. Obviously, the subjects knew what arm they were in.

But the people assessing them were blinded as to which arm they were in. And the arm was, hey, look, eat as much as you want any time of day, and we'll see how things go. And these were diabetics. These were people with already diagnosed diabetes. And as we know, with diabetes, there's amazing amounts of unfortunate inflammation that can cause coronary disease, that can cause heart attacks, strokes, all sorts of problems. And then the other group, the intervention group, they said, look, we're going to limit your meals to just 10 hours a day. And that actually is pretty good,

because I've seen studies where they did it to eight hours a day. But no, they did it 10 hours a day. And that actually is pretty good because I've seen studies where they did it to eight hours a day. But no, they did it 10 hours a day. And they specifically allowed them to eat from eight o'clock in the morning until 6pm. Okay, so that's, that's reasonable. Now, now, again, that means that their first bit of food that they had in the morning was not before 8 o'clock in the morning. They were basically asked to eat well before 6 o'clock so that their fed state, they were done by 6 o'clock. You've got now from 6 o'clock in the evening all the way through to 8 o'clock in the evening, all the way through to eight o'clock the next morning where there's no food. There's not even a snack, nothing. Nothing goes into your mouth except for water and maybe a little bit of lemon juice if you wanted to have that with it, but no calories whatsoever.

So what they found was astounding. They were allowed to eat as much as they wanted. They just had to eat it between these hours. What they found was that there was a drop, a 20% drop in the hemoglobin A1c. Let me explain what the hemoglobin A1c is. It's a measure. Somebody has elevated glucose for a period of time. That glucose can bind with the hemoglobin and stay on there. And we use that in medicine to measure the average blood sugar over the last three to four months in these

patients. So this was a study that went over about a 12-week period of time. So in 12 weeks, these patients, these subjects in this study were able to drop their hemoglobin A1c by 20%. That's more than medications could do alone. That's the effect of just, we're not even saying to change your diet. They didn't say to change their diet. They didn't say to change the amount of food they were eating. They just asked them to eat it more concentrated in the day and have a longer period of time where there was no food going into the mouth. I think that's astounding. It is incredible. And you know, the big thing I think as you describe that is

coming full circle to the start of our conversation, it doesn't cost any money for people, does it? It's like, it's potentially saving them a bit of money because they're snacking less in the evening um but it's not necessarily it's not only the money it's that it's not necessarily requiring a huge lifestyle upheaval a brand new diet i need to learn to cook new new foods it's like saying, okay, well, hold on a minute. Maybe don't worry about that at the moment. Just keep eating what you're eating. Just change the window in which you're eating it. And I think it's got such potential and message like that. I'm like you, I prefer the term time-restricted eating to intermittent fasting,

because I kind of feel intermittent fasting is a bit confusing sometimes. You know, what does it actually mean? Whereas time-restricted eating, I think, can be very, very clear. What sort of recommendations do you make if you've started making these recommendations with your patients when it comes to time-restricted eating? Yeah, and it's really important to be able to look at their lifestyle. So for me, it's really important to be able to look at their lifestyle. So for me, some weeks I'm in the intensive care units from seven o'clock in the morning to seven o'clock at night. I don't get home till late. And so you don't want to be shifting this around. You want to sort of pick something and go with it. So there's really two variants of this and here are the rules. Number one is you don't want to have your feeding anywhere close to

the time that you're sleeping. That's the important thing there. And usually you want it maybe a good three to four hours before you go to bed. So eating close to the time that you go to bed is not a good idea for a number of reasons. If you eat close to the time that you go to bed, that can increase the risk of gastroesophageal reflux. It can increase the risk of aspiration and also has issues here. So the two ways is either having breakfast very early in the morning, maybe about an hour or two after you get up. And that's hard to do depending on when you get up. And then having a lunch or a very early dinner, or you flip it the other way around and say that you're going to skip breakfast, have a lunch, being the first meal a day at

around 12, and then eating relatively early in the evening, early enough, like maybe around six or seven. So you're well within that eight to 10 hour window, but then give you at least three hours before you go to bed at night. I think those are the two systems that seem to make the most sense from a practical standpoint that is going to be most common, but everybody's got to sort of figure this out for themselves and see what works for them. This is the thing. It's very personal. Yeah, I completely agree. I think the research in this area is simply just growing by the week in terms of the potential benefits, but then it's converting that and going, okay, well, I know the kind of 8am till 6pm

window worked for my friend Bob, but actually that ain't going to work for me. There's no way that's going to work with my school run, kids, job. And I kind of feel most people are able to find something that works for them in the context of their lifestyle. So it's definitely worth people experimenting. Roger, I want to thank you once again, you're so generous with your time. Of course, you make fabulous videos for people on MedCram, where you're trying to educate the public and doctors about all kinds of aspects relating to our health. You have a brilliant way of simplifying information and sharing it with people. So I want to thank you once again for that. Just to finish off today then,

we've been talking about inflammation. We've been talking about, I guess, primarily these four pillars, sleep, stress, exercise, and food. Have you got any final words of wisdom for people who are watching or listening and thinking, you know, I'm worried about chronic inflammation. I don't want to get sick when I get older. What are some of the sort of top things that I can do and focus on to keep me well? Yeah, let's just review some of those things. is making sure that you're getting bright light exposure in the morning, making sure that you are not getting bright light exposure in the evening. This is going to allow your circadian rhythm to advance and allow you to get that sleep that you're going to need and not have the anxiety of not falling asleep at night. It's making sure that you're

restricting your feeding, or I should say eating, to 10 hours, 8 to 10 hours, if you haven't done so already. Making sure that you're looking at your personal schedule and incorporating exercise somewhere. Better to do it in the morning if possible, but in the evening time is better than not doing it at all. I think exercise is really important. It also helps with sleep as well. We've also talked about mental stress, and especially now that we're going into this period of time again, potentially with the pandemic and all of the things associated with it and all the things that are going around in the world, is making sure that you're part of a community, making sure that you're giving time for yourself to rest and to recuperate and to recover, because nobody is going to do that. There's a lot of demands that are

being asked of you, especially if you're in a productive environment. If you're at a job, no one's ever going to say, hey, you need to take some time off. You need to make some time for that yourself. Otherwise, it's not going to happen. So I think those are the low hanging fruit there, Rangan. It's up to us to do it. And here's the other thing is we have to make sure, and you'll notice this in a lot of these things that we've talked about today, is that our frontal lobes have to be able to sort of say yes and no. We have to sort of take control of the situation. Otherwise, society is going to sway us back and forth. We have to be able to say, no, I'm not going to eat during these hours because I need to

do my time-restricted eating. No, I'm not going to get up and look at television or look at the thing because this is not the right thing to do. So for those of us that have that very strong internal locus of control, these are the things that we can do. For a lot of us, and I may be one of those, we don't have a very strong internal locus of control. What we can do is we can talk to our loved ones, our spouses, our friends, and say, hey, this is what I want to do. Hold me accountable. Make sure I'm doing these things because I think we all want to do it. But sometimes, as they say, the spirit is willing, but the flesh is weak. Yeah. As you say, no man is an island. We're going to all need help from

time to time. A little help from our friends, a little bit of help from our community. Roger, thank you for all the incredible work you're doing. My audience absolutely love what you have to share. And I really look forward to the day where we get together in person. Yeah, I'm looking forward to that as well. That'll involve a transatlantic trip, but I think it'll be well worth it. Really hope you enjoyed that conversation.

As always, do think about one thing that you can take away and start applying into your own life. Thank you so much for listening. Have a wonderful week. Remember, you are the architects of your own health. Making lifestyle changes always worth it. Because when you feel better, you live more.