FoundMyFitness - #107 Why You Can't Sleep (and How to Fix It) | Dr. Michael Grandner

Starting point is 00:00:00 Welcome back to the podcast. Today we're taking a deep dive into sleep, one of the most critical yet often misunderstood pillars of health, cognition, and performance. Joining me today is Dr. Michael Granner, a renowned sleep expert and researcher whose work bridges academia and real-world applications in optimizing sleep for peak health and performance. Dr. Grander serves as the director of the Sleep and Health Research Program at the University of Arizona, where he's also an associate professor in the departments of psychiatry, medicine, and nutrition. science. Beyond academia, Dr. Grander consults with professional athletes, elite performers, and high-level organizations to implement sleep strategies that directly improve athletic performance,

Starting point is 00:00:41 cognitive function, and overall health. In today's episode, Michael and I cover an extensive range of critical topics, including differentiating clinical insomnia from common sleep disruptions, and the subtle yet significant signals used to identify underlying causes like hyper-arousal, circadian misalignment, insufficient sleep drive. We discuss why cognitive behavioral therapy for insomnia, CBTI, is the gold standard treatment, its most potent mechanisms, and we also discuss key interventions that yield the greatest improvements in sleep quality. We discuss practical protocols for addressing common sleep disturbances like stimulus control, strategies for nighttime awakenings, and personalized sleep restriction methods. We also discuss recognizing and addressing

Starting point is 00:01:28 sleep apnea, including non-obvious symptoms, data-driven red flags from wearable devices, and effective non-CPAP interventions like oral appliances, positional therapy, breathing training, and more. We discuss advanced evidence-based sleep hygiene practices, including actionable protocols involving temperature modulation, breathable techniques, and also precise timing of light exposure. We also evaluate popular sleep supplements and substances from melatonin dosing and timing of magnesium, lavender, glycine, and. as well as nuanced impacts of THC, CBD, alcohol, caffeine, and late-night eating on sleep architecture. We also discuss actionable strategies to manage unavoidable disruptions of sleep, like shift work and jet lag,

Starting point is 00:02:11 the accuracy and limitations of best practices for interpreting and acting on data from consumer sleep-tracking devices, like the aura ring, whoop, Apple Watch, Fitbit, and we talk about practical insights on how sleep consistency and strategic napping directly impact cognitive performance, athletic outcomes, injury prevention, and recovery. Whether you want to improve cognitive or athletic performance or achieve better cognitive health, by the end of this conversation, you'll have an arsenal of scientifically robust, actionable tools to transform your sleep. A quick reminder before we jump in, if you enjoy these conversations and want more

Starting point is 00:02:45 practical health insights, consider signing up for my free weekly email newsletter. Each week, my team and I share fascinating, actionable health. and performance research. Recent topics have included caffeine's impact on sleep quality, the metabolic effects of delayed eating, creatine's surprising benefits for Alzheimer's disease, and the importance of potassium for blood pressure. In short, it's useful and something I genuinely enjoy sharing each week. You can sign up at foundmyfitness.com forward slash newsletter.

Starting point is 00:03:17 Once again, you can sign up at foundmyfitness.com forward slash N-E-W-S-L-E-T-T-E. e.R newsletter. Also, if you'd like to support the podcast directly and gain even deeper access, including our members-only podcast, the Aalquot, and a monthly live Q&A with me, please consider becoming a Found My Fitness premium member. It's the most meaningful way to support the show and our commitment to unbiased science-based content. You can join any time and learn more about that at foundmyfitness.com forward slash premium. Once again, that's Found MyFitness.com. Once again, that's fitness.com forward slash P-R-E-M-I-U-M premium. And now onto my discussion with Dr. Michael Granner on all things sleep. I'm pretty excited to be sitting here with Dr. Michael

Starting point is 00:04:07 Grannner, who is one of the, I would say, foremost experts in sleep science, behavioral medicine. And he directs the sleep and health research program at the University of Arizona. His research focuses on, I couldn't even tell you everything. It focuses on all things. sleep. But, you know, even, I think you're probably some of your research is some of the first to really kind of throw out this idea as using sleep as a performance enhancer, both athletic performance, cognitive performance. So I'm super excited to get into that today as well as a lot of other topics on sleep. So thank you for coming to the show, Michael. Yeah, no, thanks for having me. As we were talking about earlier, I kind of wanted to start this episode talking about sleep problems.

Starting point is 00:04:52 You know, you've got a lot of patients that come into your clinic with sleep problems, insomnia being probably one of the most prevalent ones. When someone comes into your clinic and says, I have insomnia, what sort of data points or clinical features do you kind of look at to distinguish whether or not this person actually has insomnia versus all the other things that could just be causing poor sleep? Right. That's a great question. The way I think about it is that there's really two kinds of insomnia. I call it sort of insomnia with a lowercase eye and insomnia with a capital eye. Think of it. It's kind of like depression too, where it's a word.

Starting point is 00:05:34 It's a word that we use to mean a lot of different things, but in a clinical context, it means something specific. So a lot of people will say, I have trouble sleeping and I have insomnia, but is this an insomnia disorder, is how we would call it would call it an insomnia disorder? And the way to tell the difference is how they're presenting. So an insomnia disorder is defined as a persistent difficulty initiating or maintaining sleep or waking up too early. So it can happen anywhere in the night. The difficulty has to be there.

Starting point is 00:06:11 It has to occur at least three nights per week. It has to have gone on for at least three months to be considered. a chronic insomnia. It has to cause some sort of daytime functioning problem. Could be almost anything, but it's got to cause problems. You have to give yourself adequate opportunity to sleep, so just sleep depriving yourself isn't insomnia. And when you think about what that means in terms of difficulty falling asleep, there's no hard and fast rule, but a good rule of thumb we use is about 30 minutes. So if it's taking you at least 30 minutes to find, fall asleep or you're awake for at least 30 minutes during the night trying to sleep and you

Starting point is 00:06:56 can't, that's a good sign that maybe what you have is an insomnia disorder where a lot of people will have occasional sleep difficulty sometimes. But that's really the difference where it crosses the line to where it's really interfering with your function. And how do you just determine, you know, what is the underlying cause of someone's insomnia? I would imagine, you know, a hyper aroused nervous system being one of them, but there's probably others. Yeah, so there's actually something really interesting about chronic insomnia versus acute insomnia. So acute insomnia, there are an almost unlimited number of things that can cause acute insomnia for a very good reason. I mean, evolution figured out a long time ago that when

Starting point is 00:07:42 we're under periods of stress and our survival is questioned and it's bedtime, we kind of should just keep going until we're safe, right? And we have all these systems in place to protect ourselves. So under any kind of period of hyper arousal or stress or anything, whether it's mental, physical or both, we have systems in place that can prolong wakefulness relatively safely, especially in the short term. And so there are a million causes of short term insomnia. but there's only really one cause of chronic insomnia. And there's a switch that flips from short-term insomnia to chronic insomnia. And that switch is all around the concept of a conditioned arousal.

Starting point is 00:08:32 That's why when someone comes into the insomnia clinic, often the thing that caused their acute insomnia is actually no longer relevant. It's sort of like a ball is rolling, right? And if the ball is rolling down a hill and with the ball was pushed, shoved, kicked, leaned on heavily, whatever caused the ball to start moving is important because you want to prevent that in the future. But if you want to stop the ball from rolling, knowing what that is and doing anything about that is largely irrelevant. The problem you're dealing with now is gravity and momentum.

Starting point is 00:09:10 And that's what happens with chronic insomnia. It takes on a life of its own because of this concept of conditioned arousal. Can you give an example of that? So let's say, you know, someone has work-related stress or something, right? And maybe it's a project-related or maybe there's emotional related stress from a relationship. And it does eventually kind of get better. And yet there's still kind of having problems fall asleep. Now, what would be the conditioned stimulus?

Starting point is 00:09:40 So this is what happens. something causes you to lose sleep, right? And what ends up happening is you exert effort to get that sleep back. You know, when you lose your keys, what do you do? You go looking for it. Where do you look for it? The last place you had it. And if you're losing sleep, where are you looking for it?

Starting point is 00:10:00 You're looking for it in bed. But what's happening is you have this activation going on. You have this cortical or cognitive or physiological. or any combination of these arousal systems engaged. And when those are engaged, it is just physically harder to fall asleep. So even if you are tired, even if your natural sleep wake drive is working just fine, you have this counterweight sort of keeping your mind and body sort of activated. So what ends up happening is the act of trying to fall asleep,

Starting point is 00:10:37 whether it's the beginning of the night, middle the night, or wherever, becomes predictably stressful. The brain's a pattern recognition machine. You feed it the pattern of sleep is difficult, sleep is stressful, sleep is hard to obtain, sleep is a battle. You feed it that over and over and over again. Even when you are exhausted and tired and sleepy, just getting into that mode will then wake you up.

Starting point is 00:11:06 when sleep becomes predictably stressful. Think of something else in your life that's predictably stressful. So a common analogy I like to use is like you go to the dentist office. I have a friend who's a dentist who hates that I use this analogy. But people know what I'm talking about. Whatever that metaphorical dentist office is for you, you go, you're there, nothing has happened yet. You're already in this heightened state of arousal.

Starting point is 00:11:31 You're responding to it a stimulus that hasn't even occurred because you're predicting that it's going to occur. You're in the waiting room. You're already kind of a little antsy. You're delaying making the phone call to make the appointment three months in the future because you're already responding to that future stimulus that's causing you stress. Like being in a place that's predictably stressful, you anticipate it. You can predict it. And by predicting that stress, it creates arousal and activation. The The difference is when you're in the dentist office, no matter how activated or stressed you are, as long as you open your mouth, they can do their job, right?

Starting point is 00:12:14 But in bed, it doesn't work that way. If you get into bed and you are dead tired, you are exhausted, you are sleepy, you are ready, and you get into bed and all of a sudden your body is like, oh, here we go again, or is this going to be a problem or whatever that automatic process starts happening, that predictable process happens. It builds activation. That activation makes it just a little bit harder to fall asleep. You eventually fall asleep, baby.

Starting point is 00:12:45 But the connection between activation and sleep is not weakened, but strengthened. And so you're a little stressed, you get into bed, have trouble falling asleep, eventually fall asleep. Getting into bed is predictably tied with stress, and by adding stress to it, you strengthen the prediction. and it becomes a self-perpetuating cycle. So whatever the initial cause of the stress was, it's the stress about not sleeping itself that creates the very activation that makes it harder to fall asleep,

Starting point is 00:13:14 which strengthens the connection with stress, which makes it harder to fall asleep, and it becomes a cycle. That's why the best treatments for insomnia aren't about sedating you. They're about reprogramming that whole cycle. Wow. You've just explained insomnia to me in a way

Starting point is 00:13:30 that no one ever has, and it's like just clicked. And I'm like, this is... That's what happens. What happens, right. And so now I completely understand this concept of stimulus control. Right. So let's talk about CBTI, cognitive behavioral therapy for insomnia. Yeah.

Starting point is 00:13:45 And obviously there's lots of components to it, one of them being the stimulus control, which now is like making so much more sense to me. Yeah. But let's talk about what that is, why it does work so well for people. And, you know, and also, you know, back to this whole, like, training, this negative negative association, this negative stimulus, you know, where you're like just the act of getting into bed is making you hyper arouse, is giving you anxiety. Is that also true then? Let's say you do eventually fall asleep, then you wake up, whatever you have to repeat, whatever it is, it wakes you up, you're hot. And then all of a sudden, you're still in that bed and it's like,

Starting point is 00:14:17 again, that negative association, right? And so it's like every time you wake up. And that's why some people, they fall asleep just fine because, so something for people to understand is that Sleep awake is not a unidimensional line where you're sleepy, sleepy on one end and awake on the other end. There's actually two separate dimensions. There's, think of it like there's treble and there's base. And they're not, it's not just mono. There's travel and there's base. You have a wakefulness signal and you have a sleep signal that are separate from each other.

Starting point is 00:14:53 They're related, but they do function somewhat independently. And so sedatives boost that sleepiness signal. A lot of times with insomnia, what happens because of the excess activation or arousal, your sleep signal could be just fine. It's your wake signal that might be too high. And so when someone is taking, say, a sedative medication, what you're doing is you're just, you're trying to drive up that sleepiness signal so high. It's just steamrolling over whatever activation you have. And often that may work. And the reason it can work long term sometimes is if you steamroll it over enough, you can,

Starting point is 00:15:29 you can maybe break that learning. So it's not, so it isn't just the sedation, but for a lot of people, it's not sedation. That's the problem. The problem is in the activation. And when you're doing therapy for insomnia, it's often not about, so patient will come in thinking, like, how do you make me sleepier? Actually, we've got, we've got some tools for that. We'll talk about that.

Starting point is 00:15:49 But often, the magic isn't about making you sleepy. it's about making you less awake. And it's a different process. And that's also why it doesn't work 100% of the time. Nothing does. But that's why CBTI is so effective because it's actually targeting the problem that the person actually has. Okay. Let's talk about it.

Starting point is 00:16:13 Awesome. So here's the deal. A few, several decades ago now. So stimulus control was first published in 1972. This isn't new. stuff. And it was this, it was under this idea. The idea of stimulus control is if you're in a place where only a very limited number of things could possibly occur there, you will predict that they will occur and you get yourself in the zone. So we talked about the dentist chair,

Starting point is 00:16:41 but a great positive example is going to the gym, right? Like if you're going to the training room or wherever, you don't do anything else there. So even if you're kind of tired or if you're in a bad mood or whatever, once you start that process, you can usually finish the workout at the end. And then you go back to your life. But when you're there, you can get in the zone. And it's because being there creates the conditions that are predictably tied with doing what you're going to do. And so when you're in a place where there's a limited number of options, those options become predictable. On the other side of stimulus control is if you're in a place where all kinds of options exist, none of them become predictable. So a great example of this

Starting point is 00:17:24 I found is especially over the pandemic and as people are working from home more is the dining room table started also becoming where people work. And it wasn't just a place where you eat. So it used to be you sit down at the dining room table because all you do is eat there. You'd start getting hungry. But if that's also where you work and it's also where you watch TV and it's also where you're socializing, you sit down, you're thinking about work and you want to put the TV on and you may or may not, may or may not be hungry. So like it, it dilutes the ability of the place to have a response if you start increasing the number of things that occur there. And so the way this is applied to sleep is

Starting point is 00:18:02 that if in bed, if being in bed is predictably tied to sleep, you can program that association. But if being in bed isn't predictably tied to sleep, you don't know what to predict. So, So I got to, so here's an example. If I say bed sleep, bed sleep, bed sleep, bed sleep, bed sleep. I say bed, you say sleep. Sleep. Correct. If I say bed sleep, bed wake, bed think, bed wake, bed sleep, bed wake, bed sleep, bed sleep, bed think, bed.

Starting point is 00:18:38 Surf. Maybe. Scroll. You have no idea. Right. You have no idea what's coming next. You can't predict the pattern. human brains love patterns.

Starting point is 00:18:47 And if you can't control the sleep side of the equation yet, at least you can control the bedside of the equation. Stimulus control therapy, which is one of the core components of CBTI, was built around that. And since that time, CBTI has emerged as sort of this multi-component toolbox. Stimus control is one of the core components. But there's all these tools that we have that are essentially, it says therapy. It's a lot less like psychotherapy. It's a lot more like physical therapy. Where we're teaching your body to do a thing it physically can do,

Starting point is 00:19:25 it just doesn't know how anymore or it forgot or you need to build it back up again. So you have all, everything is there inside of you. When a patient comes in and says, I'm having trouble sleeping. It's like saying, I'm having trouble breathing. When someone says I'm having trouble breathing, it's not just because like they suck at breathing and it's just a skill they never mastered, right? Like you were breathing when you were born. No one had to teach you.

Starting point is 00:19:51 It's a part of how your body works. The trick is why aren't you able to do this thing you were built to be able to do? What's in the way? What's preventing your body from working the way it's supposed to? And insomnia treatment is often like that. It's like you can probably sleep just fine. You are built with this ability. There's a chance maybe there's something else,

Starting point is 00:20:12 but most of the time you have everything in you you need to sleep fine. Something is in the way. Let's get that out of your own way and clear that path. So do you, I was going to ask you a question about what you think the most important mechanism behind why CBTI works. It's through the conditioned arousal. It's teaching people that, that, A, they can gain more control over. their ability to sleep than they thought. But also paradoxically, it also teaches people how and when to surrender some control. So like, let's say you have a stomach bug and you have no appetite

Starting point is 00:20:55 for a day, right? You're eating like toast and drinking tea or whatever. I just, if you eat anything that would be bad. You don't think, what if I starve to death? That's not a thought you have. You don't think, oh, I have this stomach bug. What if I get a niacin deficiency and have permanent damage because, no, you don't. What you think is, I don't have an appetite for a couple days, but in a couple days, it'll come back and I'll be fine. And when people deal with temporary sleep loss that same way, it's a similar system. The system can correct itself if you let it. But what ends up happening is when we start stressing about it, it starts creating these problems. And a lot of times, it's us getting in our own way. Right. Let's say you had, you know, someone

Starting point is 00:21:41 that has to work on their stimulus control. Yeah. You know, there's someone that likes to get into bed. They have trouble falling asleep. So they pull out their phone. They're scrolling. They're looking at, you know, social media, whatever. And maybe they're ruminating.

Starting point is 00:21:56 Yeah. Like what would be your, how would you approach that? Like what would be like your two-week fix? Great. So first of all, in addition to stimulus control, in terms of the other tools within CBTI, a lot of them focus on this idea that, you want to drive your natural sleep drive, put that sleep drive in bed, and when bed is not really going to be used for sleep, you get up.

Starting point is 00:22:21 And so if you're going to be on your phone, the first thing I would say is try and separate the phone from the bed. Have the bed be the place where sleep is occurring, not where sleep is predictably not occurring, because it's not occurring when you're on your phone. See if you can do that. if for some reason you have to be in bed when you're on your phone, I would say the thing to do is you still want to create that separation. The best way to do that is maybe stand next to your bed. Because like I say stand, it's silly and very rarely do people actually do it, but people sometimes do.

Starting point is 00:22:59 And I do this because if you're standing, if being in that proximity is important for your ability, to sort of wind down or whatever, but at least A, you're not in bed, but B, the standing does something very important. And especially people in the athletic space will know this, that you don't lose touch with your body's communication to you. When you're standing, there will eventually come a point where you say, but I really want to sit down now. That's your body telling you that you're ready. Or you may be standing thinking like, what am I standing here like an idiot for? I've been here for a half an hour. what am I doing? That's your other signal that you're not ready. Sleep is not something that you do.

Starting point is 00:23:43 Sleep is something that happens to you when the situation allows for this. That's a concept I, barring from a colleague of my Lindsay Shaw, who's also a fantastic sleep person and sports psychophysiologist. I learned this from her. I use it all the time. It captures it really well. Sometimes sleep is is not under your, your ability to sleep isn't under your control. You're awake. Like you need to wind down. maybe you're just not ready. And if you're just not ready, laying there in bed scrolling is going to help. Go do that somewhere else. If you are getting ready, respond to those body signals. If you can't stand next to your bed, if that's a little too silly for you, sit and sit up on your bed. Don't not like just a little propped up. Your head's not on a pillow. You're not under a blanket.

Starting point is 00:24:26 Sit up. Again, you're not going to lose touch of your body's signals. And worst case scenario, at least you get the head bob. The head bob is, is. is your friend. The head bob means it's your body telling you you're ready. This is also like if you're watching TV or on the couch or whatever, and you're within that zone where you might be wanting to go to bed, lean forward when you're watching TV or your movie or whatever. We're scrolling because you'll get the head bob.

Starting point is 00:24:54 You won't get it when you're leaning back. You get it leaning forward. That's your signal that you're ready. And what happens if, you know, someone wakes up in the middle of the night and then they're ruminating. Yeah. Can't fall asleep. So again, sleep is not something you do.

Starting point is 00:25:10 It's something that happens when the situation allows for it. And if the situation is not allowing for sleep in that moment, get up. If you're sitting there and you're eating and you have no appetite, you don't just sit there and stare at your food till you become hungry and it becomes more appetizing. It actually backfires. So often when people wake up in the middle of the night, it's because something, naturally occurred to produce that awakening, whether most commonly would probably be some sort of physical discomfort like pain, or maybe you sunk into your mattress a little bit,

Starting point is 00:25:45 and it's just a little discomforting. You need to wake up and move. Sometimes it's untreated sleep apnea, super common. You have a respiratory event that you don't know you had. If you ever wake up suddenly for no reason and you don't know why and can't get back to sleep, you know, we'll talk a little bit later about sleep apnea, but that can cause these awakenings. And when you have some, you have some something that causes this awakening that arose from inside you wasn't under your control. And what ends up happening is that that physical activation escalates. And just like a snow globe, you know, you shake up the snow globe, it takes a little bit of time for it to come back down. And when your snow globe got shaken up while you were asleep and you're awake, you can't make it fall back down faster.

Starting point is 00:26:29 There's nothing you can do. You can poke at it, make it go slower, but you can't make it go faster. you just have to wait till everything settles back down. And it often doesn't take as long as people think, but what ends up happening is as your snow globe is settling, then your stress starts rising again, slowly rising, because like, why can't I sleep? What if I can't fall asleep?

Starting point is 00:26:49 What if I'm up the rest of the night? Blah, blah, blah, blah, blah. And then you start stressing and freaking out about it. So now your body is ready, but your mind isn't anymore. And I got to wait for that to come down and you just prolonged it. the because you don't have control over this part surrender that control recognize that you're going to get up you can get up take a break wait till you're ready try again just don't prolong it any more than is necessary so sometimes surrendering control actually shortens the awakenings sometimes it does it sometimes you know what what if you're up for the entire rest of the night and you just don't go back to sleep that's often people's fear but the truth is A, that's unlikely. And B, even if it does happen, you'll be fine the next day.

Starting point is 00:27:35 And guess what happens if you're halfway through your dinner and you just lose your appetite and you just don't eat the rest of it? What happens the next day? You don't die. You just are a little more hungry and you'll eat a little more the next day and the system will correct itself. Over-correcting is the problem. So to kind of just, for my understanding, for the stimulus control. Yeah. like the most important part of it, like for these, for these individuals that do have this, like, fear of like not sleeping or like it starts to, you know, they just immediately get like anxiety about it.

Starting point is 00:28:12 The best thing is to surrender or is that like the strongest part of the stimulus control? Yeah, it's the performance anxiety. The fear is what's creating the activation that's getting in your own way. So recognizing that it's not under your control, trying to control it is not going to help. Nobody got to sleep faster by trying harder. The enemy of sleep is effort. If you're engaging in effort, you're adding energy into the system. And athletes especially are vulnerable to this because, you know, athletes are used to gaining control over their body.

Starting point is 00:28:53 and learning how to control their body in ways that most people just don't know how to because they haven't been trained to. So there's always a solvable problem there. Sometimes it's like injury recovery. Sometimes you can't make it go faster. Like if you injure yourself, you got to do what you got to do to recover. You can't, there's no like dance you can do or book you can read that will make that recovery go faster. You've got to give it the time it needs. similarly, this is a process that's outside of your control.

Starting point is 00:29:25 Trying to control it will actually make it go slower. Okay. And so the next part of, you know, CBTI that, you know, you hear about is this sleep restriction, which sounds awful. Worse name. I mean, so if you actually look to the original publication, they didn't, they didn't even call it sleep restriction therapy. They called it restriction of time in bed, which is really what it is. it's a simple concept of again a lot of these things are simple in concept but difficult than execution but the concept of sleep restriction therapy which I hate calling it that because it doesn't

Starting point is 00:30:01 it's not about the restriction and that's the thing sleep restriction could be part of it but it isn't always the idea is let's say you're spending eight hours in bed but six hours to sleep. We know you physically can sleep six hours. Okay, let me give you six hours time in bed, see if you can fill it. Let's get you to the point where you can fill it, and then we'll slowly increase it from there. Actually, sleep restriction therapy has more increasing of sleep than decreasing. But there's that decrease at first. The way I explain to people is this. It's actually not super complicated. Let's say you're trying to eat your vegetables and you've got a kid who's not eating their broccoli, right? And you put 20 pieces of broccoli on their plate and they're not eating.

Starting point is 00:30:39 they can eat one or two and then they're like, oh, I hate broccoli, blah, blah, blah. Then you say, okay, I need you to learn how to eat your broccoli. Tonight, I'm going to give you two pieces of broccoli. Can you, I know you can eat that because that's what you've been eating every day. I know you can eat that. So you eat the two pieces of broccoli and then they say, but I'm still hungry. And then you say, great, you will get three tomorrow. Let's see if you can eat those.

Starting point is 00:31:03 Then they can eat the three pieces. But I'm still hungry. It's like, okay, hold off on don't eat anything else. but the next day you'll be hungry enough to eat four. And then you slowly, you start with what they can already do, but you don't give the other stuff that will, so you don't let them stay in bed when they're not sleeping. At least give them the opportunity they're already able to fill.

Starting point is 00:31:26 At first, all the mental blocks and stuff will be there. So it might drive down their sleep a little bit in the short term for several days, maybe even up to a couple weeks. But they eventually, eventually they get hungry enough for they can eat all the broccoli on their plate because you're not giving them anything else. Then all of a sudden you start introducing other foods back that they actually like, but they've gotten over their broccoli deal. And that's what it is with sleep.

Starting point is 00:31:46 You drive up their natural sleep pressure. You separate out the time in bed that's not wake. You make it so that being in bed, you're so, you go from not being able to fall asleep to not being able to stay awake because you drive up that natural sleep pressure. And it's like, well, you have problems with your appetite? Fast for a little bit. That'll help a lot of problems.

Starting point is 00:32:07 with your appetite. You're going to be hungry again. And so this idea of not having your phone in bed, it's part of that. Yeah, it's part of that because you don't want to do anything in bed that is not sleep. You want to make it so that when you get into bed, you put your head on the pillow, you're under a blanket, your eyes are closed, you're breathing through your nose, that feeling is so predictably tied with becoming unconsciously. in a very short amount of time that even when you get good at that, so this is, this is the power of this.

Starting point is 00:32:44 When you get good of that, you're using the prediction not just to solve a problem, but to create a benefit. Imagine you're a little bit stressed. You've got a big day tomorrow. But you've so trained yourself that that place is so predictably tied with sleep that you're stressed, you've got a big day, you've got stuff you're working on.

Starting point is 00:33:03 You get into bed, close your eyes, head on pillow, under blankets, start breathing. then all of a sudden you fall asleep. You can train yourself to get the outcome you want, and that gives you control. So let's say you've got to wake up super early one day because you're going somewhere, you've got to practice or something.

Starting point is 00:33:22 You need to go to bed an hour or so earlier than you really are used to. If you've got yourself well trained, you can use the environment as a condition stimulus for sleep when you want it to be. So when, so how long does it take to, for most people to train themselves, like through the stimulus control, sleep restriction, where, you know, the bed is really just for, I've heard sleep in sex.

Starting point is 00:33:45 Yeah, so sex is fine. That's usually not the problem. Right. You know, do that in bed, out of bed, wherever you want. That's fine. Usually that's not taking up so much time. I mean, and it's not interfering with your ability to sleep. Sometimes it can help your ability to sleep. But that's fine.

Starting point is 00:34:01 But it's probably the phones that are the biggest problem nowadays. It's distractions. So distraction. the activation, all of this stuff, you're adding energy in instead of taking energy out. Relaxation is fine to do in bed, but if it's brief, you know, if you're spending, you know, a half an hour meditating in bed, that might be a little too long. I know people who like, they have this whole hour long routine that they do. Like, by the time that hour is done, the bed is no longer predictably tied to sleep anymore.

Starting point is 00:34:30 So, yeah, it's about, it's about getting this stuff out. It doesn't, I'm not saying don't be on your phone. but I mean I actually think does the sleep field telling everyone get off their phone for an hour before going to bed is not a helpful recommendation because no one's going to follow it. We should be talking about how to do it safely in a way that's not going to get in your way. And that comes down to what you were saying earlier, either being in another room or sitting up or standing. Yeah. And also it's what you're doing that's important. You might want to create sort of boundaries. So like maybe within a half an hour of when you're planning on going to bed, maybe switch to something that's not too mentally activating. Like if you're the kind of person where you watch the news and it gets you all worked up and angry, don't do that before going to bed.

Starting point is 00:35:19 Maybe do it the hour, you know, in the earlier part of the evening. I mean, the great thing now is TV isn't live anymore back when I was a kid. You had to watch it when it was on and that was it. now we can gain more control over what we're exposing ourselves to media-wise. The rule of thumb I use, and this is what I use for myself, if an alarm went off right now and said, okay, time to turn it off, could I? If the answer is yes, then it's probably okay to do within that time frame, because I can easily disconnect from it.

Starting point is 00:35:54 If the answer is, no, no, no, five more minutes. I want to see how it ends. or I want to, you know, whatever, that's probably not the thing to watch in that buffer time. Watch it before the buffer time. But don't do that in the buffer time. Like if you're scrolling and you can easily put it down, I don't know that, I don't know that that's that big of a deal.

Starting point is 00:36:13 But if you're scrolling and like half an hour will go by and you wouldn't even notice and you lose that time, and then you say you don't have time, but you just threw away some time, you know, that you didn't need. So like those are the sort of things. You want to make sure that you curate what you're doing so that it's not too activated. Why are a lot of people that have insomnia? Why are they prescribed, you know, these sedatives like, you know, Ambien or...

Starting point is 00:36:40 Well, they don't not work. I mean, like I was saying, like what they do is they drive up that sleep drive so much it overpowers whatever's in the way. And it's kind of an easy solution. The thing is, honestly, it's much easier to write a prescription. Like, you can go to any primary care anyway. and they can write a prescription. But if you look at every medical organization that has any recommendation around how to treat insomnia.

Starting point is 00:37:10 And for athletes, you know, this includes like NCAA and IOC who've put out sleep-related materials. They all say CBTI first. And that's because every study that has ever been done shows that when you compare, when you pool the data from CBTI trials, it works shockingly well. Not only does it work reliably well. It works when you have other, like, well, what about if you're in chronic pain? Like, the pain is keeping you up. How is that you don't have conditioned or else?

Starting point is 00:37:46 You have an active thing going on. Still works in fibromyalgia, works in chronic pain, works in chronic pain, works in pain. cancers, it actually might be better in cancer survivors than people who aren't cancer survivors because they don't want to take these medications. They're more motivated. It works in sleep apnea. It works before your sleep apnea is even treated. It helps with your insomnia. Find me a condition. Works in older people. Works in younger people. Works in, so like, it's a blunt instrument. It's retraining yourself to sleep. It doesn't, and it works well by helping people gain control. It doesn't necessarily add hours to your night, but neither do sleeping pills either.

Starting point is 00:38:25 What it does is it removes some of those barriers. But again, about 85% of the time, about 100%. But it's also some people don't know how to get access to it. Or they read about it online and either the information they get isn't great or they have exposure to it in that, you know, maybe, you know, maybe they're doing it by the book, but they might need a little flexibility with it or something. But there's lots of adaptations. I mean, we edited a textbook on how to adapt CBTI to different populations. But, you know, a lot of people just don't know what exists. And the people who do don't really understand what it is or how to find someone who knows what they're doing.

Starting point is 00:39:03 Is that the key? Do you really have to find someone that knows what they're doing? Or can you try this yourself? Yes and yes. I mean, there are many people that I've talked to who've tried it, done it with themselves. I mean, because it's not rocket science. there's an art to it, but the basics of it are relatively simple. It's bed equal sleep.

Starting point is 00:39:26 Get out of bed if you're not sleeping. You know, compress your window of, you're giving yourself too much opportunity. You're not filling it. Compress your opportunity, but then expand it again once you can fill it. Some basic stuff like that. And some people could just do that on their own and that's all it takes. Some people, they need somebody who knows, they're doing. The problem is there's not a whole ton of people who are trained in this, despite

Starting point is 00:39:51 it's being around for a long time, despite the fact that it's really well supported. There's not a ton of people who are well trained. There are some online versions available where they can automate some aspect of this. It's a very, it'll be very by the book, but for a lot of people, that's all it takes. You can do this over telehealth. Any state that you're in, I can promise you there's someone who can do this via telehealth in your state. So it used to be very geographically restricted. It's not anymore. There's a couple of good directories online of if you're looking for somebody, we have a board certification. You can see who's board certified in this. And it exists because it's not part of normal training. So to be able to say that you're good at, you have to like

Starting point is 00:40:35 prove that you know what you're doing. But yeah, you can look online for people. And again, there's, there's telehealth options too. So whatever state you're in, um, you're, um, you have to, can find somebody. What percentage of like the U.S. population has insomnia? It's a great question. For decades, any population level study has generally found kind of the same thing, mostly. And it hasn't, it doesn't seem to have mostly changed much, that about one out of three people in the U.S. has some sort of sleep complaint or problem or something, whether it's falling asleep,

Starting point is 00:41:10 staying asleep, not feeling refreshed. that seems to be about a third of the population at least. And it seems like about one in ten people probably would meet the criteria for an insomnia disorder if you assessed them. And then what ends up happening is they start trying to fix it on their own and they start going down paths that end up being unhelpful and then they get more frustrated and then sleep becomes more stressful and they give up and they say like, I'm a hopeless case. I get one of these a week in clinic. So I'm the worst sleeper you've ever seen. I've tried everything. I've had this problem forever.

Starting point is 00:41:47 Then six to eight sessions are better. Yeah. One in ten is a lot. And I definitely think we're going to talk about some of these substances, people then turn to because they think it's going to help treat their sleep problem, which they don't necessarily know is even insomnia. Right. And so they're, you know, turning to things like alcohol and that doesn't really help. So. But before we get to that,

Starting point is 00:42:09 sleep apnea you mentioned. And that's another one that I wanted to talk about. I've known a lot of people, it seems, that have had sleep apnea. I wonder how you can tell me how common that is as well. But first I kind of wanted to ask you, like, what are some of the non-obvious presentations that, you know, of sleep apnea that you see. Yeah. Especially in people who, like, maybe don't even report feeling sleepy.

Starting point is 00:42:32 Right. So the thing with sleep apnea is, the first thing to know about sleep apnea is it is shockingly common. It is very, very, very common. The most recent data I've seen estimates that about one out of four or five men over 30 probably has at least some sleep-related breathing issues, especially if their BMI is over 30, it's more like 50-50. It's really high. Women get it less often, but it's also shockingly common in women too. It might be more like one out of every 15 or 20 women. And then as as BMI goes up, it gets more common. So it's shockingly common. It's so common that my threshold for screening for it is very low, especially among otherwise fit people. Because

Starting point is 00:43:27 the normal risk factor, so like as you gain weight, you get it more because it can crowd out your airway. Muscle too? Yeah, muscle too. It's because Think of it this way. So most mammals, their airway is a straight line, you know, from snout all the way out and to, to their lungs. It's a straight line from snout to their lungs. Humans, by moving upright, we solved a lot of problems and we've gotten a lot of benefit from being upright.

Starting point is 00:43:58 But it created a problem with us in that our tube now has a 90 degree angle in it. and if you're designing a pipe and you put a 90 degree angle kink in your hose, where is it, where is it going to start having problems? It's going to have problems at that. And that's what happens. So like right around that spot here, that's where we get narrowing of the airway.

Starting point is 00:44:25 And so like any mass, whether it's muscle or fat or whatever, any mass, I mean, there are people who look at MRIs of like tongue fat, like cheeks, like anything here, whether even skinnier people with smaller airways, you know, where it's a little more compressed, it's just, it's a, it's a vulnerability in, in the human physiology for breathing

Starting point is 00:44:51 issues. And it's actually mostly fine in that you can have four or five breathing pauses per hour in the night and be in the normal range. It's actually sleep. Papua does it begin. Five is mild. Begin, is the low end of mild. And it's not even until you get to 15 per hour that it becomes start becoming moderate. So many people who are in the mild range don't even have any symptoms and might not be causing any problems. We have a lot of flexibility in the system. But as you get older and neuromuscular control changes, as we put on more pressure here in the airway by gaining weight or whatever, it just becomes more and more common. And my My guess is it's actually been common through history.

Starting point is 00:45:39 It's just we've written it off as something else, especially in people that don't have those obvious signs. So what are some of those less than obvious signs? I have a patient who comes in. And they say, I fall asleep just fine. Actually, if I'm anything, I'm a little tired during the day. Whatever. I fall asleep just fine.

Starting point is 00:45:58 But then I wake up in the middle of the night because of stress. My stress wakes me up. And then I have a hard time falling back asleep. When I hear that, I think there's greater than 50-50 chance in my mind that that was a respiratory event. Stress doesn't wake you up. What happens is if you wake up and you're thinking, I'm stressed, your brain is reading signals like elevated heart rate, elevated respiratory rate, the endorphance of the muscles getting tense. It's reading these physical signs. and then because we live in the society we live in,

Starting point is 00:46:36 stress is readily available. We can fill that space really fast. But what was happening was it wasn't the stress that woke you up. It was that, you know, your breathing was starting to get a little bit constrained. So then what happens is your airway tries to open itself up. And it was trying and it wasn't,

Starting point is 00:46:55 it wasn't successful. So it tried harder. Still wasn't successful. Tries a little harder. Still not. successful. Worst case, you wake yourself up and you, and you can, you can wake up with a gas because you can breathe when you're awake just fine. It's a different neuromuscular control system. So as soon as you wake up, you sort of get that, that sudden awakening because you just got

Starting point is 00:47:16 that little sort of a shot of adrenaline to wake you up. And like, if I just shot you up with a little bit of adrenaline during the night, you'd wake up and you would not be able to fall back asleep. Your mind would start racing and you'd have all these physical signs. But it wasn't the stress that woke you up. The stress got superimposed on it. later. So when I have a patient who comes in and describes that sensation of, I wake up in the middle of the night either because of stress or for no reason. I don't know why. Something wasting up. I have no idea. But I cannot get right back to sleep immediately, like within a few minutes. I mean, something just happens. Some flare up just happens somewhere. Um, that's, that's what I look at.

Starting point is 00:47:55 In athletes, often what I'll look at is I feel like my sleep is really shallow and I don't know why. because what's happening is you might be having lots of these low-level respiratory. That's the thing when you get the more severe sleep apnea of like 30 events per hour or more with these other presentations. But you get a lot of the mild to moderate cases in people who, you know, don't have a lot of extra weight, aren't older and have neuromuscular control issues, like, which just happens with age. They're younger, they're healthier. But they just might have a narrow airway.

Starting point is 00:48:27 and and so like I'll never forget like there was this there was an Olympic level athlete I was working with she was she was in the trials and she's like she's not meeting the times I think I should she's still faster than everybody else but she's like my intuition is telling me something is in my way from reaching what I could be doing I don't know what it is and like how you sleep it's like I feel like my sleep is kind of shallow I fall asleep just fine but I feel like I'm up a few times during the night and I don't really know if that's a problem or not. So I'm like, well, let's see what's going on. Turns out she had mild sleep apnea, got that treated better. And she's like, oh, that was it. And in the real world, it would have been missed. It would have been someone

Starting point is 00:49:14 just slogging through their day. They would have just been like, oh, you know, life is hard. I'm tired. Not sleeping is good. And then probably in 30 years, she would have gotten diagnosed by the time it was more obvious if she weren't an athlete. So what should a person do? do? Like, how many, is this an every night thing where people are getting woken up? Like, if they're having apnea? Is this like an every night thing? Like, what sort of sort of symptom clusters, biomarkers can people look at short of like going and getting the thing on your finger and measuring the oxygen and, you know, the whole. Yeah. I mean, so, so here's the thing. It's normal for people to wake up in the middle of the night sometimes. Actually, the typical adult will wake up 10 times a

Starting point is 00:49:55 night or more during the night. They just don't remember because it's very short. I mean, again, evolution figured this out a long time ago. You wake up, no bear, back to sleep. Like, that's normal. But if you're remembering more of those awake, if you're remembering three, four awakenings, if you have an awakening, especially waking up like with a gasp, like, if you wake up like that, or you wake up with a snort, like, if you wake up with something like that, if you, or if you feel like you just can't get enough sleep. Like you try and sleep a little bit more, but it doesn't help.

Starting point is 00:50:31 It's like it's just empty calories. You know, like it's not about the amount anymore. There's like something that's keeping it artificially shallow. There's lots of things that could be. It's just sleep apnea is so common. Why not take test? Why don't just get tested?

Starting point is 00:50:45 Just go get a referral. Get tested. You can do them at home now. It's easy enough. In turn, it's, there's no real good bio marker for it. yet. I know people are working on it. There's no real good biomarker except that that sleep is shallow.

Starting point is 00:51:02 It's fragmented and you don't know why. I mean, it could be something else. Could be inflammation. It could be pain. It could be environmental. There's lots of things. It's like if you're not breathing, is there a problem with your lungs? Is there a problem with your air? Is there a problem with the pollution in the air? So like, is it, is there something that's preventing your body from being able to sleep? Or, and, and if it is sleep apnea, it's so common. This is why my threshold for screening is just ultra low because if it was that, and I do all the tips with you, and I work out this, and I do all this, and you're still feeling like, oh, but my sleep just isn't good. And I knew when day one that this was a possible reason why, then I'd feel like an idiot for not even checking, because we did all this work and maybe we didn't even need to. do those at home kind of could have I remember doing one once like years ago when I was in graduate school and I was I think I was waking up because of stress but yeah yeah um the test came out negative but I wore this like yeah ox pulse thing I think I don't know what it was in my figure so there's there's a bunch of devices they've gotten better and smaller over the years um there's still people who do need to come into the lab those are usually reserved for when there's like another sleep disorder you're also looking for like narcolepsy or or limb movements or something.

Starting point is 00:52:20 or if you're medically complicated, like you need supplemental oxygen or if you might have heart failure or something where you need to kind of be monitored in the hospital while you're doing it for safety. Other than that, or the test you did at home was negative, but you still have a lot of symptoms and maybe it missed it because the home tests aren't as sensitive.

Starting point is 00:52:38 Like you won't get false pauses, but you might get false negatives. That's the only time you'd really need to come into the lab most of the time. Usually they just give you the thing to take home. And these days, you can wear it as a strap, They have ones that just go on your wrist and they measure, they measure your oxygen levels during the night. And what you can see is how is your respiration tied with your O2? Because respiration drops during the night too.

Starting point is 00:53:03 And so does O2 a little bit. But if your respiration is dropping and then your O2 starts dipping and then it opens back up again and gets recovered, like you look at these patterns of what's happening during the night. And you can see in one night if someone's clearly has sleep happening. or not. Okay. It's easy enough. If you're working with someone who has obstructive sleep apnea, like, how do you go back differentiating if it's, like, caused by allergies or positional or, you know, something, something like nasal congestion? I don't know. Yeah, yeah, especially when it's more on the mild to moderate side. Right. Where, um, so the great thing

Starting point is 00:53:42 is the, the ones that are on the strap, they usually have a gyroscope in it and they can measure your breathing separately on your side and on your back. There's a lot of, of people where it's just that it's on their back. That's the issue. And for those people, there's actually really simple fixes. They sell these devices where it's really just a strap you wear. In the old days, they used to sew a tennis ball in the back of a t-shirt. And that's all it. So like whenever you rolled on it, you just roll off it. And they have like fancy versions of that now where that's essentially what it is where it's, there's a couple of words, a strap. It's like a belt, but like the back of the belt has a little bump on it.

Starting point is 00:54:19 And so like whenever you roll on it, you just roll off it. Just stays off your back. That's it. You can't force yourself to stay off your back when you're asleep. You're like, well, I'm just going to fall asleep on my side. Well, you can control it when you're unconscious. So like you can see if it's positional easily in the diagnosis. And if it is, then just try treat it positionally.

Starting point is 00:54:37 And then what I would do is retest using the positional device and see if it all goes away. Because it might, might not. If it's allergies, this is why. The sleep docks, you know, we get a lot, they get a lot of training. And I've gotten some of this too when I rotated in sleep medicine. Like, you see what to look for. So like you look at nostrils. You look at their nose.

Starting point is 00:54:58 You have them breathe in. You look inside the airway in the mouth. And like you can see where their soft palate is. You could see their tongue. You can see some of these things. And, you know, sometimes, you know, there's a lot of sleep medicine that's using, you know, Flonase and some of the stuff to sort of clear up the nose. But remember, the obstructions almost all the time are back here in that 90 degree angle in your airway.

Starting point is 00:55:24 It's not up here. It's like people think snoring is a nose based thing. It really isn't. Sometimes you get like sort of floppy nostrils or whatever, but almost entirely it's the issue is back here. It's the back of your tongue. That's also why on your back it's worse often because gravity starts pulling stuff back. Or like when you open your mouth and your tongue falls back and can block the airway. So, so that's, so like you can do that in the physical exam when you go to the sleep topic and take a look at your mouth and take a look at your nose and, and they'll be able to see.

Starting point is 00:55:55 But I'll, but I'll tell you it is a vast, vast minority of the time where that's actually the cause. People want it to be because it's an easier fixed, but that's usually not it. What happens if someone has untreated sleep apnea? So, I mean, what happens to their sleep architecture? I mean, first of all, maybe we should briefly mention, like, the sleep stages, but, like, does it affect their sleep architecture? So here's the different sleep stages. Stage, so when you fall asleep, you enter stage one. Stage one is super ultra light sleep.

Starting point is 00:56:27 If you sort of, like, nod off and someone bangs a table and you're like, what, what was that? That's stage one. When they say, you were asleep and you say, no, I wasn't. That's stage one. It's very light. This is also where you get hypnot jerks in. If you have one of those, you were in stage one of those. you were in stage one sleep.

Starting point is 00:56:44 Totally normal, medically harmless. Everyone gets them. So that's stage one. It's a light transitionary stage. Then you drop into stage two. Now stage two, when you first drop into it, you're in it pretty quickly. But for most of the night,

Starting point is 00:56:57 that's actually what you spend the most time in. Stage two is sometimes called light sleep. I don't like that name for it. I like just calling it normal sleep. It's regular sleep. It's vanilla sleep. It is more than 50% of the night. Most of the work that your brain does

Starting point is 00:57:11 in sleep is done in stage two. But then you drop into stage three, which is also, you know, in our world we call it slow wave sleep because the brain waves are bigger and slower. A lot of people also call it deep sleep. It's not called deep because it's the good one or the most restful one even. It's called deep because your arousal threshold is the highest

Starting point is 00:57:35 and it is hardest to wake you up from that sleep stage. Because the thinking part, of your brain are largely like detached and offline. You're not, you're not thinking during that time. Your muscles are very relaxed. This is, for athletes,

Starting point is 00:57:51 this is super important because this is when growth hormone is secreted in N3 sleep at stage three or non-REM stage three sleep. Um, but it's also highly protected. Even sleep deprived people are mostly getting all of the stage three sleep their body once. Like it's, it's actually,

Starting point is 00:58:09 again, evolution figured this out a long time ago. you, it's the hardest to wake up from and it frontload, it front loads it front loads it into the night. So usually within the first few hours you're done with it anyway. So it's not a, so sleep deprivation doesn't actually eat into slow wave sleep or deep sleep very much. And people, so they don't need to worry about it so much. So anyway, you get into that and then you come out of that into an episode of REM. REM sleep, a lot of people have heard of now, is weird.

Starting point is 00:58:40 REM sleep is just fundamentally weird. So like this is where dreams and nightmares happen. Peak blood flow in the brain is actually REM sleep. Like your brain is extremely active. It's actually more like waking than many other sleep stage. But the waves are very different from waking brain waves. But it is it is more more like that than than other stages of sleep. You're also your arousal threshold is different in that it's easier to wake up out of REM sleep.

Starting point is 00:59:10 But there's also a couple of other weird things that happen that you're paralyzed. So if in the deep sleep, your muscles were very relaxed, that's nothing compared to how you're relaxed where muscles are in REM sleep, not because they're recovering, but because you're actively paralyzed. Your alpha motor neurons are hyper polarized. You cannot move. Even if you wanted to, that's because otherwise you'd be acting out your dreams because you think they're real at the time.

Starting point is 00:59:37 It's just part of your brain has its foot on the break while it's just, jam it on the accelerator at the same time, and that's why it's not going anywhere. That's why sometimes you see twitches where it sort of breaks through a little bit, but that's it. It's fascinating. And then also, that's also why you get sleep paralysis sometimes, where you wake up at a REM sleep, but you're still a little bit paralyzed,

Starting point is 00:59:55 but you're also conscious and that switch forgot to get flipped really briefly. So anyway, so you get that in REM sleep. You also get the eye movements, which might be looking at things, but might not be. It's, the data are very mixed where when you,

Starting point is 01:00:07 if you go looking to match eye movements in REM sleep to dream sleep to dream content, you can sometimes find it, but then sometimes you can't. It's, it's fascinating. But what seems to be happening in between deep sleep and REM sleep, there's a really, really interesting dichotomy, where they're both important for different reasons. Or one of the things, the main thing that seems to be happening in the deep sleep is synaptic pruning and synaptic homeostasis. So what, and in REM sleep, there's a lot of synaptic strength. and connection building. And those two things work in concert with each other.

Starting point is 01:00:44 Think of it this way. When you're experiencing the day, you're taking in lots of experiences and information. Some of those experiences and information are important. You will learn from are related to important things. Maybe they're not super important, but they're worth keeping. And a lot of those are not that important.

Starting point is 01:01:01 Like that piece of equipment over there, I don't need to remember it tomorrow. I will remember it for the next few minutes, but it's not that important to my life. It will get filtered out. So what ends up happening in slow wave sleep and in the deep sleep, the, the, the experiences from the day and all those new things floating around, they sort of get sorted and the things that are important are kept and everything else gets let, it gets let to fade. Interestingly, this is a similar thing happens where the spaces between your brain cells actually increases and like sort of like a, like actually like a like a filter, it increases and actually waste products can start clearing out of your brain.

Starting point is 01:01:45 Is it because you're thinking parts of your brain are working a little bit less and it gives it the chance to do that? Who knows? But it seems to happen specifically during that time. Just very protected the beginning of the night. So when you're after a few hours into the night, that cleaning out process is done and then the cycles toward the end of the night. So drop down to deep up into REM and then you cycle through. But the cycles change. The second cycle, you'll have a little bit less deep and a little more stage two and a little more REM.

Starting point is 01:02:12 By your third cycle, you might have no deep left. And it's all just stage two and REM. Maybe a little stage one interspersed in there if you wake up. And the REM episodes get longer. The dreams get more interesting. That's why the dreams in the first half of the night, you probably won't remember them anyway. But if you did, they're usually a little more boring. But the dreams at the end of the night are the cool ones, the ones with the stories,

Starting point is 01:02:33 the characters, and then and the blurring of reality. and all the, and emotion in the later parts of the night, like nightmares. Nightmares, to a sleep scientist, a nightmare is a dream that wakes you up. That's the definition of sort of a nightmare in our world, a dream that is so, where the emotion is so powerful, it overcomes that, that process. Sorry, if this is the sleep stages, you go through these during the night. And in REM sleep, it takes those important experiences that you, that you segregated in deep sleep, where you got rid of all the junk, kept the good stuff.

Starting point is 01:03:03 And REM sleep, what the dreams are doing is you're witnessing the brain rewire itself. using what was left. So basically the dreams are, among other things, essentially what's happening is, okay, here's what's left? How do I, what do I do with this? How is it, how does it connect to other things? How do I sort it? How do I file it? How do I process it? And the other stuff that's floating around that I was thinking about during the day, where is that? Where do I do with that? How do I process that? So dreams are, you're witnessing your brain rewiring itself speaking to itself in its native language of ideas and metaphors and concepts and feelings and how they relate to each other without rules.

Starting point is 01:03:48 And so that's why all the stages are important. And in stage two, that's not happening. But in stage two, it's happening. It's a lot of recovery and repair stuff is also happening. Because in REM, your brain's active doing this stuff. And in deep sleep, your brain's also active doing this other stuff. And in stage two is when everything else gets to have. happen in a more particular. So like all the stages are important. You cycle through them and it's

Starting point is 01:04:13 about every 90 minutes. Anyone can Google that. But it's not exact. It's they're different across the night. And that's also why it's easier to wake up out of stage two and REM than deep sleep. But so if you woke up and you remember a dream, it's because you woke up at a REM. That's all. That's all that means. So anyway, how does sleep apnea affect this? Can I before you get to that? It's so fascinating. particularly the part where you're talking about, you know, all the new information that you're learning every day, you know, you're during that transition between deep and REM, you kind of your brain is like sorting it out and getting rid of the things that you don't really, aren't really that important to remember. And then during REM sleep, you're like using what's left and somehow attaching it to like other memories and stuff and concepts. And sometimes there don't even seem to make sense. Like you'll like. They may not make logical sense. And maybe they're wrong. I mean, you're sorting through. you're playing stuff out. And that's also why like, when you're awake,

Starting point is 01:05:11 a person is a person, a house is a house, a car is a car. But when you're in a dream, the rules of the universe don't apply. The concept of a car can also be the concept of a person. And that person can be somebody else too. And then it was me. And then it was my sister.

Starting point is 01:05:29 And then we were in this house that I grew up in. But actually, no, it wasn't. It was really a mall. Like things can happen. It's because. you're not bound by the rules of the universe. You're just bound by how your mind is organizing that information. Well, based on what you just said, I have now a new hypothesis for why we dream, but I want to ask you, why do you think we dream? I think we dream because evolution figured out

Starting point is 01:05:57 a long time ago that you can learn a lot by reading all the words on the page, but you can also learn some really important things by reading between the lines on the page, by reading things that aren't on the page and reading the concepts behind them. But when you're engaging in the day, so the way the brain works, which is fascinating, is the brain works by shortcuts. It's extremely efficient. It's extremely efficient because it makes a gazillion guesses and shortcuts without actually doing any real work except when it absolutely has to. So for example, It's like when you take a picture, your brain doesn't store every pixel. Your brain stores this line here, this line here, this sort of pattern of colors and a set of instructions and fills in the gut.

Starting point is 01:06:46 Your brain stores the blueprints, not the house. And the blueprints are rolled up this. The house takes up, the building can take up a whole city block. That's why the brain is super efficient. It stores, it figures out what is the minimum amount of information actually needs. and then what are all the assumptions it needs to make to fill in all the details? And the good thing is the universe works that like when things go farther away, they get smaller. And like there's all kinds of rules of the way that like you are you and you will be you five minutes from now.

Starting point is 01:07:20 And I don't have to assume make any assumptions that that can change. There's rules to the universe. And when you're engaging with the world that way, it could be really efficient. but maybe there's, maybe there's connections that aren't explicit that might help you navigate your life. So like, let's say we're having this conversation now. Maybe you remind me of somebody who's a friend of mine from like years and years ago. And, but you're not that person. My conscious mind knows you're not that person.

Starting point is 01:07:56 There's no question about that. but it may change how I speak or what my body language is going to look like or how much I choose to ramble when I tell these stories, like these sorts of things. Dreaming is about, I think, it's about taking the actual written words on the page of life and sorting through those connections and sorting through those unspoken and and details that don't actually exist but do and inform. our life. So dreams are the difference, I think, between memory and experience, where it's, it's a difference between what you did and who you are. Like, the dreams are what sort of make you that person who reacts to things based on your own history that, that forms those connections. But I don't know. That's my, that's my ramble of what I think. Well, thank you. Okay, so back to the sleep. Yeah, because, you know, people having these awakenings where there

Starting point is 01:08:55 are multiple wakings in the night, obviously this is happening during different stages, how does sleep apnea, untreated sleep apnea, affect the sleep architect? That is one of, sleep apnea is one of the few things that can artificially, reliably, dramatically reduce your slow wave deep sleep because it prevents, because you can't detach, because your bodies keep trying to get your attention. The other thing it does is it dramatically increases, it can dramatically increase stage one. and it can also because your sleep is more shallow and you have more of these arousals and awaken, even if you don't wake up all the way, your brain is still sort of moving around.

Starting point is 01:09:37 The other thing it can do, it can dramatically reduce your REM sleep. Because remember what I said about muscles in REM sleep? Even your respiratory muscles get weaker. That's why snoring is worse in REM and or worse at the end of the night because you have more REM at the end of the night. So if you're already in a floppy tube, trying to breathe. you that of this floppy tube that's already having an issue and then you make the muscles go extra limp, your snoring's going to get worse. So you're going to have more awakenings out of REM.

Starting point is 01:10:05 You're going to have less deep sleep and your sleep is going to be more shallow overall. So that's why people with sleep apnea, they wake up and they feel like it's sort of like I just ate a whole meal and I'm still hungry. Right. Yeah. I wonder if anyone's or maybe you can tell me if anyone's ever looked at, you know, because you mentioned deep sleep is really important for this, you know, cleaning out the toxic waste. These are aggregate protein aggregates, amyloid beta 42, pang one. I wonder if anyone's ever looked at like people with Alzheimer's disease to see if any of them have sleep apnea, like the untreated sleep apnea. Oh yeah, untreated sleep apnea is a known risk factor for neurodegeneration, especially when it's more severe.

Starting point is 01:10:46 So this is the thing. Mild to moderate sleep apnea is a gray area. Severe. Severe. Severe Sleep apnea seems very, and that's 30 events or more an hour, seems very reliably tied to bad outcomes. Mild seems like it's really only tied to bad outcomes when you also have daytime symptoms. Like you're mostly treating like the fatigue and the memory issues, whatever, you can still get cell death and you can get neuronal problems because you're, think of it this way. Every time you have one of these respiratory events and you're having it, you know, maybe dozens of times per hour in the night, your oxygen drops.

Starting point is 01:11:27 And it's not the hypoxia that's the problem. This is what a lot of people get wrong about sleep apnea. It's not really the hypoxia. It's the intermittent hypoxia. So you're not hypoxic because what will happen is you drop a few points, most people, unless you have some other lungs. Most people with sleep apnea, their O2 doesn't drop a lot for sustained amounts of time, unless you have like emphysema or something.

Starting point is 01:11:50 It'll drop a few percentage points. then your body wakes up and then it recovers. Then it drops again. Then your body wakes up and it recovers. And it drops it. So it's like it's constantly putting out all these little fires all over the place. The fires are never burning any houses down. They're just sprouting up all over the place.

Starting point is 01:12:08 But when it ends up happening is all of these cells are releasing reactive oxygen species every time this happens. So you're releasing these reactive oxygen species. This oxidative stress is happening. And then it's quelled. And then it's stressed and then it's quelled. And then it's stress and then it's quoth. And it's stressed.

Starting point is 01:12:26 Then it's all night. Four days or months or years or decades usually. Imagine the stress like your cells are trying to do their job and they're constantly dealing with all this nonsense instead. Imagine trying to do your job and you're constantly having to do all this other stuff. So you're not getting the recovery function that you're trying that you were built for. And so your trajectory. goes slightly off. So that's why sleep problem, not just sleep deprivation, but also sleep,

Starting point is 01:12:58 untreated sleep apnea can lead to liver problems, kidney problems, brain problems, heart issues, you know, immune system problems because all of the, every cell that relies on oxygen starts getting stressed. And some of them are more sensitive than others. Right. And you're also disrupting your sleep architecture and not getting enough sleep. So people with untreated steep apnea, then probably do have problems with working memory. Yeah. I mean, emotional regulation. Motion regulation, executive function, attention.

Starting point is 01:13:30 So this is the thing. When you, when your sleep is poor, whether it's sleep deprivation or sleep apnea or fragmentation or whatever, the first brain function to go is vigilant attention. Your ability to maintain focus, especially when whatever you're focusing on isn't super excited. That is usually the first brain function. That's the first warning sign that something's up. And that can start creating memory issues, but a lot of the memory issues are memory issues because sleep is really important in memory. Remember, you're taking, all this stuff I was talking about. It's all memory connected functions. It's about sorting through information, processing information,

Starting point is 01:14:12 consolidating information, integrating information. And if you're not able to do those things, you're operating inefficiently. You're not performing those functions. But memory is also a function of attention where if you're not able to focus and attend, even if your memory and machinery was working perfectly, you have nothing to process because it never got in there.

Starting point is 01:14:37 This is the thing with people taking sedating medications. Sometimes it impairs memory. Sometimes it impairs attention, which also impairs memory. You mean so it does that, not while you're on it, but like, that's just, yeah, wow. So, I mean, that's why a lot of these medications and stuff, and really anything, anything that is impairing your ability to focus will have ripple effects to memory and decision making as well

Starting point is 01:15:05 because the information you took in informs those other processes. I mean, just like just most simply, you can't recall a memory that never got stored because you, your working memory couldn't process it because you didn't attend to it in the first place. Is this why men have a lot more attentional issues? Maybe. Maybe. I mean, there's a lot of untreated sleep apnea out there.

Starting point is 01:15:32 And then there's a lot of other sleep problems, too. And they all, I mean, sleep does a lot. You know, we live in this society that sees sleep as an unproductive use of time, especially people who are training, especially people who are like trying to maximize their day. And sleep is not an unproductive use of time. Sleep is an extremely productive use of time. I mean, if you're working out and you're trying to get stronger, when you're working out, you're stressing the system so that it rebuilds back stronger, right? When do you think that other part happens? Not while you're working out. It's when you're recovering. It's the recovery.

Starting point is 01:16:10 Sleep should be your number one recovery protocol for any kind of performance driven person, And whether it's physical performance, mental performance, I mean, when you sleep-deprived people, we trade sleep for work all the time, but you actually get less done. And we've actually measured this. You actually accomplish more on less time if you're well-rested and your brain is clear. Right. Okay. Well, let's talk about treating, you know, sleep apnea.

Starting point is 01:16:39 I know we can talk about CPAP and what that is and it certainly works. Yep. It's a blood instrument. It works. long-term adherence, maybe not so great. What do you find to be some of the best evidence-based non-CPAP and preventions? So the thing about CPAP is, it's a blunt instrument because it's, think of it, it's just a split that keeps open your railway. It creates a pillow of air.

Starting point is 01:17:04 So if your airway wants to collapse, it can't. And CPAP, it's continuous positive airway pressure, continuous because it's blowing continuously, positive airway pressure, as opposed to negative pressure, which is sucking. positive airway pressure is blowing. So just continuously blowing air in your airway to create a pillow of air to keep it open. That's all it is. It's a blunt instrument. If your airway wants to close, you blow enough air in there. It won't be able to close.

Starting point is 01:17:31 But for some people, it's too uncomfortable or whatever. So there's other approaches. The one I tend to use the most, especially with athletes who are often presenting with more mild to moderate sleep apnea anyway are what are called mandibular advancement devices. But these are, it's essentially a retainer you wear at night. Mandibular, like your mandible advancement. So essentially, it's a retainer that pushes your jaw forward. And in a nutshell, that's all it is.

Starting point is 01:17:57 There's obviously a science behind it. But what it does is it creates a little muscle tone here, even when you don't want, even when you're trying to rest. So usually that's not a good thing, but it creates just not enough muscle tone to keep you awake, but enough muscle tone to keep this part of your airway open a little more than it normally would be. and for a lot of people with especially more mild sleep-related breathing issues does the trick. That's all it takes to knock out at least enough of those events so that you don't end up noticing it anymore. And you don't have to plug it in.

Starting point is 01:18:30 You don't have to switch out your hose every couple months. Like it's a little easier. You do have to get it adjusted. And as your jaw remodels, you might have to do some adjustments. You do it with a, there's a whole field called sleep dentistry. It's sleep medicine dentistry, not sedation dentistry. not sedation dentistry, but sleep dentistry where it's about people diagnosing and treating sleep mania with these dental devices. That's a very common one. There's there's also

Starting point is 01:18:55 musculos, myofacial therapy. So like you can use the musculoskeletal system and essentially exercise these muscles so that they just carry more muscle tone. That can work. I mean, there's there's very famous work done with like people who play the didgeridoo where they have to do the cyclical breathing, it ends up strengthening certain muscles that even when you're asleep, they're a little stronger and they can maintain a little more tone. So sometimes that can help, especially for more mild apnea cases. There's a device called ExciteOSA where it's, you put it on your tongue when you're awake and it's sort of electrically stimulates your tongue muscle. So then you go to bed, it keeps a little, it's like a tens unit kind of where it like, where it stimulates

Starting point is 01:19:38 your tongue muscle so that when you go to bed, there's a little more muscle tone in there. That seems to work okay. There's a new device. People have maybe seen commercials called Inspire, which just means breathe in. But it's sort of like a pacemaker that they install. So it's an implantable electrical device that they do surgery. But it's a sort of a pacemaker for your tongue muscle. And so what it does is when it detects that your tongue is falling back, it zaps it to open it up. And that also, for people for whom it's a candidate for it, that can also, it's, you don't have to, again, there's no equipment to replace, but you do need surgery for it. And, and there's complications there sometimes,

Starting point is 01:20:14 but seems to work okay. There's more options now than ever. And the technology is always getting better. Even with CPAP, there's more than 200 different kinds of masks out there. So for people who don't like their device and don't like their mask because it's uncomfortable or whatever,

Starting point is 01:20:32 it's rare that I find a mask problem that can't be fixed, if what you need is one of those. What about mouth taping? mouth taping. So, all right. Mouth taping. So mouth taping for decades in the sleep medicine field we've been using chin straps. It's just like an elastic band,

Starting point is 01:20:55 chishrymerichost at night. For people who are snoring that don't, that, where it's just mild snoring and they don't have sleep apnea, or their sleep apnea is mild, or their sleep apnea is due to them opening their mouth at night and their tongue falling back. can breathe through their nose okay, chin straps have been great. They've been, again, used for decades.

Starting point is 01:21:17 Mouth taping, I think, is just sort of the same thing where you're essentially just keeping your mouth closed. You're just keeping your mouth closed in a way that you can breathe through. Like, it's special tape where air flows through fine. If the problem is that you're opening your mouth, I have no problem with it. And it probably may help those people. But if the problem is that you actually have sleep apnea, and if you don't open your mouth, then you can't breathe, like in you're opening your mouth to gasp for air, then that's probably not what you want. It's probably the opposite of what you want. If you need to open your mouth to breathe or else you're going to have your oxygen is going to plummet. Don't do that. But for like more mild storing case,

Starting point is 01:21:58 or for people who are, it's mild enough, or if it helps you keep, like, maybe you're using a nasal device or like strips or, or rhino med makes these nasal splints. We can keep your nose open. Like, If you're using one of those and you just need to keep your mouth closed, I have no real problem with it. I just don't think it's going to cure cancer and save the world. But I feel like it's, it gets overblown by people's. Yeah, it's gotten overblown. And it sounds more like maybe for snoring than anything. And it's if you need, if keeping your mouth closed during the night solves your problem, go ahead.

Starting point is 01:22:34 But if that's, but if you're hoping that keeping your mouth closed during the night will solve your problem and it's, doesn't, there are other options for you. Are there any for people that are experimenting with some of these, perhaps the retainer or the myo-functional training? We're going to get into sleep wearables soon, but like how do they really know it's working? Do this what's... Yeah, it's tough. The best way to know, and this is not a perfect way, second best way to know is, are you, how do you

Starting point is 01:23:07 feel during the day? How's your energy level? how's your ability to focus? Are you falling asleep whenever you stop moving? A lot of people sleep after you. They can't stop moving because then they'll fall asleep. They can't watch TV. They can't watch a movie. They can't go to a dark movie theater without nodding off. Like they have a hard time with that or meetings. They hate meetings because they have trouble keeping awake. If all of a sudden that's just not a problem for you, it's like your appetite isn't ramped up because you're starving all the time. You're actually getting good nutrition so you're not starving. that's a good signal.

Starting point is 01:23:41 But it's not a great signal. It's not a perfect signal because there's a lot of people where their sleep apnea seems to be treated just fine, but they still have some of those daytime symptoms. And no one really exactly knows why, but it seems just means we need to learn more about what this condition really is and what it's doing in the brain, what's permanent and what's not permanent. We don't know yet. And I say that's second best because the best is just get retested.

Starting point is 01:24:05 And a lot of people with sleep apnea, if it's been, a couple years, get to do it to do the test again. Do it while you're using your treatment to see. And for a lot of those devices, insurance requires you to do that anyway to make sure it's working fine, see if you needs to get adjusted. Because sometimes they need to get adjusted, and they're not working great because your mouth changes or something. So that's one way. I mean, really, really, there's no other way besides either looking. I mean, you can, you might in the future might even be easier to look at the wearable data. Check your oxygen levels during the night. Check your heart rate during the night. See if you have these spikes that you used to have.

Starting point is 01:24:41 Or see, most, most importantly, see how you feel the next day. All right. I kind of wanted to shift gears. We're going to get into the supplements because that's something everyone wants to know about. Before that, I kind of wanted to ask you a little bit about, you know, we've, a lot of people have heard about sleep hygiene. Yeah. The most important things for sleep hygiene. I mean, rapid fire. I do quit sleep hygiene. I do all the sleep hygiene. Yes, yes. Or I, well, my sleep hygiene is bad. Like, people talk about this all the time. But yeah, but there's a difference between sleep hygiene and behavioral sleep medicine. They're different things. Right. Exactly. I mean, obviously people need to have good sleep hygiene too. Like that's important. But like everything you were talking about with CBTI, like that's different.

Starting point is 01:25:25 Yeah, the sleep hygiene is just something that already needs to be done. Yeah, hygiene. Hygiene is hygiene. Hygiene isn't medicine. So like washing your hands is hygiene. everyone should wash their hands more than once. You know, you should be, and if you're sick, wash your hands more. But washing your hands won't cure an infection. Right. But for people that perhaps don't have insomnia, you have apnea, sleep hypoenaing. But everyone should still be washing their hands.

Starting point is 01:25:52 Everyone should still be brushing your teeth. Even if you can't brush your way out of braces, doesn't mean you shouldn't be brushing your teeth. So sleep hygiene is all about setting yourself up for success or dealing with some of these more minor problems. Right. So I was wondering if you had any tips on some more advanced type of sleep hygiene. Like we all know dark, cold, quiet. Rocket science, right? Yeah, rocket science. But like, are there any other sort of more advanced sleep hygiene techniques like, oh, maybe

Starting point is 01:26:21 you're resting heart rate or respiratory rate or something like that? Like, people could. Some unconventional. The stuff, you know, if you Googled, if you Google sleep hygiene, what's some stuff that might not come up on those initial lists that are still being? useful. One of the things that you'll see often on sleep hygiene lists is keep a regular schedule because predictability, the brain loves predictability. So if you keep a regular schedule, time itself becomes a cue. So like if you want to eat lunch at noon every day, start eating at

Starting point is 01:26:53 noon every day and your body will learn to get hungry at that time. But what if you can't keep a regular schedule? Well, an alternative approach I would take is find other ways of building predictability into your sleep. For example, so like, so one of the groups I do a lot of work with is major league baseball. And in major league baseball, when they're in season, they're constantly moving around and playing in different time zones and sleeping in different hotels. How do you keep regularity when you're constantly moving around? And so like for people whose lives are like that, what do you do? well, I usually say, okay, stop trying to keep a regular schedule,

Starting point is 01:27:36 but find other ways to build predictability in. So maybe have a nighttime routine that is highly predictable where you do the same things in the same order, even if you do them in different places in a different hotel room or whatever, especially if you can bring things with you, like bring the pillowcase with you as a condition stimulus. Use the same toothbrush, whether it's at home or on the road if you travel a lot. Use, do the same things in the same order.

Starting point is 01:28:06 So even if they're at a different time and a different place, find alternate ways to build predictability if time itself is not the predictable one. Another one is avoiding bright light at night. What if you can't? So blue blocking glasses are great for this because, and by blue blocking glasses, they have to be orange or red most of the time. Some of the other ones will work. the yellow ones or brown ones will work. But if you put the glasses on and you look at something blue

Starting point is 01:28:36 and you know that it's blue, it's not going to do its job from a circadian perspective. So some of them block blue for eye stream, but that's a different thing. So if you put on, say, orange tinted glasses and you can't see the color blue, then the environmental light is not going to interfere with your sleep in the same way because it's not going to send a daytime signal. Another one that even fewer people know about is bright light in the morning can help set your sleep up at night in three ways that are that are actually a little unconventional. Number one, by having that morning be a regular timing and a strong daytime signal, I'm talking about daylight. I'm talking about like outdoor light, not just turn on a light in my bedroom light. That's a couple hundred lux. Step outside. It's thousands

Starting point is 01:29:28 of luxe of light. Getting that strong daytime signal in the morning at a predictable time starts a clock. And that clock, just like when you finish a meal, you'll start getting hungry a certain number of hours later. If you don't really have a really strong meal, you're sort of hungry all over the clock. You don't have that rhythm. But if you have a strong morning signal with some bright light at a predictable time, about 16 to 17 hours later, your body will expect to be ready for sleep.

Starting point is 01:29:58 and if you can make that a little more regular, it makes, it's like if you want to be, if you want someone to catch a ball down field and you throw it the same amount of, about the same distance every time, but you keep moving, the person downfield doesn't know where to stand. But if you stay still,

Starting point is 01:30:17 they can predict where the ball is going to land. So like by setting that time, it creates, it sets you up for success by starting that timer. The second thing that it does is, that it creates a circadian amplitude. So your circadian rhythm, this 24-hour cycle, it's like when you're on the couch in the dark all day,

Starting point is 01:30:36 you don't have a strong daytime rhythm, so you don't have a strong nighttime rhythm. But if you get a strong daytime signal by being active and getting, especially outside light, especially in the morning to start that curve going, by the time nighttime comes, you'll have an even stronger nighttime signal.

Starting point is 01:30:53 And then the third thing that it does that even fewer people know about is you know, everyone knows that light at night is bad and that light in the morning is good. But light across the day matters where the more outdoor light, the more bright light, but it's mostly means outdoor light. The more light you get during the day, it inoculates you against light at night. Because if you got a really strong light daytime signal, you can get all kinds of light from screens or whatever at night and it actually won't matter for most people.

Starting point is 01:31:26 You can actually, you can, so you, again, it's lesser known, but because the system knows where it is, it's not looking for information anymore. And conflicting information will get thrown out as opposed to like, I don't know, it's light now, but I didn't get a ton of light during the day. Maybe it's daytime, I don't know. But you can inoculate yourself against nighttime light by getting plenty of daytime life. That's fascinating. I've noticed that, of course, when I'm traveling and I'm outside all the time. And then it's like being in my hotel, I don't usually have my dimming lot, my identity. dimmers and everything that I usually have, but it doesn't matter because I am dead tired,

Starting point is 01:32:01 right, you know, after being alive. This is, humans lived for most of our existence in equatorial, bright days, dark nights, relatively little seasonal variability all around, all around like the Mediterranean area and, and that part of the world. You know, we solved all kinds of problems by creating these walls and buildings and artificial lights and everything. We solved a lot of problems. We've created some new ones.

Starting point is 01:32:26 too. And we're still running the same code. Right. A couple of questions, follow-up questions for that. Do you think the time of morning light matters a lot? Like, you wake up in the morning and like, is it like first thing you go outside and how long should you have to go outside for 30 minutes? Yeah. Morning light is key. Earlier, the better. I mean, honestly, earlier the better. And how much, I would say 15 minutes is probably fine. 30 minutes is probably better. Like a morning walk or a morning run is actually probably perfect. And because what's happening, it's not only that daytime.

Starting point is 01:33:16 The other thing it's doing. And we'll talk about this one when we're talking about supplements, but melatonin. So melatonin naturally, your natural melatonin will drop in the morning. morning down to like almost from its peak to almost nothing. Light suppresses melatonin naturally. That's what it does. And so the early, if your melatonin is still kind of high and it's dropping, by getting that light, you accelerate its ability to drop. It's like coffee. Yeah, kind of. And actually, this is also why I don't recommend that people caffeinate as soon as they wake up. I recommend people wait an hour because if you caffeinate as soon as you wake up,

Starting point is 01:33:56 the amount of adenosine that that caffeine is blocking is still very low. You haven't produced enough yet to really have much of an effect. But if you drink caffeine as soon as you wake up in the morning and you feel more alert, it's probably your sleep inertia naturally coming down and your melatonin naturally getting blocked and you're feeling the effects of it and you're attributing it to the caffeine. When actually you could have skipped the caffeine, you probably would have felt mostly the same. It's just the caffeine is still.

Starting point is 01:34:26 still having effects later, but you've missed the caffeine peak. So like, actually, you time the caffeine a little bit later. So you're saying you want to use the caffeine for, you know, when, when you basically more need it, when you're working, maybe that genocene builds up. Yeah, use the cap. So the denocene builds across the day and you're at your lowest levels as soon as you wake up. Why are you going to block something that you're, you know, if caffeine works mostly by blocking

Starting point is 01:34:50 adenosine and your lowest levels of adenosine are first thing in the morning, why would you recommend someone block it first thing in the morning. Wait till it accumulates a little bit, especially if, if you, for most people, that natural sleep inertia will wear off within 10 to 60 minutes as soon as they wake up. And my favorite way to tell this story is like, you know how you wake up and you smell the coffee? And then even that kind of perks you up a little bit. They say, yeah. And I say, did you know that there's a term for that? And they're like, oh, there is. And I say, yes, it's called placebo. And then so they laugh and like, what do you mean?

Starting point is 01:35:31 I'm like, coffee doesn't work olfactory. It doesn't work through the nose. If you smell it and you start perking up, it's because you're predicting what its effects are going to be before you even ingested it. And which means when you're drinking that coffee, it's giving you a placebo effect as much as it's giving you anything else. So like, wait a little bit because you're, because you don't need it. That's why I drink decapped coffee like, you know, it's a lot. 11 a.m. And I feel like it's totally working. And I'm totally fine with that placebo. Right. Right. Because you had it in you all along. Right. So it sounds like the morning routine

Starting point is 01:36:05 would be wake up. Yeah. Go outside. Get some water. You probably dehydrate a little bit. Get some water. Yeah. Go outside. Whether you're taking your puppy or dog out. I just got a new puppy. Going for a run. Yeah. But go outside for at least 15 minutes. And then, you know, wait a little bit. Then you make your coffee. Obviously, there's some people are. kind of rushing to get to work, but you can drink your coffee in the car on the way to work. Yeah, or wait till you get there. A way till you get to work. Yeah.

Starting point is 01:36:32 Okay. I'm going to try that. Yeah, I mean, and also you got to remember, caffeine, caffeine doesn't reach its peak effects for at least like a half an hour after you ingest it. So, and then it'll last for a few hours afterwards. So if you want to, if you... Wait, say that again? So it doesn't reach its peak until 30 minutes later.

Starting point is 01:36:51 Until about 30 minutes later. So if you feel it sort of right away, that wasn't, that wasn't, that was. was sort of the effect of caffeine. Right. Okay. And then, yeah, and then it'll trail off. Like, it'll have some effects. It builds. So it's something there.

Starting point is 01:37:03 But it's actually the peak effects of caffeine, uh, for alertness or, or about a half an hour in. So that's why what a lot of people will do is they do the, the whole calf nap or the or whatever they call it, where like, they drink the coffee, take a nap for 15 to 20 minutes, wake up right when the coffee starts ramping up and then they, then they go. I've never heard of that. Oh, yeah.

Starting point is 01:37:23 It's a thing. Um, I mean, I don't do it, but not because I have any moral, you know, opposition to it. But it's a thing where because they leverage the delay in the caffeine reaching its effectiveness. So, and they use that to limit their nap time. But we can talk about strategic napping a little bit later. Yeah, let's do that. Okay, well, let's talk about supplements.

Starting point is 01:37:44 I mean, obviously we're talking about behavioral interventions being absolutely the best. The most likely to actually help. Okay. That's the way I think about it. It's like they don't always. work and other things may sedate you more faster, but they're the things that are most likely to solve your problem long term with the least negative effects. What about, you know, you were talking about early light exposure, the timing of like going

Starting point is 01:38:12 to bed at the same time versus waking up in the morning at the same time. How does that play a role? I would say focus more on starting the morning than timing your bedtime at the same time, because the morning will set up the evening and usually people have more control over that anyway. And the way I like to think about the evening is I think about sleep as my commute to tomorrow. Where instead of thinking, so if you had to go to work, you don't think, well, I'm going to wake up when I want. I'm going to do everything I need to do around the house, pay all my bills, do all the dishes, do all my chores. and then when I happen to be done, hope that I make it into work in time.

Starting point is 01:38:57 And then like, shoot, I ran out of time. Like, that doesn't work. Instead, what you do, you think, what time do I need to leave the house? How long is it going to take me to get ready? What do I want to do in the morning? What do I want to go for that walk or whatever? What time do I need to wake up to make that happen? And that's how we should be thinking about sleep because then you should be thinking,

Starting point is 01:39:19 keep going and think, okay, how much sleep do I want to? I get. How much time do I need to budget with a couple of awakenings during the night or whatever that's normal to get that amount of sleep? When do I want to be in bed to be able to fall asleep when I want to be able to get all the sleep I need so that I wake up naturally when I want to be woken up fully refreshed? So when do I need to start winding down? So you think backwards. And so the nighttime routine regularity I think is important, but I think more important is thinking strategically about it and start thinking, based on my goals for tomorrow, when do I, when do I need to be up and when do I want to go to bed? But the morning routine building regularity will help

Starting point is 01:40:01 set you up to be tired at the time you want to be. But going into bed at a regular time, when you're not ready for sleep, that's bad stimulus control. That'll set you up for problems later. So that's also why I don't stress the nighttime getting into bed because what if you're not ready? If you're not ready, if you're not hungry, don't eat. Like if you're not ready, don't sit there and count sheep for an hour. That'll just make you stressed. So that's why I focus the regularity on the morning. So you think people should try to have a consistent wake up time in the morning?

Starting point is 01:40:34 It's possible. But not everyone, not everyone can. And like maybe your wake up time during the week is uncomfortably early and you want to sleep in on the weekends. I got no problem with that. Regularity is good. But like, if it means you're getting a little. little bit of extra recovery on the weekends, you know, it's a, it's a tradeoff. There might be a positive there. But if they do, if they are waking up early in the morning during the week,

Starting point is 01:41:00 then you'd think they'd be, they're building up enough sleep pressure to fall asleep earlier. Right. You'd think. And it's just that's it. That's it. If they, and if they, that assumes they're giving themselves permission to go to sleep at a time that is ideal for them. A lot of people don't give themselves permission to go to sleep. You know, we have this whole concept of revenge, bedtime procrastination where you're only taking you're taking revenge on your own day right and your own resentment of your life being too full of junk and crap to have no time for yourself and it's tough and and the way the way i put it though is i i think you're cutting off your nose to spite your face at that point when people say i know i should be going to bed earlier but you're asking me to

Starting point is 01:41:48 give up the one hour in my day that's mine that I need for my own mental health. What do you say to that? And I say, you're right. I am not going to ask you to give up time. What if I could give you some more of your time back? What if the reason why that is the only hour in your day that you have is because you could be more efficient and productive during the day and you won't need as much buffer time on stuff if you were a little sharper. And actually, that's what the data show that actually, instead of asking you for time. So we did this, I went to the university and to the Division I athletes, cross all the different sports. And I said, look, I'm not going to ask you to sleep more. But if you want to fall asleep faster, here's how you do it. And we'll get into

Starting point is 01:42:35 what I said. But I'm sure you're going to ask, how do you fall asleep faster if you want to be? If you need to wake up early, how do you fall asleep earlier than your body wants to? How do you get moving during the day. Let me teach you how to do this. So that you become your own sleep expert. And if you want to get more sleep, here's what some of the benefits would be if you're not getting enough, especially in students, especially in athletes. But I'm not going to tell you what to do. Like, I don't know your life and I can't control your schedule, but here's how to make an informed choice. On average, time in bed increased by 40 minutes. Total sleep time increased by over an hour. most of the time they needed, they were already in bed anyway.

Starting point is 01:43:17 And they gave up those extra 40. I didn't ask for it. They found what was useful for them. And actually they were rating themselves as their grades were better. They were more productive. Their social life was better after they were sleeping better. And so what did they do? What was the protocol?

Starting point is 01:43:36 So first of all, I hammered stimulus control. I normalized some things like, you know, what would happen is they would freak out when they wake up during the night and they have trouble getting back to sleep. I said, don't freak out. Take a break, five, ten minutes, get a drink of water, whatever, go back to bed. And like reducing that performance anxiety, hammering stimulus control, wind down routine stuff like dimming lights,

Starting point is 01:44:00 gave them blue blockers, you know, we'd like, and in terms of morning routine talked about getting light first thing in the morning. a lot of that basic stuff. But really it was, and it also coupled it with some education of, it talked about how different sleep stages work, talked about how sleep works, not as like a, this is sleep 101 class,

Starting point is 01:44:22 but it's more of a, look, you're an athlete. You're trying to do all the stuff with your body and have it in peak condition and understand what's going on to the hood. Let me teach you what you need to know about what we know about how the system works so that you can make the most informed choice that you can make. Teach them about how circadian rhythms work. Teach them about how sleep propensity

Starting point is 01:44:41 builds across the day, dissipates. And when they're awake in the middle of the night, it just because they haven't built up enough sleep pressure yet, so you've got to give it a little bit of time before you can go back to sleep. Like, teach them how these processes work so that it demystifies it a little bit. So even if they have an awakening, it doesn't become a stressful one. And if they want to fall asleep earlier, they can learn to program that in and create those conditions when we all. Like, we, we hammered the don't lay down in bed. So like if you're going to college students, their bed is also their couch and it's also their desk and it's also their whatever.

Starting point is 01:45:13 So we had a sleeping part of the bed, wake part of the bed. You know, when you're in the wake part of the bed, you're sitting up. You know, you can lean back, but you're not going to lay down with your head on a pillow unless you're planning. Like, so we separated these things out. Worked beautifully. How many weeks? Uh, we did it for a semester. So it was like, it was like eight to ten weeks.

Starting point is 01:45:31 Eight to ten weeks. That's amazing. Yeah, that's like typically six to eight weeks is normal. That's usually even people who come in and say my sleep is terrible. Often, you know, and I'll say like, look, it's extremely unusual for someone to walk in, unless they have some other major medical complication that's getting in the way, that within six to eight sessions, they're usually sleeping way better. Often by then they're like, you know, this isn't my problem anymore.

Starting point is 01:45:57 And I'll say, you know where to find me if you need me. Oh, that's awesome. Yeah. Okay. Well, let's talk about a couple supplements. Yeah. I definitely want to get into jet lag in a little bit later, but, you know, obviously the most, the top of mind supplements people think about when they think about sleeve, I think melatonin. So melatonin is a hormone.

Starting point is 01:46:15 It's a very old molecule. It's in plants. It's in other stuff. It's not a sleep hormone, except by association. Melatonin is the hormone of darkness. Melatonin is a nighttime signal. You produce it at night. A great example of how it's not a sleep signal.

Starting point is 01:46:35 It has no sedating properties whatsoever. Melatonin doesn't. You give melatonin to a nocturnal animal. It wakes them up because it's a nighttime signal. To the degree to which your body gets a nighttime signal and that makes you sleepy, yes, it can promote sleep. Melatonin can promote sleep in humans. For that reason, it can help you fall asleep faster.

Starting point is 01:46:59 It can help you stay asleep. It can help you sleep more restfully because, it's strengthening that nighttime signal. That's what it does. It's also why it is almost universally useless for insomnia. Because if you have a conditioned arousal, remember, now everyone knows what conditioned arousal is. If you have a conditioned arousal, your body already knows it's nighttime still can't sleep. So taking melatonin is almost never going to work to treat.

Starting point is 01:47:32 to treat an insomnia condition. But if you don't have conditioned arous, if you don't, if you just need a little bit of a boost, actually melatonin probably works just fine. It's also, you produce it natural. During the day, your levels are almost non-existent. They start rising in the early evening. They pick up, they peak during the night,

Starting point is 01:47:52 and then they drop off right about the time you expect the sun to come up. And light suppresses it. So even if you're at peak levels during the night, turn on a bright bathroom light, plummets, then you turn off the light, as long as the clock still thinks it's nighttime, it'll regenerate them again. Might take a delay, especially the older you get, the less flexible the system is.

Starting point is 01:48:14 But that happens naturally. Now, some people, when they take melaton, they might be taking the wrong dose at the wrong time. So the way we've started using melaton as a treatment, for something was our natural rhythms are about 24 hours. You know, so some creatures, they use light from the sun to, so like when you put a, a blanket over a bird's cage, they'll go to sleep because their natural melatonin starts spiking as soon as it's dark.

Starting point is 01:48:47 And then it suppresses as soon as it's light. Humans, we have mammals, we have our own internal clock that guesses what time it is. So we could be in a cave and still keep a roughly 24 hour cycle. Otherwise, the systems in our body would get all out of crack. But it's not precise 24 hours. It's a biological clock that is slightly longer than 24 hours in almost everybody. Not quite 25 hours, but somewhere in that gray zone. But what happens is so it's like if you want to, if every day of your life is a string,

Starting point is 01:49:16 and every day is going to be 24 hours and you had to produce the string to be the exact same length, what you do is you make all the strings slightly long and trim the edges off. That way you can guarantee they're all going to be the same. And that's what physiology does to your rhythm. It makes it slightly longer than 24 hours, then resets it in the morning to start it all over again with the morning light as it hits the reset on the rhythm. So blind people who can't see light,

Starting point is 01:49:45 they get this, their natural rhythm never gets reset. So it's slightly more than 24 hours. So if you were living a slightly more than 24 hour rhythm, you woke up at 6 o'clock today, you'd wake up at 6.30 tomorrow. You'd wake up at 7 the next day. and then eventually you're waking up at two in the afternoon. It's miserable.

Starting point is 01:50:03 And then it cycle around. It's called non-24-hour circaded rhythm disorder, where you just can't reset your rhythm with light. They found is you give someone a third to a half a milligram of melatonin in the evening, in a blind person fixes the whole thing, sends the nighttime signal at the time when it needs to see it, and the system responds beautifully to it. You're not trying to replace their natural melatonin.

Starting point is 01:50:29 that half milligram dose is the signal. It's a clock signal. It's what tells your body, hey, nighttime now. And if you give it a little bit before you're naturally going to start producing it right around that time, it sends the signal a little early. So it's sort of like your body responds of like, oh, I didn't realize it was nighttime yet. Better get started. And it starts your own natural process a little early. So that half milligram dose, in the evening, like five hours before your bedtime, that's the evening signal where your evening hasn't even really started yet. You're giving your evening a little bit of boost. So that's, so it's basically like jet lagging yourself where you're, you're telling your body it's nighttime

Starting point is 01:51:15 before it's actually nighttime. That's not what you're really telling it. You're telling it it's evening before it's actually evening, like right around dinner or like usually two to three hours before your typical bedtime is when you start producing melatonium. You give it a couple hours. before that, it's in the zone where you're looking for it. Like, give it in the middle of the day, your body's not looking for it. It's in the zone where your body is looking for it. And you can confuse the system and think it's later than it really is. That also means you'll wake up a little earlier because the whole thing got shifted. Same thing is if you take that low dose melatonin as soon as you wake up in the morning, that drop gets delayed a little bit. So it ends. So that ball lands a little

Starting point is 01:51:56 further along than it expected to. So your day started a little bit later than it thought it was going to. So you'll stay up a little bit later the next night. So you can use that half dose, half milligram dose as a clock shifting dose. So then why is everything over the counter like five and ten? Well, A, people think more is more and sometimes more is less, especially with melatonin. If it's just a nighttime signal, more doesn't, isn't more. Five, you can take closer to bedtime, that's a little more of a sleep promoting dose where it's more of like a hey body, you idiot. If you didn't know it was nighttime already, I'm going to scream it in all capital letters for you and get your act together. And it'll boost that whatever natural

Starting point is 01:52:42 sleep drive you have that isn't interfered with by insomnia, it may boost it. So people who take that three to five milligrams with it, you know, closer to bedtime, it can have that sleep promoting effect, not because the melatonin was sedating, was it sort of got, was that strong enough signal to kick you into gear a little bit? Now, a lot of times people will feel groggy in the morning with it.

Starting point is 01:53:06 That's because you just couldn't metabolize it fast enough, that you gave yourself such a big dose, you already were naturally producing it anyway. So you were, you were, oh, you overfilled your bucket. And so by the morning, you still have melatonin floating around backfiring. So now you're telling your body it's nighttime when it's daytime. because you couldn't get rid of the nighttime signal fast enough.

Starting point is 01:53:30 And it had built up over time. So often when I say if you're taking melatonin at night and it's helping you, but you're feeling groggy during the day, cut your dose in half. And then there's the other problem. There was a few studies that have been published where, I mean, almost all these melatonin supplements that are out on the market have huge variations.

Starting point is 01:53:48 Yeah. Some of them have like a hundred times more melatonin. And then it's actually what's on the label. Yeah. So that's the thing where there's a lot of, of them out there that can be unreliable, especially from some of the manufacturers that don't have the good quality control. It is regulated by the FDA. It's just, you know, there's just not enough money for enforcement. So there's not a ton of enforcement. But any of the larger companies,

Starting point is 01:54:14 they're actually going to have pretty good quality control. And they are, if you look at those, the ones that are the bigger companies that are on the shelf, they are almost always right on target for what they should be. And I say that because what's on the bottle is actually not what's supposed to be in the bottle. And a lot of people don't know this. But the bigger companies that have the higher quality and the higher quality control are following the law. And the law says that the amount on the bottle has to be within a certain percentage

Starting point is 01:54:48 of the amount that's in the pill at the expiration date. That is the definition. So if you have a supplement that's sitting on a shelf with a three-year expiration date and you're working with a company that's trying to do everything really well and correctly, your chemists and food scientists have to calculate exactly how much they have to put in that pill so that as it degrades naturally over time, how much will it degrade to the point to hit the target two to three years out? that's actually the calculation they're making. So in melatonin, that answer is usually 30 to 50%. So when you buy melatonin off the shelf, and it says five, probably closer to eight, seven or eight when you buy it.

Starting point is 01:55:41 And then two to three years later, yeah, it's five. Because they did their job. They followed the law and they had really high standards in their manufacturing. but it's still, you're probably taking a much, you're probably taking a higher dose. And they can't tell you because the way the law is written, it's like if you, if you tell people what's in there is different than what's on the bottle, you've now changed the label and now you have to meet that. It's complicated. The law was written in the way that I think they didn't foresee this problem. But people need to know that actually, if it's a good brand, it's actually going to be higher than what's in the bottle because they're going to calculate.

Starting point is 01:56:19 and the overage needed to be able to degrade to the point that hits the target. Is that great? Like, people don't know this. So less is more for sure. Yeah. That's also why I say, if you're still having effects, actually, your dose might be too high. Just cut it in half. The other thing that's worth mentioning about melatonin is it's actually a very potent cellular repair molecule.

Starting point is 01:56:39 Those effects don't really seem, those defects seem to be stronger at the higher doses, actually, like closer to the 10. But that's where you get more side effects, too. So most people don't need it. Like, we have an immune system. Melatonin as a recovery molecule is a very old molecule. Our immune system probably does the trick. But that's also why.

Starting point is 01:57:00 When people take melatonin supplements, they get sick less. It was seen as an adjunct treatment during COVID that didn't conflict with any of the other treatments, but actually made illness recovery better. Melatonin is a really cool molecule. It's just misunderstood. Yeah, it's a hormone. I think it's regularly like 500 different. protein and coding genes. It is a hormone.

Starting point is 01:57:21 What other hormone do you just like buy over the counter and sort of unlimited amounts? Like it. Right. So when it comes to melatonin, I know there's like a lot of questions I get from people is, well, if you're taking melatonin supplement, are you going to then stop making endogenous pneumonia? Yeah. There is, to my knowledge, there is no evidence that that that actually ever happens.

Starting point is 01:57:44 To my knowledge. It's a worry. but melatonin is so old that like you're going to produce it. Like the way to stop producing natural melatonin would be aging. That reduces it. But to my knowledge, there is no data that shows that continual use of supplementary melatonin changes or reduces your ability to naturally produce it at night. What about, and that's also what the conclusion I came to.

Starting point is 01:58:12 What about the ability, like your melatonin receptors? Like, is there remodeling? I don't know. I haven't seen anything that's concerning in any way. I just haven't. Like, no one has, there's no finding that's a, that when, when people have looked, it doesn't really seem to be doing that. It's, it doesn't seem to change the same way other receptors do.

Starting point is 01:58:35 Again, it's a very old system. It's an old built in system that that isn't, that is meant to adapt, that is meant to be able to deal with flexibility rather than respond to it super quickly. I haven't seen anything either, but it's not to hear that for you. I haven't seen anything either. Maybe, like, maybe findings will come out in the future when people look at. This is the other thing that other people need to know. This is about supplements in general.

Starting point is 01:59:00 That research on supplements is scarce, especially really well done research in highly controlled conditions, not because, to be honest, not because there's any sort of like conspiracy to keep the information out of people. It's just that research is extremely expensive to do. My day job is in research. That research is extremely expensive to do. In pharma, it's because, you know, you can do some of that basic stuff with research. And pharma has the deep pockets to do this.

Starting point is 01:59:33 And the reason they do is because they have IP racked around this. Why drugs are so expensive? Because it costs about $2 billion to bring a drug to market and 10 years, at least. In supplements, you don't have that IP protection. You can't patent a supplement that naturally occurs. You might be able to patent a molecule as an additive or something, but that's extremely rare in the supplement space. So supplement companies have no, they can't,

Starting point is 01:59:58 A, they can't charge what drug companies can charge. They don't have the deep pockets to pay for this research. They don't have the IP protection around it, which would incentivize them. Why would, why would a manufacturer spend, two million dollars on a clinical trial that their competitor could just take the results from and claim as their own? Like an NIH who funds, I mean, people need to understand how absolutely fundamental NIH is to all health research in the U.S.

Starting point is 02:00:25 I mean, every, every bit of health research in the U.S. absolutely depends on a healthy NIH. And NIH, as much as they fund whatever, I mean, they're dramatically underfunded already compared to the need. but supplements don't seem to ever rate as high enough priority, where, like, they're dealing with trying to cure cancer and Alzheimer's disease and and other sleep apnea and other major health conditions. And supplements by definition don't treat medical conditions. They promote health, but they don't treat conditions. They might prevent, help prevent.

Starting point is 02:01:03 Right. They might could. They could. It's just, it's, it's, people don't understand how competitive, grant applications are for NIH. And so to survive that competition studying supplements is really hard. So that's right. Like the deep pockets don't have as much of an incentive to study it. So it's not that it's not that anyone's trying to hide the research. It's that it's really expensive to do and no one's stepped up willing to pay for it. Yeah. It's why there's not a lot of high quality studies out there on supplements and you always have to take it with a grain of salt. Right. And it's like, it's not the

Starting point is 02:01:36 supplement's fault. It's not the company's fault. It's just, you know, I would love for their, I would their love for there to be more investment or if there was a public outcry that like, look, we need these studies. Yeah. Hopefully we'll get them. Well, with that said, are there any other, I mean, I've heard of a variety of supplements like magnesium, lavender, glycine, althian, any, I mean, moderate evidence that some of these were.

Starting point is 02:02:00 So a lot of them have evidence that they're definitely not nothing. None of them have beaten placebo to treat insomnia. The closest that came was Valer. but when you pool the data, it still doesn't beat insomnia, a placebo for insomnia sort, but it is sedating. It can be calming. Magnesium also does seem to promote sleep in a number of different ways, actually, more than just one way. Doesn't treat, insomnia, but it can help promote sleep. Glycine also, great data on glycine, showing that people who take glycine, it can help fall asleep, help stay.

Starting point is 02:02:40 a little bit better. A lot of these supplements, it can help you fall asleep but stay asleep a little bit better. Some of them don't do anything to sleep per se, but they work in terms of calming. So calming isn't sleep-inducing, though for people who don't have insomnia, because if you have conditioned arousal, you can be calm and still not sleep. But for people for whom a little bit of calming and relaxation is really helpful, that's where things like the al-theonine and some of these other more calming thing, like the chamomile and some of that stuff that can be calming can actually be helpful,

Starting point is 02:03:14 even if they don't actually technically do anything on the sleep side. Other things that can help promote sleep, things that have anti-inflammatory and anti-oxidating properties, remember, your body's doing a lot of that healing at night. And so if you can help give it those raw materials, so this is where there's certain supplements out there that actually seem to be, seem to have some of those anti-inflammatory properties. and when you take them, you might be sleeping better.

Starting point is 02:03:41 I mean, when people take ibuprofen, they can also sleep a little bit better because, like, it, those awakenings and arousals due to discomfort might be just a little bit less and might help you sleep through the night a little bit more. There's a few things, like, but that's a difference,

Starting point is 02:03:56 where just because something is not nothing doesn't mean it is a cure-all. It's like, not black and white. A lot of these supplements can be helpful. I recommend them for all of the things that they do, but I also recommend them for none of the things that they don't do. And I think there's a gray area that I think people have a hard time wrapping their head around. Yeah. No, I'm definitely not talking about insomnia.

Starting point is 02:04:19 And, you know, some people just like to have a little bit of help. And glycine is interesting. That's what I've been interested in. Have you seen any of the thermal regulation stuff on that? I haven't seen the thermal regulation stuff. Poor body temperature. But it seems, so it's unclear to me whether that's a cause or an effect. Right. But either way, does it matter if that's what you're taking it for? It's more of the GABA inhibit, like more of that inhibitory. Yeah, it does seem to promote those inhibitorial.

Starting point is 02:04:49 But so a lot of people who are taking workout supplements at night for recovery, like take one that's, if you're taking aminos at night, branch chain amino acids in general could be good for recovery, especially after trading. And if it's got some extra glycine in it, all the better. But if it's got a lot of glutamine. in it. You want to not be using that because glutamine is activated. And so, I mean, I've had athletes I've worked with who like complain, complained about their insomnia, turns out they're taking these nighttime supplements with a whole bunch of glutamine in it. And that's sort of what's

Starting point is 02:05:21 counter, that's, that's what's getting in their way. So it's not just about supplements at night that can be helpful. It's avoiding stuff that can get in with like B12. B vitamins are good to take at night because they can help with recovery. B12 help boosts the ability of light to suppress melatonin. You don't want to take that at night. You want to take that in the morning. B12 is great in the morning because it can help wake you up a little more for a bunch of reasons, including its ability to help light suppress melatonin.

Starting point is 02:05:49 But you don't want it at night when even a little bit of light can get and start getting in the way. Fascinating. So take your multivitamin in the morning, not in the evening. Yeah. If I have, I have this dream one day of having like an AM vitamin and a PM vitamin where like some stuff might be better at night. Like you want to, if sleep is all about recovery and repair.

Starting point is 02:06:06 put those raw materials in play at the time you want to use them if they're going to degrade. Or you could just take them in the morning if they're going to hang out all day anyway. But yeah, I mean, some is some, the, that multivitamin you might want to take in the morning. Okay, let's talk about substances that affect sleep. Yeah. This is another one. I mean, a lot of people will get into CBD because that's like the biggest thing now that, I mean, I just hear it in peer groups. I hear it on the internet.

Starting point is 02:06:34 I hear it and just everywhere in the audience. Yeah. But kind of even a step ahead of that, you know, was marijuana, right? Like, which has CBD and THC. Right. They're two separate compounds. Right. And so I kind of want to start maybe with THC.

Starting point is 02:06:51 Yeah. Like if someone's doing the whole bang. Yeah. Chy is a good place to start because THC seems to have pretty reliable effects on sleep. Surprises nobody who's used it when I say that. But it can help you fall asleep. It can help you stay asleep. can help you feel more refreshed, THC does.

Starting point is 02:07:08 However, there's three downsides of THC. Four, if you're an athlete. One is that the sleep promoting effects fade over time. So often it works great for a period of maybe a few weeks. But then you'll notice that it stops working in the same way. And so people start escalating doses for that reason. And so maybe, you know, it's short-term benefits and long-term benefits are different. That's number one.

Starting point is 02:07:42 Number two, in a lot of people, not doesn't seem to be everybody, but in a lot of people, it can be a very potent REM sleep suppressor. A lot of people don't realize that antidepressants also, most antidepressants are potent REM suppressors. Like, you can knock out 50 to 75% of all your REM sleep of the night by taking, like, Alexa Pro or an SSRI or THC. Does that affect memory? Because isn't REM important for incorporating? Isn't that weird, huh?

Starting point is 02:08:11 Like, why is it? If REM sleep is so critically important, and we'll get to this when we talk about sleep stages on wearables, if REM sleep was so critically important for what it seems to do, why is it that when all these people who are taking antidepressants are not falling down, not being able to remember things? Don't know. my hypothesis is these processes are way more complicated that we realize.

Starting point is 02:08:37 And when we see a decrease in REM sleep, we're not seeing a decrease in the process itself. We're seeing a decrease in an effect of the process. And in a downs, like, what we call REM sleep as these, these physiologic signals and brainwave patterns, maybe it's downstream of whatever's happening under the hood. And just because you don't hear the downstream signal anymore, it doesn't mean the thing wasn't still happening to some.

Starting point is 02:09:01 degree. But then again, with depressed people, if their ability to process information is fundamentally flawed, and I mean this, and like when people are depressed, they see a neutral stimulus, it feels negative to them. And it makes their life more miserable. Well, stop processing things emotionally then, like, at least, at least coming to neutral and blunting is better than, it's like, who knows? The answer is who knows? Is that a benefit? Is it impacting memory? Might that be part of what's going on in terms of THC's impacts on brain neurochemistry and some of the negative effects, maybe, I don't think anyone's been able to take the time to study that pathway. So anyway, that's the second one.

Starting point is 02:09:40 The only, the third one I just did want to mention is when you stop using THC, you get, just like any kind of sedating medication, you get an insomnia rebound. And with that insomnia rebound, because it was a REM suppressor, you get a REM rebound. So you can get vivid nightmares and like really unpleasant dream. and the worst insomnia you've ever had. So then you're like, I need to take this or else my insomnia comes back when the insomnia was a withdrawal symptom.

Starting point is 02:10:08 So, like, so that... So you could become dependent on it. Well, psychologically, where it's just like you get that tolerance. So like you're taking it and you're sleeping sort of normal and then when you take it away, your insomnia rams up, but then it'll usually fade back to baseline.

Starting point is 02:10:23 It was just a reaction. But you don't know that. You think that you're using the THC to keep the bad insomnia away when really, whenever you pull that band-aid off, it's going to hurt for a little bit, but then it'll be fine. And then the only other thing I was going to mention for athletes is the increased injury risks due to THC because of the A motivation and the coordination stuff that you get sometimes that, like, whatever your sleep problem is, if you're thinking of using THC for it,

Starting point is 02:10:51 there's probably a better option that's less harmful. But is that if they're using the THC at night, is it, is it, it the THD directly affecting the coordination or is it the indirect effect of REM sleep? I don't know is that people who are using it more. I mean, we don't have great data on the timing of use. That would be a cool, cool study to do. But it just does seem to be that there's more injuries. There's more. There's the daytime a motivation. There's the and a motivation being like, not just like, you know, the stoner's sitting around like, I don't want to do anything all day. But if you're an athlete on the field, you need every split second to make the,

Starting point is 02:11:29 these choices to be paying attention, to be thinking ahead and all that stuff. And if you've got just a fraction of a piece of a cloud there, it gets in your way. And one wrong step, you know, could be twisting something, you know. Like it's just one of those things of like, there's probably a better option out there. I mean, I'm just saying. But, but that's THC. So THC does have effects on sleep. they could be relatively short-term, they could produce a rebound when you stop taking it,

Starting point is 02:12:03 and there could be REM effects. But having rum effects doesn't sound like it's a good thing, though. Maybe not. Is it the same REM effects as you get with antidepressants? Not clear. It's murky. The literature is murky. You got to remember, until very recently, researchers were almost not even allowed to study it

Starting point is 02:12:22 because it was a scheduled substance, and it was federally illegal. So anyone who takes federal money for research, and again, NIH is the lifeblood of all research. You were essentially forbidden from even studying it. Now we can sort of start and that work is being done. Canada started it because they legalized it first. So they're actually doing a lot of really great THC research up there. Watch the space next 10 years. I think more stuff is going to come out.

Starting point is 02:12:48 Okay. What about CBD? CBD, much more murky of a story. CBD is a legit molecule, especially in terms of the things that it does, but the sleep data from CBD are extremely murky. About half the studies that have used CBD have shown that it could benefit sleep. The other half don't. Some of them actually show that it makes sleep worse. The dose and the timing seem to matter.

Starting point is 02:13:14 The individual differences seem to matter. It also seems, so it's one of those things where, like, if I have a patient who says, should I try this? I would say, I won't have any objection to you doing it. I just don't have super high hopes. And to be totally honest, most of the patients that I've had say, yeah, didn't really help. Or maybe helped a little bit. It's also the difference between relaxation and sleep promotion. So if you have insomnia, a little bit of relaxation isn't going to be enough.

Starting point is 02:13:45 But, you know, if a little bit of relaxation is all you need, maybe it'll help. What kind of dose and timing are we talking about here? I don't know. Lower dose better. Yeah, it looks like, it looks like there's a sweet spot for dose. You can have a dose that's too high, which can actually make sleep worse. But then again, if it's too low, then it won't be doing anything. I don't know all the doses in the different studies.

Starting point is 02:14:08 So that might, that's also why there was such murkiness in the literature where people are using different doses, at different combinations, at different times a day. I don't, I don't have any clear answers about CBD, except I, um, I, I would keep, I would keep an open mind with it, but expectations in check. How does it, how does it work? Does it just reduce anxiety? I mean, is it like an L-theon-in kind Yeah, see, it's, it's, it's from a sleep perspective, it doesn't, I haven't seen any strong data that shows that it does much to sleep wake regulation itself, that its effects on sleep are usually secondary through anxiety and stress. I could be wrong. I am not, I am not,

Starting point is 02:14:52 Like, there are people who know way more about cannabis and sleep than me. But from what I've seen, it seems to be going through that indirect path. And does it affect sleep architecture at all? Like, does it have the REM stuff? I haven't seen anything that shows that it does in the same way. I mean, it's like most of the studies show it doesn't do much of anything to sleep anyway. So unlike THC. Yeah.

Starting point is 02:15:20 Okay. Another one that people use to help themselves fall asleep is alcohol. Yeah. Right. I mean, that's like... Alcohol is probably the most used sleep drug in the world, right? Right. So the thing about alcohol, alcohol, it would surprise nobody to tell you that alcohol can

Starting point is 02:15:36 make you fall asleep faster and actually sleep a little bit deeper in the very beginning of the night. But the thing about alcohol is, sorry for the fact that it's not good for you for all kinds of reasons, it gets out of your system very quickly. You metabolize it relatively quickly. And so what often happens with alcohol is when the alcohol leaves your system, it creates activation, creates a rebound. So often when people are drinking to fall asleep, they fall asleep fast, but then they wake up in the middle of the night and can't get back to sleep. I mean, anyone who's had sort of too much to drink and fall in asleep will, they have

Starting point is 02:16:16 that experience where you wake up and you're up and you're just like, oh, I don't want to be up, but you're not falling back asleep. And it's because the alcohol creates that reaction. One of the reasons it does that is as the alcohol molecule metabolizes and becomes acid aldehyde, it can become a neurostimulant. The acetaldehyde could become acetate, which could become a neurostimulant. And as the liver is processing the alcohol, it can create a glutamine rebound, which can be activated. So, like, there's all these things that can end up being activated from the alcohol couple hours in. That's also why, like, it's not a, it's not a great sleep aid. I mean, a glass of wine after dinner is not going to, for almost everybody is not going to be

Starting point is 02:17:02 that big of a deal. But if you're drinking enough where it's making you sleepy, that's how much it's going to be waking you up later, probably. Do you think, um, timing it early? earlier helps. Like if you're not, so if you do it earlier, then you're, if you're, if you're having wine at dinner

Starting point is 02:17:19 and then you've still got a few hours, alcohol is probably out of your system by the time you get to bed. The only thing you don't want is to time it so that, that the activating part of the alcohol being out of your system isn't when you're going to bed. So like,

Starting point is 02:17:31 that's sort of a tricky part too. But usually, to be honest, the amount that most people are drinking, it's really not, that's not so much the issue. But what's really cool is that you can see, if you drink before going to bed,

Starting point is 02:17:45 what's great is some of the newer wearables, like they pick it up right away. You see that heart rate data. You see that lack of recovery happening. It was still a toxin that you're processing. And I've had a number of patients come in thinking like, yeah, I used to, you know, I used to drink some wine before going to bed,

Starting point is 02:18:01 and I thought that would mellow me out. And then I looked at my wearable data and realized it made my sleep crappy. It made my sleep terrible. And so I stopped. And so getting that feedback could sometimes be helpful. Yeah, no, I mean, I will talk about Whirripples think. Yeah, we'll definitely get into that.

Starting point is 02:18:18 Okay, I mean, any other these, there's caffeine we could talk about. Yeah, I mean, caffeine, probably the most used psychoactive substance in the world. There's a reason why people use it. It works. It's relatively safe. Coffee is actually a great source of antioxidants and phenols, especially if you're actually just, if you're drinking it from coffee, not just the isolated caffeine molecule. it picks up, peaks at around 30-ish minutes, then trails off.

Starting point is 02:18:45 For most people, four to six hours before bed is the last time they should be caffeinating in any way. Some people, they can drink an espresso, go to bed just fine. People metabolize it differently. For some people, 10 to 12 hours is actually too much where they need to stop in the morning or else. There's just just enough floating around their system in the evening where they're not like jittery from caffeine. they just might have a harder time settling in. So that's a real thing. People can actually,

Starting point is 02:19:16 because doesn't caffeine shift your circadian rhythm over as well? It's not a circadian signal as much as it can be like an alerting signal and which can change your activity rhythm, which is more of the circadian signal. I don't think, I don't know, I haven't seen anything, I could be wrong,

Starting point is 02:19:31 but I haven't seen anything with caffeine itself as a potent circadian marker, except that if you drink caffeine around the same time every day, you can make it one. And it increases activity, which is itself a circadian marker. I thought there was one study. Maybe. Maybe.

Starting point is 02:19:48 And it was like they were giving men caffeine. It was like nighttime. Like close, it was evening. And I think it somehow shifted there. Well, it might have. 45 minutes or so. Like it might have shifted.

Starting point is 02:20:01 Well, my guess is it would have shifted. It would have delayed. They would have probably increased their activity level, increased their light exposure. laid everything by an hour. Yeah. So that's why like it delayed sleep onset, but I don't know what it did to endogenous circadian timing. But I'll have to take a look. I don't remember a paper looking at. So like in my world, there's a difference between behavioral rhythms and circadian rhythms. Yeah. Because there's like a circadian patterning. But like if did the melatonin rise at the normal time, it just got blunted because of the light you turned on and the activity you were engaging in, for example.

Starting point is 02:20:35 Right. Yeah. Yeah. So I just. I never, does caffeine not do anything to sleep architecture? If someone drinks. Yeah. I mean, like it'll, it'll, I mean, it increases fast frequency, EG activity. So it'll make your sleep shallower. So it'll probably, I mean, I'd have to look at the literature. But like, if I had to make a prediction, my guess is it would dramatically reduce

Starting point is 02:20:56 slow of sleep and deep sleep because you can't, you can't get into that stage if your brain's sort of still wired and active. So for those people that say, I can drink a cup of coffee and then go to bed 30 minutes later, they may be disrupting their sleep It might be. It might be. But also, again, people, there's huge variability in how people metabolize caffeine also. So some people might be more resistant to it. Some people, like, I'd be, for those people, I would really be curious to see their data.

Starting point is 02:21:24 Yeah. I mean, what's the quickest you could metabolize caffeine, though? I mean, 30 minutes. Or, or, you probably. No, that's when it's peaking. Right. Like, I don't know. They would never feel the effect.

Starting point is 02:21:35 Or maybe, or maybe just. the way it interacts with the Denedocene is different. Or maybe they're just so sleepy. Their sleep drive is so high. It's the way adenosine is interfacing with their sleep wake rate. Because adenosine itself isn't sedating. It builds across the day and interfaces with that system. But the adenosine itself, like you can't like take adenosine and fall asleep.

Starting point is 02:21:58 Like that's not how it works. So maybe different, you know, humans are humans. We're all different. and, you know, are wired. Sometimes sometimes some people, their system might be hooked in in a different way. You're talking about like one person here and a person there and like Outletters.

Starting point is 02:22:15 Getting 20 of them to come into the lab all at the same time and look at a systematic evaluations. I don't know that anyone's ever really done, to be honest. Right. It's more like clinical reports. Like, yeah, I could do this and sleep fine. And I've seen people who drink coffee at night and their sleep looks fine. So like, who knows?

Starting point is 02:22:31 Another one that I've talked about with Dr. Sautchen Panda, who's been on the podcast a few times, is late-night eating. Yeah. And obviously food is a substance. Yeah. And at least with my conversations with Sotchen, it seems like a good sort of, on average time to stop eating before you go to bed. It seems to be at least like three hours or so before you go to bed. How does food affect sleep? Yeah, I mean, so he is the world's leading expert on that, on that issue of the timing.

Starting point is 02:23:06 And he tells these incredible stories about how just the cellular machinery of transporting glucose fuel into the cell is partially clock dependent. And from the first bite of the day, once that machinery starts, it has a certain window of maximum efficiency that just that only fades. It's fascinating work. But as a psychologist, I have other perspectives on this as well, where a lot of times people don't eat at night for metabolic reasons. They're eating at night for emotional reasons. They eat at night because they feel like it helps them wind down. They eat at night because they're stressed.

Starting point is 02:23:52 And what's interesting is when you, in a sleep deprivation study, if you take somebody and you sleep deprive them, there have been a number of studies that did this and they look to see what you see what calories they're consuming and on average people tend to consume about 350 to 600 extra calories per 24 hours when you sleep deprived them in the lab not in the morning

Starting point is 02:24:16 if anything they eat a little bit less first thing in the morning not in the middle of the day not snacking not dinner but after dinner that's when all the snacking the extra snacking seems to occur, especially when people are kept up past the point that their body wanted to go to sleep. So if you're up and all of a sudden, and it's getting late and all of a sudden you're really hungry, you probably should have been in bed already.

Starting point is 02:24:45 That was your brain telling you, what are you doing up still? I guess you're going to have to have another meal if you're going to keep going, but because you're supposed to be in bed already. I was done. Like, we checked out. Like, are we doing another shift or what? so there and there's reasons for this but but people start craving for a lot of years people in the sleep world we're talking about is it carbs is it fat is it I just think it's it's energy people

Starting point is 02:25:12 are craving energy they're craving calorie dense food they're craving craving pleasurable food food that feels good to eat highly palatable food and especially sort of of like the later at night it gets. I mean, there's a reason why people generally don't crave a salad at two o'clock in the moment. You know, even if they would during the day, it's your thinking and your emotional reasoning and your choices are fundamentally different, especially between two and five in the morning.

Starting point is 02:25:46 That time seems especially vulnerable. In our lab, we're studying that vulnerable time. We're calling it the mind after midnight, like, and how you're, you make different choices. in that zone. All kinds of bad things. Like suicide spikes in that time. Four times greater than you would expect by chance than any other time of day. Spikes in that time.

Starting point is 02:26:11 Violent crime also spikes during that time for maybe different reasons. But unhealthy eating also like 3 a.m. food, if I tell you this is the kind of food you want to eat at 3 a.m., you know what kind of food I'm talking about. And it's not healthy food. Why is that? Why is that that there's this, and I don't think this is a pathological thing. I think this is a normal human function that when our brain is awake, when it wants to be asleep, especially when it's right there in that circadian dip of all kinds of other functions, it's this perfect storm of bad choices where we, it's reward seeking, but decreased reward

Starting point is 02:26:48 processing. So we seek the thing that feels good, but it feels less good when we do it. So we seek it more. and our decision making is we're not thinking about tomorrow. This is also why people wake up in the middle of the night and they're all freaked out about stuff. And then in the morning they look back and they think, man, I was all worked up about that,

Starting point is 02:27:07 but it's really not the end of the world. I can solve this problem. Our brains, when we're kept awake when we don't want to be, that we're not our best self. And it applies to food too. So how does this apply to shift, working and people that have these irregular schedules. I know.

Starting point is 02:27:28 I don't know. I mean, we've known for years that, that, so like if you ask a circadian scientist, is shift work worse for you than smoking? They will usually have to stop and think and be like, ha,

Starting point is 02:27:42 good question. And then you were supposed to say, I didn't realize that was a hard question. I thought it was obvious that smoking is the worst thing ever. Like, if you smoke, whatever else you do, it's the smoking that's probably going to kill you. shift work isn't good for you.

Starting point is 02:27:56 Shift work is a problem. You know, shift, like, we're the only species that shift works ourselves on purpose. Like, anyone who has a pet knows, like they might be up for a bit during the night, but not because they have to be. Because, you know, mammals sometimes sleep in bouts. And humans also are awake in the middle of the night for a certain amount of time. But, you know, it's forcing a square peg into a round hole. and there's consequences.

Starting point is 02:28:25 Some people may be more resilient. People who are more night owls, they might be more amenable to taking a night shift as long as they're able to go home at 4 o'clock in the morning and go to sleep. People who are early birds might be more amenable to taking a night shift as long as they can sleep between like 8 p.m.

Starting point is 02:28:45 and 2 in the morning. So for them, maybe it's not as extreme of shift work as, you know, maybe it's not as extreme, but shift work in general. It's a carcin, known carcinogenic. It increases diabetes risk, increases dementia risk. Like shift work isn't good. But yet we live in a society that demands it.

Starting point is 02:29:04 Someone's got to man the phones. Someone's got to drive the fire truck. Someone's got to work the hospital. You know, do all shift work occupations require shift work? I don't know. That's like, do all factories need to run 24-7? like, I don't know. But it's a trade-off. You know, there's this phenomenon in the hospital. I mean, it's just, that's the shift work that's closest to my life, where someone brings the box of

Starting point is 02:29:33 donuts at the start of the shift and no one touches them because everyone knows that, like, they're bad for you. But by the end of the shift, they're all gone. Decision-making, it gets impaired, especially when, and what food is available in the middle of the night, too. What would happen if we go into a shift working setting and set up palatable but healthy food? You know, why don't we have nighttime snacks that are just healthier that feel good to eat, that satisfy those cravings, but just don't do the same kind of damage? And why don't we make those avail? I don't know. I mean, I don't know why this isn't, why everyone isn't doing this.

Starting point is 02:30:19 It seems obvious to me. Just don't buy the bad processed food stuff and don't have it in your house. That's a good solution to not have it available. For shift workers, is there any way they can use these strategic kind of napping strategies to, you know, improve? Yeah, I mean, so the first thing for shift work is if you can keep a reliable shift, if you want to turn your day in tonight and make that permanent, that will actually minimize the damage. you're just in a different time zone. But if you stay in that time zone, it's the shifting around that causes,

Starting point is 02:30:51 it's the, it's unsettling the system that causes the problem. So the more, the more infrequently you keep shifting. So most people have families and stuff and they don't, they can't do it. That's the problem. But anyway, so napping.

Starting point is 02:31:06 Napping can be great. Think of a nap like a snack where our snacks good for you or bad for you. Well, it depends. healthy snacks are great. A healthy snack in the middle of the day can health stave off hunger, increase your energy, increase your focus, especially if it's kind of a healthy snack, high protein, some fiber, you don't, maybe a little bit of sugar or something in there to make it palatable, but you don't want to load it up with calories because you don't need them.

Starting point is 02:31:33 Same thing with a nap. A nap on purpose that is restricted in time before, you want to wake up before you drop down into that deep sleep. if you want to make it sort of like a power net. And you should remember you're dropping down to stage, but you want to wake up before you drop into stage three sleep. So how long would that nap be? So in the middle of the day, it could be an hour. If it, the closer you get to where your body is trying to drop into it,

Starting point is 02:32:02 that window shortens. So it could be just 15, 20 minutes, the later in the day. Sometimes you're going to drop, like you can't, you shouldn't nap when you're in your biological night. Don't expect to nap because. you're going to drop straight into it. But the further out you are, the longer you can make it. And so that it can increase reaction time, increase focus, increase learning, increase training

Starting point is 02:32:25 recovery. You can, there's data that shows like even in sleep deprived people, a decent nap in the middle of the day can dramatically improve metabolism, muscle strength, all this stuff. It can be, they can be great. And that's sort of a power net. If you're napping all the time, It's like if you're snacking all the time. It's not the snack that's the problem. It's why are you snacking? There's also a different kind of nap that shift workers can use. And I call that a sleep replacement nap.

Starting point is 02:32:55 Sort of like a meal replacement shake where no one looks at that and thinks that that looks like a meal. No one's confused that it's really a meal, but it does the trick in a pinch. And what a sleep replacement nap is. Athletes do this too when they, especially when they're when they have late games and they have to wake up in the morning. College students do this. one all the time where you go through a full cycle. You actually make it all and you get all you get a whole cycle of deep sleep,

Starting point is 02:33:21 which does exactly what it does at night too. It's not quite quite as good, but it, it does the trick. And you want to wake up after you've made it all the way through in the middle of the at night during your regular sleep period. That'll take, you know, 90 to 100 minutes. During the day, it might take two to three hours to make it all the way through. because you're not expecting it. You're, you're, you, you have, you have, you have a system to protect yourself from dropping into deep sleep during the day. You don't, your body doesn't want it there because it's trying to protect you. But if you stay in your nap long enough, your body's like, all right, I guess we're doing this.

Starting point is 02:33:57 And so it gets in it and you get all the way through. And if you, if you, if you wake up out of that feeling pretty good, you know, that counts almost the same as nighttime sleep. It's just most people don't have the three hours in the day to do that. Shift workers do. Um, and so, so they can do like either like right after a shift or before a shift or something, you can do that. Um, or even a strategic nap like while you're on a shift, you can get a little bit of a nap and, and be sometimes be able to function. Sometimes you're, you're too much in the middle of your biological night and that one little nap.

Starting point is 02:34:32 It's like you're starving and you only get one bite and sometimes that's a little worse. So everyone's a little different. But think of a nap like a snack and use a strategic. strategically, like you'd strategically use a snack to stave off hunger and to make it through a shift. Okay. That's great. All right. As long as you're not drinking a lot of coffee. Right.

Starting point is 02:34:50 Well, that too, because then a lot of times you could be drinking a lot of caffeine on your shift, but then you get home and you can't sleep. Right. And which makes you more tired on your next shift. So how should shift workers use coffee? Strategically. I mean, you should use it as, think of it as, I will drink coffee in about 30 minutes, it'll have its peak effectiveness. and I, in about six, for at least the next six hours, I will not be in a sleep window. And so the higher the dose, the longer that window goes.

Starting point is 02:35:22 So what you, you might want to like caffeinate at the start of the shift, but not in the second half. Okay. That makes sense. I want to kind of shift and talk about jet lag. Yeah. And we kind of, you're talking a little bit about this sort of strategic timing of Melatonin.

Starting point is 02:35:38 Yeah, and light. Right, and light. But I've heard you talk about jet lag in a way where you've talked about, like, when you get on a plane and you're going somewhere to a different time zone. Yeah. As soon as you get on the plane, you're, you need to mentally be in that time zone that you're going to be in. Yeah. So I'd love for you to kind of walk us through, like, how does this relate?

Starting point is 02:36:03 Let's say you're going, you know, to the east versus the flying eastward versus westward. I'm going to be going to China. Yes. Soon. A 17 hour difference from where I'm at. I mean, how am I going to get to that time zone? So, yeah, let's talk a little bit about how can we help ourselves adjust to the new time zone. If you're only going somewhere for a day or two, should you try to adjust?

Starting point is 02:36:28 So mostly, but the answer to that question is like mostly no. Traveling a couple time zones is totally different than traveling a bunch of time zones. It's like going to China. or going to Europe is very from the West Coast, U.S. anyway, is very different than going from New York to L.A. New York to L.A., it's a few hours. And you'll adjust within a couple days. You could adjust probably within two to three days. You're probably fine. Traveling that far, the circadian literature would say that it takes about an hour per day to adjust, obviously faster going west, a little slower going east. But when you're traveling,

Starting point is 02:37:08 when you're 10 to 15 time zones away, like, what is day four versus day 12 look like? You're not going to slowly adjust. It's going to be in, it's going to be jerky. So what I would say is when you get on that plane, think of yourself as having had maybe just a very short day. I like sleep depriving myself a little bit before these long flights. and you get on the plane. I like to try and schedule my flights so that it would be great. If I traveling to Europe, it's easier to do this where you time the flight so that it lands in the morning local time.

Starting point is 02:37:53 So you're taking off in the afternoon from the U.S. and it might be three, four, five, six in the afternoon, but you're landing at 10 a.m. local time. So as soon as I get on that plane, I'm like, okay, it's nighttime. I have this eight hour, eight, nine hour flight. Um, this is going, this is my night. So I'm going to have crappy sleep. I'll sleep for sleep on the plane when I count. I got my earplugs.

Starting point is 02:38:18 Got my eye mask. Got my melatonin. Got like, you know, whatever. Um, I will do what and, and I'll do whatever I can to catch a little bit of sleep on the plane. I'll have a crappy fragmented night of sleep on the plane. Land in the morning local time. wake up. I'll make it through my day just fine. I'll power through the day because my sleep's generally good beforehand, so I'll be pretty resilient. Make it through the day. I will be

Starting point is 02:38:47 exhausted by nighttime local time. And I'm essentially brute forcing my sleep wake homeostasis, even though I'm essentially my circadian rhythm is way off. But I'm tired when I want to be asleep and I am awake when I want to go around during the day and I'm getting the light exposure during the day. So I spend a lot of time outdoors when I travel. And so I'm sort of brute forcing a little bit. It's like I'm not going to be fully adjusted. And, you know, maybe if I'm there for a week, I will be. But, but those first few days, I mostly make myself sleepy when I want to be unconscious at night when it's dark, even though my body thinks it's daytime. And be awake when the sun is out and be moving and don't nap. I do not nap for that reason.

Starting point is 02:39:34 because I'm, I would be, it's sort of like, if you're taking a snack, don't, if you're going to have a light snack, don't have it be at dinner time because that snack is going to be miserable. Because then you're going to wake up and you'll have dropped into deep sleep. And so. So no naps when you're, when you travel. Yeah, I would, especially as you're still in the adjusting period, don't give yourself mixed signals. But try and, and if the, and if traveling to age is more complicated because the fight's so much longer. But think of it as long. local time. Think of when you're going to land. When do you want to wake up before? You know, it could be a few hours off. That's, that's probably fine to adjust to. But like, you know, if your flight is going to be landing, say, like, in the afternoon, but you're going to be taking off like the day before or whatever on the clock. Think of it as you're going to be landing the next day, have some crappy sleep on the plane. The other thing that will help is planes are slightly hypoxic of an environment. And oxygen rhythms, actually, there's some great data.

Starting point is 02:40:34 There's a lab in Israel that's been working on this especially showing oxygen itself is a circadian signal because oxygen dips during the night when you're asleep. So being in a slightly hypoxic environment for extended period of time, it's easier to trick your body into thinking it's nighttime than it's daytime. And then as soon as you leave the plane and they open the door and now it's normoxic again, that can be an alerting signal. So timing it that way is also helpful. What about exercise? exercise too exercise is an awakening signal so so there's not much exercise you can do on the plane without annoying everybody at least i guess but um as soon as you get off the plane that's a great time to be moving because you want to send that daytime daytime daytime signal even though you're in your

Starting point is 02:41:21 biological night say no no no it's daytime daytime daytime day time daytime and get light suppress whatever natural melatonin you have take the melatonin at night to to because because you might still be producing some of the melatonin during your biological night, which is the environmental day and not producing that melatonin at night when you want to be. So that's when you might supplement. Yeah, which is why being outside is so important during the day when it's your biological night. Yes. Great. All right. Well, Yeah, that's the thing with jet lag. Send yourself a daytime signal when you want your body to think it's daytime. Send yourself a nighttime signal when you want it to think that it's night. And, you know,

Starting point is 02:41:59 so you can block light as a daytime signal. So, uh, at, or give light as a daytime signal and use melatonin as the nighttime signal. So no sunglasses in the morning. Right. Yeah. Or if you're going to use sunglasses, make them kind of blue tinted. So even if it's, even if like it's blocking the UV or whatever, at least the light, so it's the blue-green frequency of light that sends information to the clock. That's why the orange lenses block it. But wear like a blue or green or tinted sunglasses if you're going to wear sunglasses in the morning. So that actually works where you can. I don't know. There's no data on this. I just made that up. But it should work because as long as you're getting that frequency of light, it's the bluish, greenish light that sends the information to the clock. But it's also, I live in Arizona, some to sunglasses, if you don't want macular degeneration, you need to wear sunglasses when you're outside. So how do you get enough light to influence the clock without doing retinal damage? And so that's why, you know, I don't know. I'd love to see data on this. I don't know that anyone's actually studied this if they have.

Starting point is 02:43:03 I'd love to see it, but that's my pet hypothesis. Yeah, because I would imagine, like you were saying earlier, obviously the early morning light, it's not as damaging, so you play don't meet some glasses then, but you're talking about being outside long, like hours during the day and how that also protects you from the blue light inhibiting melatonin later. You want the blue light to inhibit melatonin. Right, sorry, where it.

Starting point is 02:43:29 No, no, no, in the morning you want it to. Exactly. In the evening you don't want. want it. Yes. Yeah. Okay. So let's talk about where we do have a lot of data.

Starting point is 02:43:37 And this is definitely an area that you're an expert in as well. And that is these sleep tracking devices. Yes. Lots of them out there. Or the whoop. Yeah. What do we have? Apple Watch.

Starting point is 02:43:50 The Fitbit and Pixel. You and I are both on the scientific advisory for the Google. Google, yeah. Which is where we first met. But I want to know what metrics. do you think are truly good at being captured accurately? And which ones should we interpret with caution? Yes.

Starting point is 02:44:12 Excellent question. People need to know that using wrist-based movement to estimate whether someone was asleep or awake across a night has been around since the 1970s. That data has been well worked out. Those algorithms are pretty robust. it's actually shockingly good. You can predict with about 90% accuracy using movement alone. And this was analog devices that were on a tape backup or eventually 64 kilobytes of memory

Starting point is 02:44:46 on the whole watch. With that level of technology, you could get over 90% accuracy minute to minute, were you awake or were you probably asleep relative to brainwave activity? Sleep versus wake. That's what these devices are best at. They've always been best at. That is the data that I would trust the most with the asterisk of it's going to be different from the brainwave activity in that the brainwave activity will pick up lots of little awakenings that the movement detection probably won't. So it will underestimate wake time relative to looking at brainwave activity.

Starting point is 02:45:26 But it will overestimate wake time versus yourself report. So if I asked you how much you slept and you said seven hours and your watch says six and a half, that's not a problem. You're measuring two different things because the watch is probably picking up awakenings that you don't remember. So were you physiologically awake during that time? Probably. Could it have picked up stuff erroneously? Yeah, maybe. Were you awake during that?

Starting point is 02:45:52 Probably. Does it matter? Probably not. So because all of the guidelines and recommendations that people, you know, the seven hours of sleep guidelines, I mean, I, I, I, I, I, I, I, I, I, I, I, I, I, I was on one of the, the, the, the panels, I was on the ASM and SRS, the panel funded by the CDC to develop time recommendations. We were there in the room. We were arguing over this. And those recommendations are not based on wearable data.

Starting point is 02:46:14 They're based on, on average, how much sleep do you feel like you get? Because that is what's correlated with the health outcomes. The wearable data is a lot more murky in terms of its correlation with the health outcomes. It's different. So if you're, if you're targeting a certain amount of sleep, based on guidelines, the wearable data can fall under that and you're totally fine, like up to maybe an hour even under that and you should be totally fine. So that's, I trust it to be correct and accurate for what it is,

Starting point is 02:46:44 but it doesn't mean it's measuring the same thing. And so I expect it to be a little different. So that's, and that is what it's best at. The heart rate data are also really good. Separate world in that the heart, you know, photoplyphismography for getting heart rate data, that science is really well developed. And, you know, you can get really good heart rate data with pretty good resolution from the wrist and even from the finger. You can get pretty good heart rate data. So, so yeah, terms of the other stuff, there's, there's sort of two levels of other stuff.

Starting point is 02:47:17 One is the sleep staging data. And the other one is other metrics like recovery or readiness or sleep score and all that sort of stuff. The sleep stage data, um, it's a ballpark. It's actually, it's actually better than a lot of sleep people assume that it is in terms of its level. It's probably between 60 and 80% accurate.

Starting point is 02:47:45 So it's not nothing. It's also not perfect, but it's also not garbage. Like it's, it's helpful. It's, it's probably ballpark correct. Um, kind of remember what sleep stages are.

Starting point is 02:47:59 We're looking at different patterns of brainwave activity. And then in the 1930s, people looked at these squiggly lines on paper and put them into four buckets. And then it became five and it was back to four. Just are you stage one, two, three, or REM based on the pattern of squiggly lines? This is humans rating it. Do they exist in nature? No. We made them up.

Starting point is 02:48:24 You know, this is how humans categorize stuff based on. patterns of brain activity on the outer layers of the cortex that are fluctuating during sleep. The fact that you can look at heart rate fluctuations in combination with movement and get a really good estimate about which state of brainwave patterns you happen to be in at that moment, even though two humans can't always agree when looking at the same squiggly lines. Is that stage one or stage two? Is that REM or did they drift into stage two or stage one at this point? It looks kind of similar.

Starting point is 02:48:58 I'll call it Ramble. I'll call it stage two. You see this all the time. This is why we don't even use AI yet to rate these things because humans don't trust them because they can't even agree with each other. There's no gold standard that you can even train a lot of these AIs against because even the humans can't agree. So it's a moving target anyway.

Starting point is 02:49:17 So the fact that you can get that close from from this stuff on the wrist, I think is a miracle, but you've got to keep your expectations and check. It's like playing two games. of telephone going in opposite directions and using the result of one game of telephone to guess not what the source was, but what the other game of telephone came up with. So the fact that they're even in the same ballpark, I think, is great and useful. But what that also means is don't read too much into it. Like if it shows very little deep, first of all, I can't distinguish stage one and stage two at all.

Starting point is 02:49:51 So they call it light, usually. And as I mentioned before, those are very different things. If you have a lot of stage one, that's bad because your sleep is super shallow. You have a lot of stage two. That's normal. That's what it should be most of what sleep is. And the deep sleep detection is only about 60 to 70% accurate at best in most people. So when people say, like, it's not showing I'm getting enough deep sleep,

Starting point is 02:50:17 and I say, well, the algorithm isn't picking it up. It doesn't mean you're not, A, it doesn't mean you're not getting it. And B, if you weren't, as long as there's no barrier. to your body obtaining, if you don't have untreated sleep apnea or chronic pain or an environmental stimulation to prevent that deep sleep from occurring or drinking alcohol or whatever, your body is doing whatever it wants to do. So if it doesn't want to take more, because as people get older, they take less anyway. You know, growing people, healing and recovering people usually need more. But if you're not getting it, A, does it matter? And B, how do I know you're not getting it?

Starting point is 02:50:54 And so it's, you got to interpret it with, with that caution. So that's the caution with the sleep stages. If I show you what a brainwave tracing of sleep stages and a wearable tracing, that you can, you could, if it's a good device, you can easily tell these are the same person on the same night if you looked at them. But if you actually counted the exact number of minutes, you would probably find that 20 to 30% at least of those minutes didn't exactly agree with each other. But you can tell visual.

Starting point is 02:51:22 That's why clinically, I look at it visually. I don't actually count the minutes because I don't depend on it. And actually one night of data, is it worth much? It's more about the weekly trend or like trending and changing over time. That's what I care of them. So that's the sleep stage of data. The third bin is the metrics like the scores with very few exceptions. Most of those scores are, I give almost no attention to those.

Starting point is 02:51:50 I can be ungenerous and say they're mostly made up nonsense. anyway. Can you repeat what scores we're talking about here? I'm talking about anything that's called like sleep score, sleep quality, sleep needs, sleep readiness, recovery, any of that stuff. If I'm being ungenerous, I'm saying it's mostly made up nonsense to sell devices because telling people what they want to hear. But that's not the truth either. They're not nothing. They have a lot of these companies, not all of them, but a lot of these companies have smart people working for them who are not idiots, who know how to work with the data and are trying to make prediction algorithms that are actually useful. The thing is, none of these things are published.

Starting point is 02:52:33 None of these things have been vetted. None of these things, it's like, it's kind of like at the trust us level of like, well, how do I know what you're putting in your algorithm and how to interpret those numbers? So like, if I drink alcohol the night before, but I'm otherwise totally healthy and the number looks bad, should I worry or not? Am I, is, is it actually impairing my ability to perform or not, or is it looked like it is because of how the algorithms using heart rate data. I don't know because none of it's transparent and forget the transparent. I know Google did a study on the, that was a Google was FIPP it before it was Google, I think,

Starting point is 02:53:08 where they had their sleep score and they correlated the actual global sleep score to outcomes and they presented the data at a conference. As a global thing, I don't think they ever really followed up with it, but I don't know that that that that that that that that that that that that that that that that that that that that That's even that baseline level of is this correlated with anything remotely useful is a step that, I mean, that that they did, but I don't know that anyone else has ever really done that much. So as the literature is coming out, as more and more people are using these metrics and seeing what's it related to, what's it not related to? What does it predict reliably? What does it predict unreliably? What does it not predict at all, even though it thinks it does? As a researcher, you give me a number. I don't know what to do with it. unless I can, unless I understand how it works. So I guess what I'm saying is I don't trust these numbers almost at all. I almost 100% of the time completely ignore them because they don't give me any information

Starting point is 02:54:04 I can use because I don't know what they mean. And at worst, they're made up. But at best, they're really good educated guesses made with assumptions that I don't totally know, so I don't know what to make of it. I mean, I'm trying to be fair and not throw them all under the bus. They probably aren't useless. They probably have value. And they're probably not all incorrect either.

Starting point is 02:54:28 It's just you gave me a number and I don't know what to do with it. So I was going to ask you what the biggest misconception about these wearable devices you kind of wanted people to know like right now. And I'm thinking maybe this. Yeah, that's the big one. It's also, I think the biggest misconception is that accuracy matters. It's not about are they accurate or not accurate to relative to what. accurate relative to your memory of the night or accurate relative to the physiology, those predict different things.

Starting point is 02:54:59 And even if it is accurate relative to the physiology, does the number give you a useful metric that you can actually use to do anything with it? What are you going to do with that information? And if you're going to make decisions based on it, you better know what it is. And, and I feel like a lot of companies, like they're stuck in a bind because if they're too transparent with their algorithms, other people are just going to copy it. patent and algorithm. So what are you going to do? How do you maintain your competitive advantage? And I mean, that's a line to walk. And as these companies, they're just going to try and come up

Starting point is 02:55:33 with better metrics and better metrics as a researcher and as a scientist and as someone who cares about public health, who has family members who ask me what to do with this information, give me the data I need to make choices, to make an informed choice of what to do with this information. So that's probably a big misconception is that these numbers are what they say they are. Okay. Well, let's talk about actionable then. Like, how can you practically advise people that are watching or listening to this to use their data? What data can they use and how can they make it actionable? Excellent question. So another saying that I should be to a colleague of mine, Amy Athe, who's a sports psychologist, who's a colleague of mine, and she's helped me a lot on a lot

Starting point is 02:56:18 of sleep stuff. And, and I was explaining this wearable stuff to her. And, and as we were developing our own trainings with this, and she came up with this, this way of thinking about it as a bathroom scale is not a weight loss program. And just because these are measurement tools. Measurement tools are not interventions. People, if you're buying this to give you information to make a change and you don't know to do with the number it's giving you,

Starting point is 02:56:50 how is it going to make a change? You know, just because it gives you a number, just because it has a, just because it's a bathroom, a fancy bathroom scale that has an app and has all kinds of other metrics in it, doesn't mean it's giving you useful information that you know what to do with. So, so the way, the first thing in terms of creating actionable steps out of this is first to realize

Starting point is 02:57:14 that it's, it's spitting you out a number. It's measuring some. something. To make an informed choice of what to do with that information, you have to know what that number means. So first is, I got to teach you a little bit about what these numbers mean and what these numbers don't mean. Then, just like, just like when you see the amount of sleep you got, what does that number mean? Does it, does it mean on meeting guidelines or not? No, it doesn't mean that. But does it, if I see it over time, if I see, I'm usually hitting six and a half, six and a half,

Starting point is 02:57:46 but today I was at five, what happened? It's like it's, that is the number it's probably best at. So if I'm going to make a decision based on wearables, the first number I'm looking at is the how much sleep did I get? And where did it detect the awakenings? Because those were probably correct, especially if they were more than a couple of minutes. And are there discrepancies between what my memory of the night was

Starting point is 02:58:10 and what the device found? And in those discrepancies might be some wisdom. So sometimes people with insomnia feel like they were up all night. But they actually got more sleep than they thought because they were up and down. So they could use the wearable device to sort of de-stress a little bit and find the sleep that they may not remember. On the flip side, if it's detecting awakening, if you're trying to figure out why you're tired and you feel like you slept okay, you can look at the device and say like, oh, I see what's like, I'm up and down a lot during the night. This seems very fragmented.

Starting point is 02:58:46 No wonder why I feel kind of. It's like you use that information. So like the continuity data, the the wake versus sleep data can be used for all kinds of things that might not even be totally conventional. That's what that's without even looking at the heart rate data, sleep stages data. Then I'd look at the heart rate. Heart rate should start relatively low in the evening compared to your resting and it should be dropping. And then at some point, you should have an inflection point where it sort of starts picking up again. probably around three or four in the morning when a lot of people wake up around that time.

Starting point is 02:59:18 Maybe you're just kind of sensitive to that that shift in your circadian rhythm where your, your daytime is starting up. And as some people get older, they might be more sensitive to it. Or you might have a natural awakening around that time, but you don't have the same sleep pressure to get back to sleep. So also in that heart rate data. So like if it's staying, if your heart rate is staying high during the night, what's going on? If it's not dropping, what's going on?

Starting point is 02:59:41 If it's rising during the night, what's really going on? what's really going on. If you see your heart rate data looks normal, then you have a couple of periods of intense fluctuation. What's going on in those periods of time? They might give you some insight that there's something under the hood that's causing activation that's going on. If you see your sleep, your sleep stages, irrespective of what it gives you, if it shows that they're highly variable across the night, something's up. If it's putting deep sleep in the second half of your night, something's up. If it's putting a big bout of REM sleep in your first three or four hours of the night, something's up. It doesn't belong there. Could be, but it's unlikely. And if anything that tells me that

Starting point is 03:00:24 I don't know what's going on under the hood, but something is aberrant there, not that your sleep stages are in the wrong place, but that the algorithm is finding them where they don't belong. And so why? Well, what's the algorithm using? If it's using movement and heart rate, it means, there's something unusual going on with your movement and your heart rate in that time where it doesn't belong. And then you could start thinking about what that is. Could that be sleep apnea and you're jerking around or something? Or you have limb movements. Or maybe, you know, it's a bed partner who keeps rolling over or making noise. So like it might give you a window into, you know, I was unconscious during this time, but something was going on during that time. And then you can start

Starting point is 03:01:06 looking into what that could be. So if let's say someone is, like their heart rate isn't dropping like it's supposed to or, you know, like, what sort of things can people do to try to help with that? Yeah. So first I would look to see, is there anything chemically in the way? Is there alcohol? Is there medication that you're taking at night that you should be moving earlier in the day, for example?

Starting point is 03:01:30 I actually see this not uncommonly where people have trouble with sleep because a medication that is perfectly acceptable to prescribe in the evening is being taken in the evening. is being taken in the evening is just you're sensitive to it in a different way. So I see this a lot. So first see if there's something chemical or if you're eating, you're eating a food that's too metabolically active, too close to bedtime. Or you caffeinated too late.

Starting point is 03:01:55 Yes, it was four hours ago, but it was still too late and it's still hanging around in there. Or something like that. Or you have something, something active going on. So like, do you need, is there a pain issue going on? Is there some inflammation going on? Is your mattress 10 years old and needs to get replaced? It's just uncomfortable and it's creating too much activation during the night. You know, there's,

Starting point is 03:02:20 there's all kinds of reasons for that. And then if not, what's your relaxation wind down routine like? Why is your heart, are you exercising too late? And your, and your, and your, and your, and your core body temperature and your heart rate is, is high because of what, what you happen to be doing, where it's not dropping. Why not? Or maybe you need to introduce some more relax. techniques into the evening, whether it's physical relaxation, like breathing exercises or stretching or yoga stuff or or mental stuff like, you know, there's imagery exercises and other stuff and body scans or mindfulness exercises and meditation or like a mind body approach, like I'm a huge fan of progressive muscle relaxation, um, where especially done right involves both. Um, maybe you're, maybe you're going to bed too hot and you need to, you need to chill out a little bit first. whether it's mentally, physically, or both. What about, I know we talked about the accuracy of the sleep state, being able to measure sleep stages, anywhere between maybe 60 to 80%, which isn't terrible.

Starting point is 03:03:22 No, it's not terrible, but it's nothing to, but it's not, it's not gold standard either. No, it's not gold standard. But, you know, let's say that someone is, we're not just talking about a night, but we're talking about weekly, like, month, like, we're seeing a consistent pattern of not getting enough either deep or REM sleep. Right. And so the way I would interpret that is you may or may not be not getting enough, but you're definitely exhibiting a pattern where the algorithm is saying you're not getting enough.

Starting point is 03:03:50 Why? Is it the problem with the algorithm? Is it a problem with maybe you are getting it, but there's something in the peripheral system that is, like maybe your heart rate is just too variable and it's not big enough for other reasons or something? I would say the way I do this is just like the breathing example where it's like if you're having trouble breathing, okay, do you have a problem with your lungs? You have lung disease of any kind. If so, let's figure out what that is. Treat it.

Starting point is 03:04:23 Okay, lungs are fine. Do you have an airway disease? You have asthma. Do you have airway inflammation? That could be interfering with your ability of your lungs to be transferring oxygen correctly. Are those fine? If it's identify any problems there, fix them. Okay, that's fine.

Starting point is 03:04:38 Okay, well, is your air very polluted in that case? In that case, you know, maybe you need an air purifier. So from a sleep perspective, it's, is there anything physically that's preventing you from getting deep sleep if you wanted it? Do you have some sort of systemic inflammation going on? Do you have untreated sleep apnea? Do you have chronic pain? Do you have some, are you taking a medication that could be suppressing this?

Starting point is 03:05:01 Like, is there something? that's a physical barrier. Let's go down the list and rule them out. Because if there's something preventing you from getting deep sleep, let's get it out of the way. Let's unprevent it. Let's treat that condition. If there isn't, and we still see that there,

Starting point is 03:05:17 then it's like, okay, well, maybe it's environmental. Do you have, is your room too hot? Is your bed too uncomfortable? Is your spouse too snoring too loud? Or rolling over too much? Are you just too sensitive to light? do you live on a street where you're asleep, but there's still cars driving by and that's creating that's like, is there something in your environment? If we go through with somebody and their environment is

Starting point is 03:05:43 fine, their sleep continuity is fine, they're falling asleep fine, they're sleeping through the night, there's no medical reason that's preventing them from getting deep sleep at all. My perspective on it is, don't worry about it. Your body's doing what it wants to do on its terms. If it wanted more, if it needed more, it would take it. But it doesn't. So forcing it may or may not be a good thing anyway. Well, this is a, this kind of leads into the next question, which is the pitfalls of these sleep tracking devices. And I've known several people that have fallen into this pitfall. And that is obsessing over their sleep data, which may not fall into what they want it to be or think it should be.

Starting point is 03:06:27 And that actually causing worse sleep because they're just obsessed with it. And I've heard you refer to this as orthosomnia. Yeah, yeah. So that was a term developed invented by a colleague of mine, Kelly Barron. She's at the University of Utah. She's like me. She studies sleep and sleep health and wearables and stuff. And so she came up with this idea, putting a name to what we would see in clinic of people who overly fixated on the data to the point of where it was sort of like orthorexia was the idea where people are obsessing over food ingredients where it's like you're missing.

Starting point is 03:07:02 the point here, you know, like the degree of information that these data are giving you is not the level of precision you should be using that that could even give you to be obsessing to this level of detail. It's these are, these are rough estimates that's a fuzzy picture at best. It's a fuzzy picture that's probably true, but it's still a fuzzy picture. So just because you see things in there that that might not be perfect doesn't mean they're not fine. And sleep doesn't have to be perfect to be perfectly fine.

Starting point is 03:07:30 So as you're talking about conditioned arousal, what do you think is going to happen when you start obsessing in bed over your sleep metrics? You're going to start developing arousal. And so orthosomnia can be a precipitant to insomnia. And it's going to make your sleep worse. And then you're going to worry about it more. Actually, for a lot of those people, a lot of times we'll just say, take it off. Just take it off.

Starting point is 03:07:56 It's not, it's a net loss for you. It's not a net gain. But I want. But I want. want like you know what you can't handle the truth i guess it's it's sort of like let me teach you how to be happy with the sleep you're getting then you can put the device back on and you're approaching it from a place of happiness and you know your sleep is fine and this is just giving you more information it's not and and you know your sleep is fine as opposed to relying on this information

Starting point is 03:08:23 for what it can't give you it can't give you those answers we don't have that level of precision So there's nothing worth worrying about. I mean, at least, I mean, if you're, the way I think of it this way, if your device is giving you information, you think it's bad news, come see someone like me. We will probably, I'll look at your wearable data, but most people in my world don't even do that. They don't look at your wearable data because they don't care. If you have a problem with your sleep, I will ask you the questions I need to ask, do

Starting point is 03:08:51 the tests I need to do to figure out what that problem is and use all the tools I have to fix that problem, irrespective of what. whatever your wearable sets. And if that wearable is what got you into the clinic in the first place to say, hey, I thought my sleep was okay, but now I'm a little worried about it. I will say,

Starting point is 03:09:08 okay, well, I'll tell you if you need to worry. Well, I'll ask some questions, figure out what's going on. Sometimes I'll say like, you know what?

Starting point is 03:09:15 You have what we call normal and I can't fix normal. I might be able to optimize a little bit. Can work on that. And actually destressing, your, your sleep is more impaired. because of the stress around your sleep than anything else that you're doing. It sounds much like the negative stimulus, right.

Starting point is 03:09:35 And so often that's the case. So like if you're looking at your wearable data and you're not happy with what you see, if there is if there's a problem that needs to be fixed, come to a sleep specialist. We will find the problem. We will fix it. If there is no problem to be fixed, if you're within a normal range,

Starting point is 03:09:56 a sleep clinician is probably not going to fix it. It's not going to have anything to fix for you. You might have to come to somebody who has a little more experience with optimization if you really want. If your question isn't, is this bad, but could it be better, then you might need to go to somebody who has more experience on the performance side who can read those numbers, read those T-leys, and say, yeah, no, this is totally fine. I couldn't, I couldn't make these numbers better if I wanted to, or we could do something about this. Let's talk about making these numbers better. And I know that we've kind of talked, we've touched on it a little. little bit. So you tell me, like, if there's more information that you want to share about it,

Starting point is 03:10:33 but like using sleep as a cognitive performance enhancers. You talked a little bit about this. Yeah. I mean, think of sleep is, sleep should be a joy. Sleep should be your friend. Sleep is what helps you face the next day with as much resources and resilience as possible that, um, a colleague of mine, Teresa Aurora, she led this project that I, that I also helped on. looked at, we basically scoured the entire medical literature on resilience and sleep. Because everyone talks about not getting good sleep is bad, but is getting good sleep good? And basically what we found was cross the board, people, if you can sleep better, your resilience will improve.

Starting point is 03:11:17 You can improve your level of resilience, whether it's physical or emotional or whatever. It was very, it was defined however the study, whatever the study defined it. Any study, if you improve your sleep, you can improve your degree. year of resilience. You can improve your reaction time. You can go from normal to better. You can go from good to great. There will be a ceiling, but especially athletes, especially younger athletes, like adolescents, young adults, you know, most people in elite sport are under 30. Younger people will benefit more from more sleep than older people will, to be honest. If you're 20, It's, you know, I'm not saying more is always better, but too much is very rarely a problem

Starting point is 03:12:05 for adolescents and young adults. There is such things as too much sleep, especially as you get older. And if you've ever, like, slept 10 hours in a row and woken up feeling groggy, they call it the rip van winkle effect, you know, like, it's a real thing. You can't oversleep. But it's kind of hard for a 20-year-old to oversleep. I mean, there have been studies where you take where they're already sleeping maybe six, seven hours. If you get them up to like nine, ten hours, they're faster. They're stronger.

Starting point is 03:12:32 They're mentally sharper. So, so you, so first of all, just sleeping a little bit more if you're younger. That's probably the easiest thing you can do. And that's about budgeting time. And that's about planning your wind down routine so that you land where you want to land, when you want to land there. So it might be thinking a little ahead and giving yourself permission to put stuff down. Is that harder for younger adults? Because they're, I mean, at least I know as you hit adolescence, your circadian rhythm later. It shifts later. Yeah. So you're, I mean, I go to bed at midnight instead of, you know, when a typical adult looks at a clock and sees midnight, clock says midnight, their body says midnight. When a five-year-old looks at a clock,

Starting point is 03:13:13 clock says midnight, their body's like, oh my gosh, it's three o'clock in the morning. Why are you awake? Right? Little kids go to bed early, wake up early. When an 18-year-old looks at a clock, clock says midnight, thereby is like, it's only 9 p.m. Why are you going to bed now? And when when they have to wake up at seven, they're like, oh my gosh, it's four in the morning. Why are you trying to wake up? So yes, they are shifted. And it changes with age. So yes, you can use light behavior and melatonin to physically shift that.

Starting point is 03:13:41 You can do that. But they are more naturally inclined to staying up late. I mean, high school should not start before 9 a. Totally. 100%. Colleges shouldn't start before 9 a 8. 100%. It's developmentally inappropriate.

Starting point is 03:13:54 It's a lot. I mean, colleges, I can't speak for that, but for like high schools, it's a It's about the parents' work schedule. Yeah. It's logistics. It's not about what's better for learning or it's not about what's better for the student. I mean, and all of the data that shows that when you delay school start times,

Starting point is 03:14:08 California led the way on this. California took the step and at least pushed it to 830. Right. I don't think any other states followed yet. And there's tons of data on this. My colleague Wendy Trollisle, she has a fantastic TED talk on this on school start times. it's just it's wherever you look you know when you delay school start times you improve everything not just academics why do you think kids are so sleepy why do you think teenagers are falling

Starting point is 03:14:39 asleep you know all these ADHD diagnoses how many of them are just sleep deprivation you know mental health problem is depression and anxiety how much of it is just is just insufficient sleep and circadian phase shifting so like you can actually improve these outcomes by getting kids at a time that actually works for them. So there's that. So yes, part of this is we live in a world mostly designed by old people who make all the rules. You know, if you look at who's in, who's in Congress, who's making all this legislation? It's not 20 year olds. And they way, they're like, I wake up at five, six in the morning just fine, you know, so what's your problem? You're just lazy. You know, like, I'm not saying

Starting point is 03:15:19 they say that. I'm just that we live in the society of like, what, early to bed, early to rise. Well, it's nice if you're 60. But if you're 20, early to bed, early to rise, you know, you might have a circadian rhythm problem. But you said you can sort of use strategically light, so early light exposure and then, you know, melatonin. Yeah. You can help with that.

Starting point is 03:15:39 You can give melatonin to, you can give melatonin, low, that low dose, half milligram melatonin is a phase shifting dose and light as a phase shifting dose of bright light. You can, you can do that. If you get a 20-year-old up early, flood them with bright light and movement. Physical activity, exercise, movement is extremely powerful also as a phase shifter. What time of day? Early. Early.

Starting point is 03:16:03 Early exercise. Yeah, early exercise. Get them up. Get them moving early. They will get tired a little earlier. Their circadian rhythm might still be a little bit off, but they'll be able to sleep. And over time, especially if you have the dim lights in the evening, those dim lights in the evening can help pave the way for, you know,

Starting point is 03:16:25 even if their natural melatonin isn't going to rise, give a little bit of melatonin the evening, force that rise a little early. You can, I mean, you can essentially jetlag yourself on purpose without traveling by doing that, by giving light and melatonin at the time. I mean,

Starting point is 03:16:39 that's good to know, right? I mean, yeah, some people are more resilient to it than others. Some people are more sensitive to it than others, but you can do it. And actually, um,

Starting point is 03:16:49 it peaks, this, this delay seems to peak in the early 20s, like 22. But then after that, like you can, you can get, I mean,

Starting point is 03:16:58 I work with athletes all the time. Athletes tend to be pretty good at getting up in the morning because they wake up, they get light, they get movement first thing in the morning. And we did this study looking at looking at, looking at this called chronotype, which is like sort of where in the 24 hours are you,

Starting point is 03:17:12 chronotype and athletes, athletes, maybe it's also self-selection. where the teenagers who were just super late people were less likely to survive the training schedules to make it to the elite level. Who knows? Or maybe they've adapted to it a little bit more. But yeah, athletes tend to be on average not as much of a night owl as typical people of their age. Right.

Starting point is 03:17:39 What's the most, if we're talking about like athletic performance, what's the most consistent sleep? hack you could, you know. Get a little more. Get a little more and see how you perform because the data show over and over again that extending sleep, especially in younger elite athletes. I'm talking about 60 year old,

Starting point is 03:17:59 but I'm talking about like 20, 25 year olds, 19 year olds, 29 year olds, like do an experiment. Get more sleep if you can. And there's some strategies for doing this. Because if I just say, spend an extra hour in bed, We just talked about how if you can't fill that time, you might actually create an insomnia.

Starting point is 03:18:17 So you might want to slowly increase the amount of time you're spending a bit, unless you're tired enough that just spending an hour in bed, you'll knock out anything. For like 15 minutes a night? That's how I like to do it. I like to extend it by 15 minutes. See if you do that. Extend by another. Because also you don't have to find an hour in the day. You can always find 15 minutes.

Starting point is 03:18:36 And that 15 minutes might buy you enough productivity where you could find the next 15 minutes. Do you go to bed earlier 15 minutes? Usually that's what people have more control over. Okay. Usually when people wake up is not what they have control over. Usually they have to wake up at a specific time. So it's about advancing bedtime little by little. But the point is you're ready for it by the time you do it.

Starting point is 03:18:56 But anyway, so sometimes it's like go to bed an hour earlier. And if you're exhausted enough, you could do it. But over time, that might make your sleep shallower and you might create more arousal if you can't fill that time. So you don't want to just, I don't want us to say like get more sleep because not everyone needs it and not, you don't know how much more. more and you don't know if you can fill that time if you have insomnia anyway.

Starting point is 03:19:16 But anyway, but the data consistently show that if you can bank a little extra sleep, first of all, on average, you might show up, it'll likely show up in your performance, but you might need to track it objectively, using something like a tracker, like, or a stopwatch. Are you getting faster?

Starting point is 03:19:34 Are you being able to lift better? It might not be perceptible by your memory, but it might, if you are 5% faster, or you won't notice, but the stopwatch will, for example. Yeah. So that's the first thing I would say. The other most important sleep hack for athletes is sort of comes after that. And it's sleep banking.

Starting point is 03:19:57 Bank good sleep. Get as much good sleep as you can while you can because if you have a competition tomorrow and it's high stakes, you're not going to sleep great. Probable. Maybe you will. But many athletes don't. even at the very elite level, they are not sleeping well right before competition.

Starting point is 03:20:17 But if you've banged good sleep up before, like if you're already off balance and barely keeping on two feet and someone bumps into you, you're going to fall over. But if you're well planted and someone bumps into you, you can recover pretty well. So one to two nights of short sleep does not dramatically impair performance.

Starting point is 03:20:37 It might stress you out and you might psych yourself out. That might impair your life. performance. But if you're coming from a place of strength, one or two nights dropping your sleep from eight down to like six or five hours, you might have some cognitive impairment, but it's going to be quite minor. A week out, it's going to be very pronounced. It builds. It's cumulative. But one or two nights isn't going to be that big of a deal if you're coming from a place of strength. Is this? So it's really about the week before your week or two. A week or two. Okay. Yeah. Come from that place of sleep. Is this the same for a cognitive performance?

Starting point is 03:21:12 as well. Yeah. So sleep banking, really, it's not just about the day, the night before. Right. It's not about the night before. And that's great to know because so many people stress about the night before. Yeah. If they know that, a head time.

Starting point is 03:21:23 Come in with confidence. It's like, it's like with nutrition. It's like, you know, it's not about what you ate today. It's about what you've been. Right. I mean, it's the same thing with the sleep on the weekends where when people say, how much sleep do I need to make up on the weekends to make up for being sleep deprived during the week. I'm like, well, that's like saying how much kale do I need to eat on the weekends,

Starting point is 03:21:46 but to make up for eating nothing but cheeseburgers and pizza all weeks. Like, well, it's like I was saying about weekends. Like, it's better to do that than just having cheeseburgers and pizza all week. But that's not the answer. You know, and that's also why you don't recover right. That's why it's, you know, it's not, it's not like a debt. Sleep debt isn't like a financial debt. It's not like you don't have to pay it all back, which is good. You just have to get back in balance and your body will start taking care of itself once you're doing the right thing. For in terms of like recovery, injury prevention, how strong is that data that you really do? So yeah, it looks like sleep.

Starting point is 03:22:25 First of all, sleep is critical for recovery. And everyone knows that. Like when you're sick or when you're injured, you actually have an instinct to rest more. I mean, yes. But from injury prevention standpoint, sleep-deprived people injure themselves more. We see this from all occupations. Like you crash your car more. And actually, if you ask people how well rested you think you are, but you see how much sleep they're getting, it's how much sleep they're getting, not how well rested they think they are the predicts drowsy driving, for example.

Starting point is 03:22:55 Like even if you say you're fully well rested, if you're getting five or six hours of sleep, you are three times as likely to not off behind the wheel. Even if you say I am 100% well rested, data don't bear that out. People are not a good judge of how impaired they are through to sleep deprivation. So how much sleep you get is important in terms of those sorts of things. In terms of athletics injuries, what seems to be a bigger driver actually is, are two variables, insomnia and daytime sleepiness, which are very common in college students. But actually, if you're sleepy during the day, even if you're getting, if you feel like you're getting plenty of sleep at night, if you're nodding on. If you're nodding off during the day, if you're having trouble staying awake, you're more likely to hurt yourself. You're more likely to wink out.

Starting point is 03:23:45 You're more likely to like not focus on something. You're more likely to hurt yourself. Same thing. If you have really bad insomnia, irrespective of how much sleep you're getting, that inability to sleep when you're trying is predictive. So, so one example. So we did probably what is like the biggest controlled study of this where what we did was, We, again, went into a Division I school, measured everybody over the summer before they showed up for classes and training. And then we just combed through every interaction with any health care person.

Starting point is 03:24:20 And in this school, everything from I feel stressed to I twisted my ankle gets documented in their record. Everything. Every headache gets documented. So we just combed through to see what over the summer, predicted concussions. And what we found was prior concussion history, being male, and being in a high-risk sport, were the three biggest predictors of concussions, except for the sleep variables. Insomnia, having a high insomnia severity, which is a questionnaire we use to see, like,

Starting point is 03:24:59 how much is your insomnia interfering with your functioning during the day, and how much is it stressful for you, and daytime sleepiness saying at least two days a week, I think it was a week, at least two days in a period, I'm having trouble staying awake. Those two, not amount of sleep, but those two were better predictors of whether you were going to get a concussion than even the concussion variables. Has it been replicated? No one's been able to do something this large since. I'd love to do it. I'd love someone else to do it. But, this is consistent with the literature that's coming out that shows that it's not just the amount of sleep sets you up for acute sleep deprivation effects, but it's going to bear out in terms of daytime functioning. And if your daytime functioning is bad, then, you know, you're more likely to injure yourself.

Starting point is 03:25:54 And getting better sleep is the best way to not be sleepy. Yeah. That's very interesting, your study. Yeah, well, and it was actually inspired by a study that was done a bunch of years ago by a guy named Ben Potenciano, who's actually a sports person. He's a sports psychologist. And he did this project. And I read it when I was a postdoc who it was brilliant. He worked with Major League Baseball. He still works in pro sports. He's a great guy. But he did this project where he gave sleeping his questionnaires to a whole bunch of MLB players, followed them up a couple years later. I don't remember exactly the time frame. Just look to see. who's still in the majors. And you could see dose response. Every one point extra increase on that scale, the likelihood of no longer being in the majors.

Starting point is 03:26:44 Wow. And the ones who were in the clinical range, who scored over a 10 at that baseline time, 75% of them were not in the majors anymore. Incredible. One simple questionnaire, more than a year in advance, could predict someone's career trajectory.

Starting point is 03:27:01 And so that's what gave, that that gave me the idea of like, wow, what other simple questionnaires can predict just at screening? Who's at risk? Yeah. I want to ask you, before getting on to the rapid fire audience questions. Sure. Sure. The cognitive performance, one I'm very interested in just personal reasons.

Starting point is 03:27:21 And I'm wondering, like, is there, let's say someone's getting pretty good-ish sleep? Yeah. Like, would you have a couple of your top tips that do you, do you think? they could still improve cognitive performance with a couple of sleep tips. Yes. And if so, what are they? Yes. So the first thing I'm going to say about the cognitive performance is caffeine can dramatically

Starting point is 03:27:47 improve performance in some domains but not others. You can caffeinate things like attention, focus, reaction time, speed, all that stuff. but data show over and over and over again, whether it's military samples, whether it's sports samples, you cannot caffeinate away complex decision-making. You just make bad decisions faster. That's what happens when you caffeinate a sleep-deprived person.

Starting point is 03:28:14 Over and over again, the data show this. You can, so like a great example, there's this great study where they did in tennis players, semi-pro tennis players. When they took them down to five hours of sleep, impaired their serving accuracy by a five-broseph, remember correctly something like 35%. Um, it recovered, about a third of the loss was recovered when they caffeinated,

Starting point is 03:28:38 but not all of it because there's other higher order stuff that's happened. Like that's the sort of stuff you see in the literature that it's not fixed by caffeine. Some stuff is, some stuff isn't. So caffeine is not the answer. Um, but what one of the things that would be the answer is actually, and there's actually data on this, insulate yourself a little bit, bubble wrap your sleep a little bit. What does that mean? If you can protect yourself against minor environmental disturbances during the night and protect the sleep you are getting, you can make it a little more consolidated, especially the

Starting point is 03:29:16 deeper sleep and get a little more benefit from it. So here's a great example, the simple example. Some of the best sleep technology on the market, simple cloth eye mask. There was a study, I think was in Switzerland where they had a eye mask, just not just a plain old cloth eye mask. And they had a placebo eye mask where they cut the holes out in the middle. Same strap. Just cut the holes out. Improved sleep consolidation during the night. These were in college students so they were in sort of noisy environments anyway, but consolidated their sleep better in the night, translated to better test scores the next day. That's just one example. Like eye mass and ear plugs, some of the best cheap sleep technology that exists.

Starting point is 03:30:00 So darkness and noise. But it's not, but it's also, you might need to just, the extra layer of insulation. Extra layer, yeah. Yeah. Like a white noise machine could be good for something like that. Don't have a puppy in your room. Yeah, something like that.

Starting point is 03:30:13 Like, yeah, anyone, anyone who, who has an animal in their room, another mammal in their room, like. Moving around. Yep. You're going to have more fragmented sleep. Okay. Awesome.

Starting point is 03:30:24 Okay. Let's get to some of these rapid fire audience. questions? Yes, let's do it. Best evidence-based way to fall asleep and stay asleep, fall asleep faster and stay asleep. Yes. I'll give you two because one is cheating. The one is stimulus control because if you can be rigorous about stimulus control, you can get into bed anytime, anywhere. It's like when I travel, like when I travel to a different time zone, even if I'm in a totally different time zone, I'm so rigorous about stimulus control. I can be at a very off time zone, but the lights are out, my eyes are closed, my head's on a

Starting point is 03:30:57 pillow, it took condition stimulus. I fall, I fall asleep fast. So you can train, if you can train yourself that that situation is reliably paired with sleep coming soon thereafter, you can make yourself, even if you're stressed, you can fall asleep faster by putting yourself in that situation. Rigorous, highly empirically supported, lots of data to support this. The other one I would say is allowing sufficient wind down time with nighttime signals, dimming lights, literally and metaphorically for at least a half an hour before bed. Literally meaning you want them orange, you don't want them bright and blue. And metaphorically, I mean, give yourself time and space to detach. That is actually usually, if you're going to bed at the right time or within your window of

Starting point is 03:31:44 time, if you're having trouble or your mind's racing, it's because you're trying to go from 30,000 feet to parked at the gate right away. Just put a little bit of space in there. Let yourself come to a stop and you'll find it's way easier and you don't have to fight so harmed. Those are great. If you're trying to stop at a stop sign, start breaking more than one foot in front of the stop sign. You will find it so much easier to break wherever you want if you're coming in a little slower.

Starting point is 03:32:13 I definitely do number two. I'm definitely now going to, I'm going to be on top of this control thing because I'm super interested in it. Bang for your buck, sleep tip in the world. Great. Okay. Awesome. Most effective pre-bed routine you've seen.

Starting point is 03:32:26 to shorten sleep onset. Yeah, so that I would say is orange lights, um, putting, putting screens down if you can. Um, if you can put down screens, reading.

Starting point is 03:32:38 Reading actual paper books is great before sleep. Unless you're me, I actually suck at reading before bed because I get into it. But for most normal people, the data actually support reading because it's self-paced. If you can't maintain muscle tone, you'll learn, you'll learn,

Starting point is 03:32:56 you'll know it. And you'll, you will tap right into your body signals. You won't be overstimulated. And, and as soon as your body's ready, you'll know it. And you can put stuff down. So reading dimmer orange light, the way to go. And that's sort of the way to go. All right.

Starting point is 03:33:15 Best strategy to fall back asleep quickly after waking in the night. If I were going to turn this into an algorithm, step one is, if I wake up in the middle, the night. What do I do? First, step one is, okay, can I fall right back to sleep within the next two or three minutes? I try. And if I don't, then I, then I evaluate, okay, is there something going on my body right now that I actually need to get up or not? Is this something I can, and let whatever activation was ride out. If it's going to be short, let it. Do not, and I guess the answer is do not add performance anxiety to it. Read the room. If you are, if, if you're not in control of your ability to fall asleep. If it is outside of your control, don't try and

Starting point is 03:34:01 control it. Let it be. And don't panic. You will fall asleep just fine. If it's possible to fall asleep fine, if you didn't panic, you will. As soon as you start panicking, you're adding energy into the system. All right. Don't panic. I go to recap. One proven method to increase deep sleep in healthy adults. Proven method. So there is some really, not that I think anyone really, whether or not people need it, I don't know. But there is some data you could improve the deep sleep, not improved.

Starting point is 03:34:32 You could potentially get more of it and get it more consolidated. Besides, the obvious is if you have a barrier, get rid of it, if it's sleep apnea or whatever, but in healthy adults, there's some actually cool data on neural stimulation where you can induce more deep sleep activity using auditory stimulation by sort of tricking your brain to create those waves. Jury is still out on exactly, is it just creating the waveforms or are you actually getting the extra benefits of what looks like more deep sleep or does it just look like you're getting more deep sleep

Starting point is 03:35:01 because your brain's creating the waveforms? Not quite, I'm not quite sure yet, but there's actually a bit of data. You can do that. And actually, like I said, with the eye mask,

Starting point is 03:35:11 the environmental bubble wrapping of your sleep, because if anything is going to prevent you from getting more deep sleep, it's extra stimulation. With the auditory simulation, is this something that you listen to while you're... Yeah, it's like the binaural beats kind of a thing where like it induces, it basically sends waves that are in the wave forms that you want your brain to sort of create to echo them. Okay, cool. Yeah. It's like biofeedback, but for brain waves. Most effective way to reduce nighttime urination and wakeups.

Starting point is 03:35:45 Most people, when they are peeing a lot during the night, it's not because they have to pee. a lot during the night. It's because they're awake during the night. So what I would say is, first of all, see if there's something that's waking you up. Untreated sleep apnea are probably the leading cause of nocturnal frequent urination because you keep having these arousals at night and your bladder's like, okay, while you're awake, might as well. That usually comes afterwards. The other thing is, if you're used to getting up to go to the bathroom a lot, maybe you don't need to, and you might want to do an experiment and see if you can go

Starting point is 03:36:20 back to sleep without going to the bathroom if you don't need to, and then you can get used to that too. Because if you can hold it till the morning, just hold it to the morning. I've done this before. In fact, I used to go, I used to get up to go to the bathroom one time in the night. And now I don't get up at all to go to the bathroom. And, you know, I'll usually wake up and it's probably like around five-ish or so. And I'll feel like, oh, I could go pee, but then I just like close my eyes and go back to sleep. And guess what? You're fine. I've made it. I've made it now months without having to do that. See? And that's the thing. It's actually. actually you might have accidentally programmed yourself to do that.

Starting point is 03:36:53 Remember what I said, the average person will wake up 10 times a night or more. That the awakening occurs as not the problem, that it's blossoming into something you're remembering as stressful as the problem. Take the stress out of it being like, oh, I just had one of my hundred awakenings during the night that I, I just happened to be conscious of this one, but nope,

Starting point is 03:37:11 go back to sleep. And if you can train yourself to do that, it's actually shockingly effective. If you reduce that performance, exactly like you talked about. Yeah. No, I'm going to be all over the stimulus control thing. That's going to be my new, my new thing. Okay, one actionable change that measurably improves overall sleep quality.

Starting point is 03:37:29 Overall sleep quality. I talked about a lot of stuff, whether it's nighttime routine, getting, you know, having the bed be a, be a good place for sleep. But in terms of sleep quality, actually, daytime, morning, have a day, get activity. Don't sit around in the dark all day. Humans are not built for that. eat well. People who, people who eat like crap, especially late at night, their sleep is more disturbed at night. Reduce systemic inflammation in your body, your sleep will feel better. If you're sharing a bed with somebody and that somebody has

Starting point is 03:38:07 sleep issues, drag them kicking and screaming to get tested for whatever it is they have and get it treated. Or get two twin excels, put them next to each other. Sleep in a seven, you know, you can sleep with somebody but not on the same mattress. You can just put them next to each other. Like people underestimate how much this environmental stuff is, is shallowing out their sleep quality. My husband and I, we have our own separate blankets. Yes. Yes.

Starting point is 03:38:33 On our best. See, there's nothing wrong with that. There's people who talk about this as if it's a bad thing. But actually, from a sleep science perspective, you get all of the social, positive human benefits of sleep. Humans were not really meant to sleep alone. But at the same time, you get to be in your, essentially your own microclimate and an environment where you get to be under control

Starting point is 03:38:55 and not have it be, it's best of both worlds. Right, where I'm not feeling the movement as much. Exactly. For sure. Okay. How can you quickly assess if you're getting enough sleep without a lab test? You couldn't even do that with a lab test.

Starting point is 03:39:08 We don't have a good test of, are you getting enough sleep? Test number one, if I put you in an otherwise quiet, dark room for 20 minutes, could you stay conscious? If the answer is no, you're probably not getting enough sleep. And it might not be amount. It might be about quality. Because for people with a sleep disorder like apnea, more isn't always better.

Starting point is 03:39:27 More might just be, you can get an unlimited amount of sleep and still feel tired because the quality you're getting is poor. So it's just like nutrition that way. It's multidimensional. But by more, I mean more quality or quantity. So one is, if you're having trouble staying awake during the day, or if you put yourself in a situation where it would be really easy to fall asleep. Could you, like, would you fall asleep right away? If the answer is yes, something like, why are you so hungry that, like,

Starting point is 03:39:56 you put it if you, if you put a plate of food in front of you, can you resist it? If you can't, what's up with your appetite? If it's not meal time, you should be able to resist it. Um, the other thing is you can experiment and get a little more and see if you feel better. If you don't, Okay, good to know. Another way to tell is if you fall asleep as soon as your head hits the pillow, you probably waited too long. It's just like saying I cleaned to my plate in 30 seconds as soon as it was put in front of me. Should have taken a little bit of time.

Starting point is 03:40:29 So maybe you're going to bed too late. Maybe you're waiting a little too long. Yeah. How do you know you're getting off? Unfortunately, we don't have a good test for that. I like those. I like those. Yeah, it's practical.

Starting point is 03:40:40 Do you really need eight hours of sleep? No. first of all, the recommendation these days is seven, because when we looked at the data, there was no distinguishable difference in almost all cases between seven and eight. Plus, people don't tend to have that. It's all based on recall anyway. So people don't have that much resolution. Seven's kind of the new eight.

Starting point is 03:40:58 At six, people were starting to show problems on average. Are there people who sleep six hours and are fine? Yeah, I'm sure, probably. Are there people who are sleeping five hours that are fine? Possibly. Is it you? Probably not. Think of it as a bell curve where you're probably somewhere in the middle.

Starting point is 03:41:15 The chances that you're on an extreme outlier are low. Just because you're an outlier in one part of your life doesn't mean you're an outlier here. An athletes especially probably need more because they have a higher load on their recovery system. So you want to recover. You need to give yourself the time and space to do that. Do you need eight though? No. Do you need seven?

Starting point is 03:41:36 Maybe. But then also need for what? How much sleep do you need to not die is different than the amount of sleep you need be optimally functioning. Yeah, optimally functioning. I would say most people probably need seven. By self-report, that might mean six or six and a half on your wearable. Right.

Starting point is 03:41:54 Okay. And then one practical tip for aligning lifestyle with your chronotype. Yeah. I mean, give yourself permission to schedule stuff out in different times. You may or may not have control. I mean, if you're a night owl and you have a job that works early in the morning, I don't know what to tell you. But if you could control your day such that maybe you're doing certain things at certain times

Starting point is 03:42:18 or adjusting meal times or adjusting meal times or adjusting where the heaviest workload of your day is, scheduling meetings at certain times, like you might be able to do that. I mean, if you're a heavy night owl, but you have to go to work in the morning, just wake up as soon, you know, give yourself as little time as possible to get there so you can stay up as late as possible and do all your household stuff at night, you know.

Starting point is 03:42:39 and keep that schedule as consistent as possible seven days a week. Well, this has been very, very enlightening and interesting. I've actually learned quite a bit today. So thank you so much for coming on the show. You have a book coming out in, I think, October of year. Yeah, it's planned. It's a textbook. So it's an academic book, so it's a wearable's book.

Starting point is 03:43:00 It's all about wearable sleep technology. Yeah, yeah. We have, we also have, I've also edited a few other textbooks. There's one on sleep health, another one on sleep in sports. and another one on adapting CBTI for clinicians. Like, I'm an academic, you know, like this is what I've got. But if people are interested in them, they're not priced like a regular book. They're priced for libraries and for academics.

Starting point is 03:43:24 But so if people have any questions about anything in them, just shoot me an email. I'm actually easy to find. And I'm happy to be responsive. Yeah. I mean, I'm looking forward to it. A book on wearable sleep technology written by an academic who actually knows about it. It sounds interesting. It'll be fun. So great. So people can look you up. You got your lab at the University of Arizona.

Starting point is 03:43:44 Yep. Thank you so much for coming on the show and sharing all this really, really knowledgeable, you know, important information with everyone. And thank you for everything that you do. No, you're very welcome. Thanks for having me on. Thank you so much to Dr. Michael Grannner for sharing his incredible knowledge today. And thank you all for listening and supporting the podcast. If today's episode resonated with you and you're interested in even more practical science-based insights, don't forget. to sign up for my free weekly email newsletter. We explore actionable topics like caffeine's effects on sleep, creatine and cognitive health, and diet's role in regulating blood pressure. For those who want to dive even deeper, joining as I Found My Fitness Premium member is an excellent way to directly support our mission while accessing exclusive content like the Aliquot podcast, monthly live Q&A's with me, and you help keep this podcast evidence-based and unbiased. You can learn more about this membership at foundmyfitness.com forward slash premium.

Starting point is 03:44:43 Once again, that's foundmyfitness.com forward slash P-R-E-M-I-U-M premium. Thank you so much for listening and I'll catch you next time.

FoundMyFitness - #107 Why You Can't Sleep (and How to Fix It) | Dr. Michael Grandner

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