Why You Can’t Sleep (and How to Fix It) | Dr. Michael Grandner

The first thing to know about sleep apnea is it is shockingly common. One out of three people in the US has some sort of sleep complaint or problem. Untreated sleep apnea can lead to liver problems, kidney problems, brain problems because every cell that relies on oxygen starts getting stressed. >> So I was wondering if you had any tips on some more advanced type of sleep hygiene. >> The enemy of sleep is effort. Sleep is something that happens to you when the situation allows for this. >> Let's talk about a couple supplements. The top of mind supplement people think about when they think about sleep, they think melatonin. >> Melatonin. Some people when they take melatonin, they might be taking the wrong dose at the wrong time. >> Best evidence-based way to fall asleep and stay asleep. >> I'll give you two cuz one is cheating, which is the >> I'm pretty excited to be sitting here with Dr. Michael Graner 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 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. >> Um, I as we were talking about earlier, I kind of wanted to start this episode talking about sleep problems. Um, you know, you've got a lot of patients that come into your your clinic with sleep problems, insomnia being probably one of the most prevalent ones. Um, 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 dis 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. Uh, I call it sort of insomnia with a lowercase I and insomnia with a capital I. Think of it, it's kind of like depression, too, where it's a word. 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 um and I have insomnia, but is this an insomnia disorder? Is that how we would call? We' 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. Um it has to occur at least three nights per week. It has to have gone on for at least 3 months to be considered uh 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. Um, 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 fall asleep or you're or you're awake for at least 30 minutes during the night trying to sleep and you 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 difficulties sometimes. But, but that's really the difference where it's crosses the line to where it's really interfering with your function. And how do you just determine um you know what is the underlying cause of someone's insomnia? I would imagine you know hyperaroused nervous system being one of them, but there's probably others. >> Yeah, there's 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 when 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 of hyperarousal 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 and that's 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. 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. 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 can you give an example of that? So let's say you know someone has workrelated stress or something, right? and maybe it's a project related or maybe there's emotional related related stress from a relationship and and it does eventually kind of get better and yet they're still kind of having problems fall asleep. Now why what what would be the conditioned stimulus? >> 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. Now 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? 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 physiologic 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 sleepwake 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, whether it's the beginning of the night, middle of the night, or wherever becomes predictably stressful. You 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. When sleep becomes predictably stressful, think of something else in your life that's predictably stressful. So common um a common analogy I like to use is like you go to the dentist's 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's office is for you. You go, you're there. Nothing has happened yet, you're already in this heightened state of arousal. 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 3 months in the future because you're already responding to that future stimulus that's causing you stress. Like being 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's office, no matter how activated or stressed you are, as long as you open your mouth, they can do their job, right? 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. 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, 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 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 >> so >> let's talk about CBTI cognitive behavioral therapy for insomnia and obviously there's lots of components to it one of them being the stimulus control >> um which now is like making so much more sense to me 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 is making you hyperaroused, 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 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 sleepwake is not a undimensional line where you're 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 bass. And they're not it's not just mono. There's treble and there's bass. You have a wakefulness signal and you have a sleep signal that are separate from each other. 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 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 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 so patient will come in thinking like, "How do you make me sleepier?" Actually, I've got we've got some tools for that. We'll talk about that. 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 that's why CBTI is so effective because it's actually targeting the problem that the person actually has. >> Okay, let's talk about So, so here's the deal. A a few several decades ago now. So, so stimulus control was first published in 1972. This isn't new stuff. Um, 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, 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 beces 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 I found is is especially over the 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 cuz 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 not may or may not be hungry. So like it 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 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, um 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. I say bed, you say >> sleep. >> Correct? If I say bed, sleep, bed, wake, bed, think, bed, wake, bed, sleep, bed, wake, bed, sleep, bed, think, bed, >> 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. And if you can't control the sleep side of the equation yet, at least you can control the bed side of the equation. and 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 multicomponent toolbox. Stimulus 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 we're teaching your body to do a thing. it physically can do. 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. I mean, 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. 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 were built with this ability. There's a chance maybe there's something else, 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. get out of your own way and 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 it's it's through the conditioned arousal. It's 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 for a day, right? You're eating like toast and drinking tea or whatever. 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 gh I have this stomach bug. What if I get a nasin 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 it's us getting in our own way, >> right? Um it let's say you had, you know, someone that has to work on their stimulus control. >> Yeah. >> Um you know, there 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. >> Yeah. like what would be your how would you approach that? Like what would you be what would be like your twoe fix? >> Great. So first of all um 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 it's not when bed is not really going to be used for sleep you get up. 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, cuz it's not occurring when you're on your phone. See if you can do that. Um, 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 and very rarely do people actually do it, but people sometimes do. And I do this because if you're standing if if if being in that proximity is important for 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. Sleep is something that happens to you when the situation allows for this. And that that's a concept I I borrowed from a colleague of mine, Lindsay Shaw, who's also a fantastic sleep person and sports psychophysiologist. I learned this from her. I use it all the time. It it captures it really well. Sometimes sleep is un 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. Sit up. Again, you're not going to lose touch of your body's signals. And and worst case scenario, at least you get the head bob. The headbob is is is your friend. The headbob 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 or scrolling because you'll get the head bump. 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. 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 it's because something naturally occurred to produce that awakening. Whether um most commonly would probably be some sort of physical discomfort like pain or maybe you sunk into your mattress a little bit and and 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 but that can cause these awakenings. And when you have 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. 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? What if I'm up the rest of the night? Blah 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 now 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 doesn't. 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. 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. overcorrecting is the problem. >> So to 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 they just immediately get like >> anxiety about it. >> The best thing is to surrender or is that like the 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, 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 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 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 or book you can read that will make that recovery go faster. You got to give it the time it needs. Similarly, this is a process that's outside of your control. Trying to control it will actually make it go slower. >> Okay. And so the the next part of you know CBTI that you know yeah we hear about is the sleep restriction which sounds awesome. worst name. I mean, so, 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 it's a simple concept of um again, a lot of these things are simple in concept, but difficult in execution. But the concept of sleep restriction therapy, which I hate calling it that because it doesn't it's 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 8 hours in bed but 6 hours asleep. We know you physically can sleep 6 hours. Okay, let me give you 6 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 there's that decrease at first. The way I explain it 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? You put 20 pieces of broccoli on their plate and they're not eating. 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 cuz 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 you say, "Great. You will get three tomorrow. Let's see if you can eat those." 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 in you you start with what they can already do, but you don't give the other stuff that that will so you 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. 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 for several days, maybe even up to a couple weeks, but they eventually eventually they get hungry enough where they can eat all the broccoli on their plate cuz 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. You drive up their natural sleep pressure. You separate out um 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 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 you want 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. Um that that that feeling is so predictably tied with becoming unconscious in a very short amount of time that even when you get good at that, so this is this is the power of this. 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 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. You get into bed, close your eyes, head on pillow, under blankets, start breathing. Then all of a sudden, you fall asleep. you've you can you can train yourself to get the outcome you want and that gives you control. So let's say you got to wake up super early one day because you're you're you're going somewhere you got to practice or something. 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 conditioned stimulus for sleep when you want it to be. So when so how long does it take to to for most people to train themselves like through the stimulus control sleep restriction where you know the bed is really just for I' I've heard sleep and sex but like >> the sex is fine that's usually not the problem 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 if it's and it's not interfering with your ability to sleep sometimes it can help your ability to sleep but that's fine but um >> it's probably the phones that are the biggest It's it's distractions. So distraction, the activation, all of this stuff, it's 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. If you're I I've known people who like they they have this whole hourong routine that they do like by the time that hour is done, the bed is no longer predictably tied to sleep anymore. 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 I mean I I actually think this 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 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 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. Maybe do it the hour, you know, in the in the earlier part of the evening. Um 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 watch we can 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. 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 big of a deal. 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 you want to make sure that you curate what you're doing so that it's not too activated. >> Why why are a lot of people that h that have insomnia why are they prescribed you know these sedatives like you know ambient or >> well they don't not work. I mean, like like I was saying, like what they do is they drive up that sleep drive so much it overpowers whatever is 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 anywhere and they can write a prescription. But if you if you look at every medical organization that has any recommendation around in how to treat insomnia and for athletes, you know, this includes like NCAA and IOC who who've put out sleep related materials, um they all say CBTI first and that's because every study that has ever been done shows that when you compare when you pull 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 arousal, you have an active thing going on? Still works in works in fibromyalgia, works in chronic pain, works in cancer. It actually might be better in cancer survivors than people who aren't cancer survivors cuz 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. Um, find me a condition. Works in older people. Works in younger people. Works in so like it it's a blunt instrument. It's retraining yourself to sleep. It doesn't it and it works well by helping people gain control. It doesn't necessarily add hours to your night, but neither do sleeping pills either. What it does is it removes some of those barriers about again about 85% of the time, not 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 the information they get isn't 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 I mean 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 it exists and the people who do don't really understand what it is or how to find someone who knows what they're doing. >> 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 um tried it done it with themselves. I mean because it's not rocket science. Um the there's an art to it, but the the basics of it are relatively simple. It's bed equals sleep. Get out of bed if you're not sleeping. You know, compress your window of of opport 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. Um some basic stuff like that. Uh and some people just do that on their own and that's all it takes. Some people, they need somebody who knows what they're doing. The problem is there's not a whole ton of people who are trained in this. Despite 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 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. Um, you can do this over tellahalth. any state that you're in, I can promise you there's someone who can do this via tellahalth in your state. So, it used to be very geographically restricted. It's not anymore. Um, there's a couple of good directories online of if you're looking for somebody um we have a board certification. You could see who's board certified in this and we it exists because it's not part of normal training. So, to be able to say that you're good at it, you have to like prove that you know what you're doing. But um yeah, you can look online for people and again there's there's tellahalth options too. So whatever state you're in um you can find somebody. >> What what percentage of like the US population has insomnia? >> It's a great question. Um for decades any population level study has generally found kind of the same thing mostly and it hasn't doesn't seem to have mostly changed much that about one out of three people in the US has some sort of sleep complaint or problem or something whether it's falling asleep staying asleep not feeling refreshed that seems to be about a third of the population at least and it seems like about 1 in 10 people probably would meet the criteria for an ins insomnia disorder if you if you if you assessed them. Um, 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 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. Then six to eight sessions are better. >> Yeah. I one in 10 is a lot. And you know, 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 um and that doesn't really help. So um but >> let's before we get to that, um >> sleep apnnea 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 um first I kind of wanted to ask you like what are some of the nonobvious presentations? >> Yeah. >> That you know of sleep apnnea that you see especially in people who like maybe don't even report feeling sleepy. >> Right. So so the thing with sleep apnea the first thing to know about sleep apnnea is it is shockingly common. It is very very very common. Um, the most recent data I've seen estimates that about one out of four or five men over 30 probably has at least some sleepreated breathing issues, especially if if their BMI is over 30. It's more like 50/50. Um, 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. Um, and then as as BMI goes up, it gets more common. Um, so it's it's shockingly common. It's so common that my threshold for screening for it is very low, especially among otherwise fit people because the normal risk factors. So like as you gain weight, it it it 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 up and and to to to their lungs. It's a straight line from snout to their lungs. Humans by by moving upright, we solved a lot of problems and and we've gotten a lot of benefit from being upright, but we it created 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° 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. 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 like cheeks like anything here that whether even skinnier people with smaller airways you know where it's a little more compressed it just it's it's a it's a vulnerability in in the human physiology for breathing issues and it there 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 apnea doesn't begin at five is mild begin is the low end of mild and it's not even till 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 guess is it's actually been common through history. 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? If I have a patient who comes in I 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, 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 5050 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, um endor the the the endorphins of the muscles getting tense. It's reading these physical signs and then because we live in the society we live in, stress is readily available. We can fill that space really fast. But what 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 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 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 wakes me up. I have no idea. But I cannot get right back to sleep immediately, like within a few minutes. I mean, something just happened. Some flare up just happened somewhere. Um, that's that's what I look at 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 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, which just happens with age. They're younger, they're healthier, but they just might have a narrow airway. And and so like I'll never forget like there was this there was a um an Olympic level athlete I was working with. She was she was in the trials and she's like just not meeting the times I think I should be. She was still faster than everybody else but she's like my inst 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 sleeping 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 she had mild sleep apnea, got that treated better, and she's like, "Oh, that was it." And and in the real world, it would have been missed. It would have been someone just slogging through their day. They would have just been like, "Gh, you know, life is hard. I'm tired. Not sleeping as 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? 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 thing? Um like what sort of sort of symptom clusters, biomarkers can people look at um 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 night or more during the night. They just don't remember. 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 awaken, 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, um if you if 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. It's like it's just 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 it could be. It's just sleep apnea is so common. Why not take test? Why not just get tested? Just go get a referral, get tested. You can do them at home now. It's easy enough. Um in ter it's it's there's no real good biioarker for it yet. I know people are working on it. There's no real good biomarker except that that sleep is shallow. 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 if you're not breathing, is there a problem with your lungs? Is there a problem with your airway? 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 and if it is sleep apnnea, it's so common. This is why my threshold for screening is just ultra low because um 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 gh but my sleep just isn't good and I knew on day one that this was a possible reason why then I'd feel like an idiot for not even checking because I we did all this work and maybe we didn't even need to. do those um at home kind of if 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 >> um the test came out negative but I wore this like >> ox pulse thing I think I don't know what it was on my finger >> so 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 or limb movements or thing 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 or or the test you did at home was negative but you still have a lot of symptoms and maybe it missed it because the the home tests aren't as sensitive like you 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 um your oxygen levels during the night and what you can see is how's your respiration tied with your O2 because respiration drops during the night too and so does O2 a little bit. But if if your respiration is dropping and then your O2 starts dipping and then it 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 apnea or not. >> Okay, >> it's easy enough. If if you're working with someone who has obstructive sleep apnea, like >> how do you go about differentiating if it's like caused by allergies or positional or you know something something like nasal congestion? I don't know. Like >> Yeah. Yeah. Especially when it's more on the mild to moderate side where um so the great thing is the 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 people where it's just that it's on their back. That's the issue. And um for those people, there's actually really simple fixes. You can se 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 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 one there's a couple where it's a strap. It's like a belt, but like the back of the belt has a little bump on it. And so like whenever you roll on it, you just roll off. It just stays off your back. That's it. Um you can't force yourself to stay off your back when you're asleep. You're like, "Well, I just going to fall asleep on my side." Well, you can't 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 and treat it positionally. And then what I would do is retest using the positional device and see if it all goes away. Because it might, might not. Um, if it's allergies, um, th this is why the the the sleep docs, you know, we get a lot they get a lot of training and and 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, you have them breathe in, you look inside the airway and the mouth and and like you can see where their soft pallet is, you could see their tongue, you could you can see some of these things. Um, and you know, sometimes, you know, there's a lot of sleep medicine that's using, you know, flown and and some of this stuff to sort of clear up the nose, but remember the obstructions almost all the time are back here in that 90° angle in your airway. It's not up here. It's like people think snoring is is a nose-based thing. It really isn't. Sometimes you get like sort of floppy nostrils or whatever, but almost entirely it's that 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 doc. They can to take a look at your mouth and take a look at your nose and and they'll be able to see. But I 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 fix, but um that's usually not it. >> It it what happens if someone has untreated sleep apnnea? So I mean what 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 so here's the different sleep stages. Stage so when you fall asleep you enter stage one. Stage one is super ultra light sleep. 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. Um, this is also where you get hypnic jerks in you. If you have one of those, you were in stage one sleep. Um, totally normal, medically harmless, everyone gets them. Um, 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, 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 in sleep is done in stage two. Um but then you drop into stage three which is also you know in our world we call it slowwave sleep because the brain waves are bigger and slower. Um 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 and it is hardest to wake you up from that sleep stage because the the thinking parts 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. 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-d deprived people are mostly getting all of the stage three sleep their body wants. Like it's it's actually again evolution figured this out a long time ago. You it's the hardest to wake up from and it frontload it frontloads 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 slowwave sleep or 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. Um, REM sleep a lot of people have heard of now um is weird. 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 the your brain is extremely active. It's actually more like waking than many any other sleep stage. Um but the waves are very different from waking brain waves. But it is it is more more like that than than um 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, but there's also a couple of other weird things that happen that you're paralyzed. You're so so if if in deep in the deep sleep your muscles were very relaxed, that's nothing compared to how mus relaxed your muscles are in REM sleep. not because they're recovering, but because you're actively paralyzed. Uh your alpha motor neurons are hyperpolarized. You cannot move. Uh 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. It's just part of your brain has its foot on the brake while it's jamming 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. Um 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 but you're also conscious and that 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 if you go looking to match eye movements in REM sleep to dream content, you can sometimes find it but then sometimes you can't. It's it's fascinating. Um what 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 for different reasons where 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 and in REM sleep there's a lot of synaptic strengthening and connection building and those two things work in concert with each other. 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. Like that piece of equipment over there, I don't need to remember it tomorrow. It's not 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 slowwave sleep in 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 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 the it increases and actually waste products can start clearing out of your brain. 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. By your third cycle, you might have no deep left. 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 you you probably won't remember them anyway, but if you did, they're usually a little more boring, where the dreams at the end of the night are the cool ones. The ones with the stories and the characters and then and and the bl the blurring of reality and all the and and emotion in the 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, this is 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. 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 it 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. Um, 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 it's a lot of a lot of the recovery and repair stuff is also happening in 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 it's everything else gets to happen um in in a more protect. So like all the stages are important. You cycle through them. And it's about every 90 minutes. Anyone can Google that, but it's not exact. It's they're different across the night. Um, 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 cuz you woke up out of 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. Um, 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 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 they don't even seem to make sense. Like you'll like >> they may not make logical sense or and maybe they're wrong. I mean, you're sorting through you're you're you're playing stuff out. And that's also why like when you're awake, 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, 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 we why do you think we dream? I think we dream because evolution figured out a long time ago that you can learn a lot by reading all the words on the page, but you can 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 gap. The 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 it 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 5 minutes from now 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 is 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. Um there's no question about that. But it may change how I speak or how 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 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 the difference between what you did and who you are like and 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 that's my that's my ramble of what I think >> well thank you um okay so back to the sleep yeah because you you know people having these awakenings where there are multiple awakenings in the night obviously this happening during different stages is um what how does sleep apnea untreated sleep apnea affect sleep the sleep architecture >> that is one of sleep apnea is one of the few things that can artificially reliably dramatically reduce your slowwave deep sleep because it it prevents you 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. Um, and it can also because your sleep is more shallow and you have more of these arousals and awaken. Even if you don't awake all the way, your brain is still sort of moving around. 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 if you're already in a floppy tube trying to breathe out of this floppy tube that's already having an issue and then you make the muscles go extra limp, snoring is going to get worse. So you're going to have more awakenings out of REM, you're going to have less deep sleep and your sleep just be more shallow overall. So that's why people with sleep apnnea, 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 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 the toxic waste. These are aggregate protein aggregates, amaloid beta 42 being one. Yep. 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 apnnea. >> Untreated sleep apnea is a known risk factor for neurodeeneration especially when it's more severe. So this is the thing mild to moderate sleep apnea is a is a gray area. 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 you're mostly treating like the fatigue and the memory issues, whatever. You can still get um 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. 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'll happen is you drop a few points. Most people, unless you have some other lungs, most people with sleep apnnea, their O2 doesn't drop a lot for sustained amounts of time. Unless you have like emphyma or something, 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. Then it drops. 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. But what ends up happening is all of these cells are rel 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 stressed and it's then it's stressed then it's all night for 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 that you were built for. And so, your trajectory goes slightly off. So that's why sleep pro not just sleep deprivation but also sleep 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, so, so people with untreated sleep apnea then probably do have problems with working memory. >> Yeah. Yep. >> I mean emotional regulation. >> Emotion regulation, executive function, um, attention. 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 exciting. >> That is usually the first brain function. That's the first warning sign that something's up. And the re 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 the stuff I was talking about is all memory connected functions. It's about sorting through information, processing information, 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 but memory is also a function of attention where if you're not able to focus and attend, even if your memory machinery was working perfectly, you have nothing to process because it never got in there. 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 just Yeah. Wow. Um, so I mean that's why a lot of these medications and stuff, um, and really anything anything that is impairing your ability to focus will have ripple effects to memory and decision-m as well 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 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. And and and there's a lot of other sleep problems, too. And they all I mean, sleep does a lot. sleep. 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. Sleep should be your number one recovery protocol for any kind of performance-driven person, whether it's physical performance, mental performance. I mean, when you sleep deprive people, they 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. Okay. Well, let's talk about treating, you know, sleep apnea. I know >> we can talk about CPAP and what that is, and it certainly works. Um, >> it's a blood instrument. It works. >> Long-term adherence maybe not so great. Uh, what do you find to be some of the best evidence-based non CPAP interventions? >> Yeah. So, the thing about CPAP is it's a blunt instrument because it's, think of it, it's just it's just a split that keeps open your airway. It's it's it creates a pillow of air that so if your airway wants to collapse, it can't. And and CPAP, it's continuous positive airway pressure. Continuous cuz it's blowing continuously. Positive airway pressure as opposed to negative pressure, which is sucking. Positive airway pressure is blowing. So, it's 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 you you blow enough air in there, it won't be able to close. 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. What these are that's essentially a retainer you wear at night. It's 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. 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 sleepreated breathing issues does the trick. That's 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. 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, but sleep dentistry where it's about people diagnosing and treating sleep apnnea with these dental devices. That's a very common one. Um there's an there's there's also um muscular myofacial therapy. So like you can use the muscularkeeletal 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 digery do 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. Um there's a device um called excytosa uh where where it's you put it on your tongue when you're awake and it 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 your tongue muscles so that when you go to bed there's a little more muscle tone in there that seems to work okay. Um there's a new device people have maybe seen commercials called inspire which just means breathe in but um it's 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, but seems to work okay. Um 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, it's rare that I find a mask problem that can't be fixed. If if what you need is one of those, >> what about um ma 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. just like a elastic bandost at night. For people who are snoring that don't that where it's just mild snoring and they don't have sleep apnea um or their sleep apnea is mild or their sleep apnea is due to them opening their mouth at night and their tongue falling back and they can breathe through their nose. Okay, chin straps have been great. They're they're they've been again used for decades. Mouth taping, I think, is just sort of the same thing where you're essentially just keeping your mouth closed. is just keeping your mouth closed in a way that you can breathe through like it's 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 it may help those people. But if the problem is that you actually have sleep apnea and if you don't open your mouth and you can't breathe like and 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 if you need to open your mouth to breathe or else you're going to have your your oxygen is going to plummet. Don't do that. But for like more mild storing cases or for people who it's mild enough or if it helps you keep like maybe you're using a nasal device or or like a or like strips or or um Rhino makes these these nasal splints where you keep your nose open. Like if you're using one of those and you just need to keep your mouth closed, I I have no real problem with it. I just don't think it's going to like cure cancer and save the world. But I I feel like it's it gets overblown by people's >> Yeah, it's gotten overblown and it sounds more like maybe for snoring. Yeah. Than anything. >> And it's it's if you need if keeping your mouth closed during the night solves your problem, go ahead. >> But if that's But if you're hoping that keeping your mouth closed during the night will solve your problem and it doesn't, there are other options for you. Are there any for people that are experimenting with some of these perhaps the retainer or or the myofunctional training? >> Um, we're going to get into sleep wearables, you know, soon, but like >> how do they really know it's working? Just what's >> Yeah, it's tough. The best way to know, >> and this is not a perfect way. Um, second best way to know is are you how do you 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 apnea. They they can't they don't stop moving because then they'll 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. But it's not a great signal. It's not 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. Um, but it see just means we need to learn more about what this condition really is and what it's doing in the brain and 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. And a lot of people with sleep apnea, if it's been a couple years, get a do it to do the test again. Do it while you're using your treatment to see. And and for a lot of those devices, insurance requires you to do that anyway to make sure it's working fine. See if he needs to get adjusted because sometimes they need to get adjusted and they're not working great cuz 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 or see or and most most importantly see how you feel the next day >> all right um 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, you can rapid fire. >> I do good sleep hygiene. I do all the sleep hygiene or I or 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 sleep good sleep hygiene, too. Like that's important. But like like everything you were talking about with CBTI, like that's just one 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, have apa sleep. >> But everyone should still be washing their hands. Everyone should still be brushing their teeth. Even if you can't brush your way out of braces, doesn't mean you shouldn't be brushing your teeth. So, so sleep hygiene is all about setting yourself up for success or dealing with some of these more minor problems. >> So, I was wondering if you had any tips on some more advanced type of sleep hygiene like we know we all know dark, cold, quiet. Yeah, rocket science. But like are there any other sort of more advanced sleep hygiene techniques like oh maybe your resting heart rate or respiratory rate or something like that like people could >> some unconventional the stuff this you know if you googled if you Google sleep hygiene what's some stuff that might not come up on those initial lists that that would still be useful. One of them 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 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, but 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 uh as a as a conditioned stimulus. um use the same toothbrush that whether it's at home or on the road if you travel a lot. Use do the same things in the same order. So even if they're at a different time in a different place, find alternate ways to build predictability if time itself is not the predictable one. Um another one is avoiding bright light at night. What if you can't? Um, 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. Some of the yellow ones or brown ones will work, but if you put the glasses on and you look at something blue 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 strain, but that's 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 of lux 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. And if you can make that a little more regular, it makes it's like if you want to be if you want to throw if you want someone to catch a ball downfield 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, they can predict where the ball's going to land. So like by setting that timer, 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, 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 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. 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. 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 and conflicting information will get thrown out as opposed to like I don't know, it's 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 light. >> That's fascinating. I've noticed that of course when I'm traveling and I'm I'm outside all the time and then it's like being in my hotel I don't usually have my dimming light, my dimmers and everything that I usually have. But it doesn't matter because I am dead tired, you know, after being >> this is humans lived for most of our existence in equatorial bright days, dark nights, relatively little seasonal variability around all around like the Mediterranean area and and that part of the world. You know, we've solved all kinds of problems by creating these walls and buildings and artificial lights and everything. We solved a lot of problems, but we've created some new ones, too. and we're still running the same code, >> right? Um, couple of questions, um, follow-up questions for that. Do you think the time of of um, 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. Um, I mean, honestly, earlier the better. And how much? I would say 15 minutes is probably fine. Um, 30 minutes is probably better. Like a morning walk or a morning run is actually probably perfect. Um, and because what's happening, it's not only that daytime, the other thing it's doing, and we'll talk about this more when we talk about supplements, but melatonin. So melatonin naturally your your natural melatonin will drop in the morning down to like from its peak to almost nothing. Light suppresses melatonin naturally. That's what it does. And so the earlier 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 and actually this is also why uh I don't recommend that people caffeinate as soon as they wake up. I recommend people wait an hour because if if you caffeinate as soon as you wake up, the 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 having effects later, but you've missed the caffeine peak. So like actually 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 builds up. >> Yeah. Use the c you so adenosine 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 don't you know if caffeine works mostly by blocking 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 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 uh 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." Then and then so they laugh and like, "What do you mean?" I'm like, "Coffee doesn't work all factory. 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 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 decaf coffee like, you know, at 11 11:00 a.m. and I feel like it's totally working and I'm totally fine with that placebo because, >> right, because you had it in you all along, >> right? So, so it sounds like the morning routine would be wake up, >> go outside, >> get some water, you probably dehydrate a little bit, >> get some water, >> go outside, whether you're taking your puppy or dog out. I just got a new puppy. Um going for a run. Yeah. U 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 drink your coffee in the car on the way to work. >> Yeah. Or or wait till you get there >> or wait till you get to work. >> Yeah. >> 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. >> Until about 30 minutes later. So if you feel it sort of right away that wasn't that wasn't sort of the effect of caffeine. >> Okay. >> Um and then and yeah and then it'll trail off like it'll have some effects. It builds. So it's something there but it's actually the peak effects of caffeine uh for alertness or are 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 nappuccino 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, it's a thing. Um I mean I don't do it but I not because I have any moral, you know, opposition to it, but it's a thing where where because they leverage the delay in in the caffeine reaching its effectiveness. So, and they and they use that to limit their nap time. But we can talk about strategic napping a little bit later. >> Before we continue, I just want to mention something important. If you're finding these episodes valuable, please consider subscribing to the channel and clicking the notification bell. It's the only way to ensure you'll be notified when a new episode goes live. Many people assume they'll be alerted automatically, but unless the bell is clicked, they won't be. We cover a lot of detailed evidence-based content here and I want to make sure that you don't miss any of it. Now, back to the episode. Okay. Well, let's talk about supplements. I mean, obviously, we're talking about behavioral interventions being absolutely the best. Um, >> the most likely to actually help. >> Okay, >> that's the way that's 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 talk you were talking about early light exposure. Um, the timing of like going 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. Um, 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. 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, keep going and think, okay, how much sleep do I want to 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 with to 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 the 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 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 cuz 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 and count sheep for an hour. That'll just make you stressed. So, it's 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? >> 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. Uh regularity is good, but like if if it means you're you're getting a little bit of extra recovery on the weekends, you know, it's it's a it's a trade-off. There might be a net positive there. >> But if they do if they are waking up early in the morning during the week, 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 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 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 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. We I went into um to the university into the division one 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 what I said because I'm sure you're going to ask. Um how do you fall asleep faster if you want to? 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. Um, 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. and and they gave they gave up those extra 40. I didn't ask for it. They they found what was useful for them and they 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? >> So first of all, I hammered stimulus control. Um, I normalized some things like, you know, they would, what would happen is they would freak out when they wake up during the night and they have trouble getting them back to sleep. I said, "Don't freak out. Just take a break, 5, 10 minutes, get a drink of water, whatever, go back to bed." And like reducing that performance anxiety, hammering stimulus control, um, wind down routine stuff like dimming lights, um, gave them blue blockers, you know, we like, and in terms of morning routine, talked about getting light first thing in the morning. um 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, but it's more of a look, you're an athlete. You're trying to do all this stuff with your body and have it in peak condition and understand what's going under 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 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 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 for me. Like we we hammered the don't lay down in bed. So like if you're college students, their bed is also their couch and it's also their desk and it's also their whatever. 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 10 weeks. >> Eight to 10 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 6 to 8 sessions they're usually sleeping way better. often by then they're like, you know, this isn't my problem anymore. 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 let's talk about a couple supplements. Um, I definitely want to get into >> jet lag in a little bit later, but you know, obviously the most the top of- mind supplement people think about when they think about sleep, they think melatonin. >> Melatonin. So, melatonin is a hormone. 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. 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 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. 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 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 an insomnia condition. But if you don't have conditioned arousal, 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 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 the 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 the less flexible the system is, but that happens naturally. Now, some people when they take melatonin, they might be taking the wrong dose at the wrong time. So the way we started using melatonin as as a as a treatment for something was our natural rhythms are about 24 hours, you know. So so some creatures they use light from the sun to so like when you put a 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 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 whack, 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 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, 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 6:00 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 2:00 in the afternoon. It's miserable. And then it cycle around. It's called It's called non 24-hour circadian rhythm disorder. um 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 and 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. That half milligram dose is the signal. It's the clock signal. It's 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 or 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 night time 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 is hasn't even really started yet. You're giving your evening a little bit of boost. So that's so it's basically like jetlagging yourself where you're you're telling your body it's nighttime before it's actually nighttime. It's not you're really telling, you're telling it it's evening before it's actually evening. like right around dinner or like usually 2 to 3 hours before your typical bedtime is when you start producing melatonin. 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 tell 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 as if you take that lowd 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 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 time. 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 10? Well, a people think more is more and sometimes more is less, especially with melatonin. Uh, if it's just a nighttime signal, more does it isn't more. Um, five you can take closer to bedtime. That's a little more of a sleepromoting dose where it's more of like a hey body, you idiot. If you didn't know it was night time already, I'm going to scream it in all capital letters for you and get your act together and and it'll boost that na whatever natural sleep drive you have um that isn't interfered with by insomnia, it'll it may boost it. So people who take that 3 to 5 milligrams within, you know, closer to bedtime, it can have that sleepromoting 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. 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 o you overfilled your bucket. And so, by the morning, you still have melatonin floating around [Music] backfiring. So, now you're telling your body it's night time when it's daytime because you couldn't get rid of the nighttime signal fast enough. And and 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 and then there's the other problem. There was like a few studies that have been published where I mean almost all these melatonin supplements that are out on the market have huge variations. Some of them have like 100 times more melatonin that's actually what's on the >> Yeah. those. So, so that's the thing where there's a lot 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, 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 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 2 to 3 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, it's probably closer to eight, seven or eight when you buy it. 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 the 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 beat that. It's it's complicated. The law was written in 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 in the overage needed to to be able to degrade to the point that it hits the target. Isn't that crazy? Like people don't know this. >> So less is more for sure with with when >> that's also why I say if you're still having effects actually your dose might be too high. Just cut it in half. Um the other thing that's worth mentioning about melatonin is it's actually a very potent um cellular repair molecule. M those effects don't really seem those effects seem to be stronger at the higher doses actually like closer to the 10. Um 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. Uh our immune system probably does does the trick, but that's also why when people take melatonin supplements, they get sick less. Um, 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 very is a really cool molecule. It's just misunderstood. >> Yeah, it's a hormone. I think it's regulating like 500 different protein encoding genes. >> Yeah, it is. It is a hormone. What other hormone do you just like buy over the counter in sort of unlimited amounts like it? >> Weird. 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 a melatonin supplement, are you going to then stop making endogenous >> there is to my knowledge there is no evidence that this that that actually ever happens. To my knowledge, it's a worry, but melatonin is so is so old that like you're going to produce it. Like the 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 or reduces your ability to naturally produce it at night. >> What about and that's also what the conclusion I came to. Um what about the ability like your melatonin receptors? Like >> um is there remodeling? I don't know. I I haven't seen anything that's concerning in any way. I I just I just haven't like no one has there there's no finding that when when people have looked it doesn't really seem to be doing that. It see it doesn't seem to change the same way other receptors do. Again, it's a very old system. It's an old built-in system that that isn't that is meant to adapt that that is meant to be able to deal with flexibility rather than respond to it super quickly. Um, I haven't seen anything either, but I haven't seen anything either. I mean, 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 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 um with with research and pharma has the deep pockets to do this. 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 in 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 as an additive or something, but that's extremely rare in the supplement space. So, supplement companies have no, they can't 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 a spend $2 million on a clinical trial that their competitor could just take the results from and claim as their own? Like and NIH who funds I mean people need to understand how absolutely fundamental NIH is to all health research in the US. I mean every every bit of health research in the US absolutely depends on a healthy NIH. and NIH as much as they fund whatever I mean they're 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 and sleep apnea and other major health conditions and supplements by definition don't treat medical conditions they promote health but they don't treat, help prevent. >> 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 why like the 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 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 supplement's fault. It's not the company's fault. It's just, you know, I would love for there I would there love for there to be more investment or or or if there was a public outcry that like look, we need these studies. >> We 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, elenine. any I mean you know moderate evidence that some of these were >> so a lot a lot of them have evidence that they are definitely not nothing um none of them have beaten placebo to treat insomnia the closest that came was Valyrian um but when you pull the data it still doesn't beat insomnia uh placebo for insomnia it can but it is sedating it can be calming um magnesium also does seem to promote sleep in a number of different ways actually more than just one way. Um, doesn't treat in doesn't usually treat insomnia, but it can help promote sleep. Glycine, also great data on glycine showing that people who take glycine, it can help um fall asleep, help stay asleep a little bit better. Um, a lot of these supplements, it can help you fall asleep and 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 sleepinducing. 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 alenine and some of these other more calming thing like the chamomile and some of that stuff that can be calming can actually be helpful. um even if they don't actually technically do anything on the sleep side. Um other things that can help promote sleep, things that have anti-inflammatory and and antioxidating 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 c certain supplements out there that actually seem to be um seem to have some of those those anti-inflammatory properties. And when you take them, you might be sleeping better. I mean, when people take ibuprofen, they can also sleep a little bit better because like it it it those awakenings and and arousals due to discomfort might be just a little bit less and might help you sleep through the night a little bit more. Um there's a few things like but that's the difference where 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, we're I'm definitely not talking about insomnia. And you know, some people just like to have a little bit of help and >> glycine is interesting. That's one I've been interested in. And have you seen any of the thermal regulation stuff on that? Yeah, like >> I haven't seen the thermmore regulation stuff, but it seem so so it's unclear to me whether that's a cause or an effect, >> right? >> But but either way, does it matter if that's what you're taking it for? >> It's more of a GABA inhibi like more of that inhibitory. >> Yeah, it does it does seem to promote that those inhibitory. 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 training. And 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 act is is activating. 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 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 away 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 mornings. It can help wake you up a little more for a bunch of reasons, including its ability to help me light suppress melatonin, but you don't want it at night when even a little bit of light can get start getting in the way. >> Fascinating. So, take your multivitamin in the morning, not in the evening. >> Yeah. If if I I 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 if sleep is all about recovery and repair, 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 of some the the that multivitamin you might want to take in the morning. >> Okay, let's talk about substances that affect sleep. This is another one. I mean >> a lot of people >> we'll 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. I hear it in just everywhere in the audience. Um, but kind of even a step ahead of that, you know, was was marijuana, right? Like which has CBD and THC, >> they're two separate separate compounds, right? And so >> I kind of want to start maybe with THC, like if someone's doing the whole >> Yeah, THC 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, can help you stay asleep, can help you feel more refreshed. THC does. However, there's three downsides of THC. Um, four, if you're an athlete, uh, one is that the sleepromoting effects fade over time. So often it works great for a 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, I may short-term benefits and long-term benefits are different. That's number one. Number two, in a lot of people, not doesn't seem to be everybody, but in a lot of people can be a very potent REM sleep suppressor. Um, a lot of people don't realize that anti-depressants also um most anti-depressants are potent REM suppressors. Like you can all you can knock out 50 to 75% of all your REM sleep of the night by taking like a Lexa Pro or an SSRI um or THC. >> Does that affect memory? Because isn't REM important for incorporating >> that weird, huh? 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 when all these people who are taking anti-depressants are not falling down not being able to remember things? Don't know. Um it what it me my hypothesis is these processes are way more complicated than we realize. And when we see a decrease in REM sleep, what we're we're not seeing a decrease in the process itself. We're seeing a decrease in an effect of the process and in a down like REM what we call REM sleep as these these physiologic signals and brain wave patterns. Maybe it's downstream of whatever is happening under the hood. And just because you don't hear the downstream signal anymore doesn't mean the thing wasn't still happening to some degree. But then again with depressed people if their ability to process information is fundamentally flawed and because you're >> and I mean this 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 and 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. 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 dreams 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. So So like, so that >> so you could become dependent on >> well psychologically. So where 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 ramps up, but then it'll usually fade back to baseline. 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, there's probably a better option that's less less harmful. >> But is that if they're using the THC at night, is it is it the THC directly affecting their coordination or is it the indirect effect of REM sleep? All I 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 there's the daytime a motivation, there's the and and a motivation being like not just like, you know, the stoner 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 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 and one wrong step, you know, could be twisting something, you know, like it's just just one of those things of like there's probably a better option out there. I mean, I'm just saying, but but that that's THC. So THC does have effects on sleep. They could be relatively shortterm. They could produce a rebound when you stop taking it and there could be REM effects. >> And but having REM effects doesn't sound like it's a good thing though. >> Maybe not. Is it Is it Is it the same REM effects as you get with anti-depressants? Not clear. It's It's murky. The literature is murky. You got to remember until very recently researchers were almost not even allowed to study it because it was it was a scheduled substance and you weren't 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 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. Um, watch the space. Next 10 years, I think more stuff is going to come out. >> Okay. What about CBD? >> CBD much more murky of a story. CBD is is a legit molecule, especially in terms of the things that it does, but the sleep data from CBD are extremely murky. Um, about about half the studies that have used CBD have shown that it could benefit sleep. Um, the other half don't. Some of them actually show that it makes sleep worse. The dose and the timing seem to matter. Um, the individual differences seem to matter. Um, 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 don'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." And 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. But, you know, if a little bit of relaxation is all you need, maybe it'll help. What 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 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 I don't know all the doses in the different studies, 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 of day. I don't I don't have any clear answers about CBD except um I would keep I'm I would keep an open mind with it but expectations in check. >> How does it how does it work? Does it does it just reduce anxiety? I is it like an eltheanine kind of? >> Yeah, it see it's it's from a sleep perspective it doesn't I 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. Um, I could be wrong. I I am not like there are pe 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 um, does it affect sleep architecture at all? Like >> does it have the REM stuff? I don't 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. Um, so unlike THC. >> Yeah. Okay. Um, another one that people use to help fall 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. >> Um, so the thing about alcohol, alcohol, it would surprise nobody to tell you that alcohol can make you fall asleep faster and actually sleep a little bit deeper in the very beginning of the night. Um, 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 can't get back to sleep. I mean, Anyone who's had sort of too much to drink and fallen asleep will may have that experience where you wake up and you're and you're up and you're just like, "Gh, 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 as the alcohol molecule metabolizes and becomes acid alahhide, it can become a neural stimulant. the acid aldahhide could become acetate which could become a neural stimulant 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 a 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 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 earlier helps? Like if you're not So if you do it earlier, then you're that >> if if you're having wine at dinner and then you still got a few hours, the 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 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, um, 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 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 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. Um, and so getting that feedback could sometimes be helpful. >> Yeah. No, I mean I >> And we'll talk about wearable sleep. >> Yeah. We'll definitely get into that. Um, okay. I mean any other of these? There's caffeine we could talk about. >> Yeah. I mean, caffeine probably the most used psychoactive substance in the world. Um, there's a reason why people use it. It works. It's relatively safe. Um, coffee is actually a great source of antioxidants and and phenols. Um, especially if it if you're actually just if you're drinking it from from coffee, not just the isolated caffeine molecule. It picks up peaks at around 30-ish minutes, then trails off. For most people, four to six hours before bed is the last time they should be caffeinating in any way. Um, some people they can drink an espresso, go to bed just fine. People metabolize it differently. Um, for some people 10 to 12 hours is actually too much. Um, where they need to stop in the morning or else there's just enough floating around in their system in the evening where they're not like jittery from caffeine, they just might have a harder time settling. >> So that's a real thing people can actually because doesn't caffeine shift your circadian rhythm over as well? 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 it's which is more of the circadian signal. I don't think I don't know. I I haven't seen anything I could be wrong, but I haven't seen anything with 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. >> Um, and it increases activity, which is itself a circadian marker. I thought there was one study maybe maybe in it was like they were giving men um caffeine. It was like nighttime like close. It was evening and I think it somehow shifted >> well it might >> 45 minutes or so >> like it might have shifted. >> Well, my guess is it would have shifted. It would have delayed they would have probably increased their activity level, increased their light exposure, >> delayed everything. Yeah. So, so 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 like take a look. I don't remember I don't remember a paper looking at so like in in my world there's a difference between behavioral rhythms and circadian rhythms 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 >> right yeah um yeah so I I just I never doesn't 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 CEG activity. So it'll make your sleep shallower. So it'll probably I mean I I'd have to look at the literature, but like if I had to make a prediction, my guess is it would dramatically reduce slow 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, >> it may be disrupting their sleep. >> It might be. It might be. Um, 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. >> Yeah. I mean what's the quickest you could metabolize caffeine though? I mean >> I don't 30 minutes >> or or or I I probably I >> No, that's when it's peaking, >> right? Like I don't I don't know. >> They would never feel it the effect. >> Or maybe or maybe just the way it interacts with the denosine is different. Or maybe they're just so sleepy, their sleep drive is so high. It's the the way adenosine is interfacing with their sleepwake rate because adenosine itself isn't sedating. It it builds across the day in and interfaces with that system. But the adenosine itself like you can't like take adenosine and fall asleep like it's that's not how it works. So maybe different you know humans are humans we're all different and you know our wire some of 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 >> outliers >> 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' and I've seen people who drink coffee at night and their sleep looks fine. So like who knows? >> Um another one that I've talked about with um Dr. Sachin Panda who's been on the podcast a few times is late night eating. >> Yeah. >> And obviously food is a substance. >> Yeah. >> Um >> and at least with my conversations with Sachin, it seems like a good sort of on average time to stop eating before you go to bed seems to be at least like 3 hours or so before you go to bed. Um, how does how does food affect sleep? >> Yeah. I mean, so so he is the world's leading expert on that on that issue of the timing and and he tells these incredible stories about how just the cellular machinery of transporting glucose fuel into the cell is partially clock dependent. and 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 like it's it's fascinating work but al as a psychologist I 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 the wind down. They eat at night because they're stressed. 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 deprive them in the lab. Not in the morning. 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. 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, bug, 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 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 are craving energy. They're craving calorie dense food. They're cra craving pleasurable food, food that feels good to eat, highly palatable food. Um, and especially sort of like the later at night it gets. I mean, there's a reason why people generally don't crave a salad at 2 o'clock in the morning, you know, even if they would during the day. It's just your thinking and your emotional reasoning and your choices are fundamentally different. especially between 2 and 5 in the morning. That time seems especially vulnerable. Um in our lab, we're studying that that vulnerable time. It's we're calling it the mind after midnight like and how you're you make different choices in that zone. Um 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. Violent crime also spikes during that time for maybe different reasons, but unhealthy eating also sp like 3:00 a.m. food. If I tell you this is the kind of food you want to eat at 3:00 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 processing. So, we seek the thing that feels good, but it feels less good when we do it. So, we seek it more. And 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, but it's really not the end of the world. I can I can solve this problem." >> Our brains when 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 mean, >> I know. I don't know. I mean, we've known for years that that So, look, if you ask a circadian scientist, is shift work for you than smoking. They will usually have to stop and think and be like, "Ha, good question." And then you're 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. Shift work is a problem. You know, shift like we're the only species that shift works ourself 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 it's forcing a square peg into a round hole. And there's consequences. Some people may be more resilient. People who are more night owls, they might be more amendable to taking a night shift as long as they're able to go home at 4:00 in the morning and go to sleep. People who are early birds might be more amendable to taking a night shift as long as they can sleep between like 9 8:00 p.m. and 2 in the morning. So for them maybe it's not as extreme a shift work as as you know maybe it's it's not as extreme but shift work in general car known carcinogenic. It increases diabetes risk increases dementia risk. Like shift shift work isn't good. But yet we live in a society that demands it. Someone's got to man the phones. Someone's got to drive the fire truck. Someone's got to someone's got to work the hospital. Um, you know, do all shift work occupations require shift work? I don't know. That's a like do all factories need to run 247? 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 it's just that's the shift work that's closest to my life where someone brings the box of 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. >> Um, decision- making it gets impaired especially when and 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 available? I don't know. I I mean I don't know why this isn't why everyone isn't doing this. It seems obvious to me. >> Well, 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. >> What for for shift workers? Um 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 into 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 the it's the it's the 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 do it. >> That's the problem. Um but anyway, so so napping napping can be great. Um nap, think of a nap like a snack where are 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 help save off hunger, increase your energy, increase your focus. Um especially if it's kind of a healthy snack, high protein, some fiber. You don't maybe a little bit of sugar, something in there to make it palatable, but you don't want to load it up with calories because you don't need them. Same thing with Same thing with a nap. A nap on purpose that is restricted in time before you want to you want to wake up before you drop down into that deep sleep if you want to make it sort of like a power nap. And uh remember you're dropping down to stage you want to wake up before you drop into stage three sleep because >> so how long would that nap be? So it dep so it dep 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, 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 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 recovery. You can you there's data that shows like even in sleepd 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 nap. Um 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 stacking? Um, there's also a different kind of nap that shift workers can use and I call that a sleep replacement nap. Sort of like a meal replacement shake where no one looks at that and thinks that that looks like a meal. Uh, 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 um uh 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, which does exactly what it does at night, too. It's not quite quite as good, but it 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're 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." And so it gets in it and you get all the way through. And if you if you wake up out of that feeling pretty good, you know, that counts at 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, it's like you're starving and you only get one bite and sometimes that's a little worse. Just like everyone's a little different, but think of a nap like a snack and use it strategically like you'd strategically use a snack to stave off hunger and and to make it through a shift. >> Okay, that's great. As long as you're not drinking a lot of coffee, maybe. >> Well, that too because then if you 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 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. 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. Um, I want to kind of shift and talk about jet lag. >> Yeah. >> And we kind of were you were talking a little bit about this sort of strategic timing of melatonin, which I was kind >> and light, >> right? And light. Um, 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. >> Um, so I'd love for you to kind of walk us through like how does this relate? Let's say you're going, you know, to the east versus flying eastward versus westward. >> Yeah. >> Um, like I'm going to be going to China. >> Yes. >> Soon. >> A 17 hour difference from where I'm at. >> Um, >> I mean, how am I going to get to that time zone? So, yeah, let's talk a little bit about um how can we 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 or >> so mostly 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 from the West Coast US anyway is very different than going from New York to LA. New York to LA 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 travel 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. Um, 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 where you time the flight so that it lands in the morning local time. So you're taking off in the afternoon from the US and it might be 3 4 5 6 in the afternoon, but you're landing at 10:00 a.m. local time. So as soon as I get on that plane, I'm like, "Okay, it's night time. I have this eight hour, eight, nine hour flight. Um, this is going, this is my night, so I'm gonna have crappy sleep. I'll sleep sleep on the plane when I can. I got my earplugs, 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 exhausted by nighttime local time, and I'm essentially brute forcing my sleepwake 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 and 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 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 will have dropped into deep sleep and so >> so no naps when you're when you're travel, especially as you're still in the adjusting period, don't give yourself mixed signals, but try and if the and and if traveling to Asia is more complicated because the fight's so much longer, But think of it as local time. Think of when you're going to land. When do you want to wake up before you 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 um there's there there's a 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 an 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 uh 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 biological night, say, "No, no, no. It's daytime, daytime, daytime, and get light, suppress whatever natural melatonin you have. Take the melatonin at night to to cuz 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 that's when you might supplement. >> Yeah. Which is why being outside is so important during Yes. >> 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, so you can block light as a daytime signal. So and or give light as a daytime signal >> or and and use melatonin as the nighttime signal. So, no sunglasses in the morning, >> right? Yeah. Or or if you're going to use sunglasses, make them kind of blue tinted. So, so even if it's even if like the 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 greener tinted sunglasses if you're going to wear sunglasses in the morning. >> So, that actually works. Or you can switch it. >> There's no data on this. I just made that up. But but it should work because as long as you're getting that frequency of light that it's the bluish greenish light that sends the information to the clock. But it's also I live in Arizona some 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 to to influence the clock without doing retinal damage? And 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. that they have. Um I I'd love to see it, but that's my pet hypothesis. >> Yeah, cuz I would imagine like you were saying earlier, obviously the early morning light, it's not as damaging, so you played on me sunglasses then, but you're talking about being outside >> long like hours during the day and how that also protects you from the um the you know the blue light inhibiting melatonin later. Um yeah, >> you want the blue light to inhibit melatonin, >> right? Sorry. Where it >> No, no, no. morning. In the morning, you want it to, in the evening, you don't want it to. >> Yes. >> Yeah. >> Okay. Um, so let's talk about where we do have a lot of data, and this is definitely um an area that you're an expert >> in as well, and that is these sleep tracking devices. >> Yes. >> Lots of them out there. Um, Aura, the Whoop. Yeah. What do we have? Apple Watch. >> Um, the Fitbit and Pixel. You and I are both on the scient scientific advisory for the Google. Yeah. um um which is where we first met. But I want to know what metrics do you think are truly good at >> yes >> being captured accurately and which ones should we interpret with caution? >> Yes, excellent question. Um, people need to know that using wristbased 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 a about 90% accuracy using movement alone. And this was analog devices with with that were on a tape backup or eventually 64 kilobytes of memory 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 brain wave 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 brain wave activity in that the brain wave activity will pick up lots of little awakenings that that the the the movement detection probably won't um there will so so it will underestimate wake time relative to looking at brain wave activity but it will overestimate wake time versus your self-report. So, if I asked you how much you slept and you said 7 hours and your watch says 6 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. Uw during probably. Does it matter? Probably not. Um, so because all of the guidelines and recommendations that people, you know, the seven hours of sleep guidelines, I mean, I I I was on one of the the the the panels. I was on the ASM and SRS, the CD, 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. 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 you should be totally fine. So that's I trust it to be correct and accurate for what it is, 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 the what it's best at the heart rate data are also really good separate world in that the heart you know photolethosmography 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 for 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. 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 stagy 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. 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, got to remember what sleep stages are. You know, we're looking at different patterns of brain wave 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 then it was back to four. Um, just are you stage one, two, three or based on the pattern of squiggly lines? This is humans rating it. Do they exist in nature? No. We made them up. 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 brain wave 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? Is that REM or did they drift into stage two or stage one at this point? It looks kind of similar. I'll call it REM. Well, I'll call it stage two. You see this all the time. It this is why we 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 we can even train a lot of these AIs against because even the humans can't agree. So, it's it's a moving target anyway. So the fact that you can get that close from from this stuff on the wrist, I think is a miracle. But you got to keep your expectations in check. This 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 you if it shows very little deep first of all I can't distinguish stage one and stage two at all. 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 because that's what 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, they're 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 cuz 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? 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 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 visually that's why clinically I look at it visually. I don't actually count the minutes because I don't depend on 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 about. So that's the sleep stage of data. The third bin is the metrics like the scores with very few exceptions. Uh most of those scores are I give almost no attention to those. Um, I can be ungenerous and say they're mostly made up nonsense. Anyway, >> can you repeat what scores we're talking about? >> I'm talking about anything that's called like sleep score, sleep quality, sleep need, sleep readiness, um, uh, 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're 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. Thing is, none of these things are published. None of these things have been vetted. None of these things. It's like it's it's 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 it actually impairing my ability to perform or not? Or is it look like it is because of how the algorithm's using heart rate data? I don't know because none of it's transparent and forget the transparent. I know Google did a study was on the that that no it wasn't Google it was Fitbit before it was Google I think where they had their sleep score and they correlated the actual global sleep score to an 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'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's 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 I can use because I don't know what they mean. Um, 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. Does that I mean, I'm trying to be fair and 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. It's just you gave me a number and I don't know what to do with it. >> So I I I was gonna ask you what big your what the biggest m misconception about these wearable devices you kind of wanted people to know like right now and I'm thinking maybe this >> Yeah, that's that's the big one. It's it's also the I think the biggest misconception is that accuracy matters. Um 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. Um, 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 they're stuck in a bind because if they're too transparent with their algorithms, other people are just going to copy it. You can't patent an 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 and as these companies, they're just going to try and come up with better metrics and better metrics. As a researcher and as a scientist and as a 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. Um well well let's talk about actionables 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, um, another another saying that I attribute to a colleague of mine, Amy Ay, who's a sports psychologist, who's a colleague of mine, and and she's helped me a lot on a lot of sleep stuff and and I was explaining this wearable stuff to her and and so 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 bec 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 what to do with the the number it's giving you, how is it going to make a change? You know, just because it gives you a number, just because it has 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 that it's it's spitting you out a number. It's measuring 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 I'm meeting guidelines or not? No, doesn't mean that. But does it if if I see it over time, if I see I'm usually hitting six and a half, six and a half, 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 minutes. And [Music] are there discrepancies between what my memory of the night was 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 cuz 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 see like, "Oh, I see what's like I'm up and down a lot during the night. this seems very fragmented. No wonder why I feel kind of it's like you use that information. So like the 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 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 3:00 or 4 in the morning when a lot of people wake up around that time. 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? If it's rising during the night, what's really going on? If you see your heart rate data and looks normal, then you have a couple of periods of of intense fluctuation, what's going on in those periods of time? They might give you some insight that there's something something under the hood that's 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 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 if anything that tells me that I don't know what's going on under the hood, but something 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 can 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 looking into what that could be. Do so if let's say someone is um 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? I I 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. It's just you're sensitive to it in a different way. So I see this a lot. Um so first see if there's something chemical or if you're eating you're eating a metabol a food that's too metabolically active too close to bedtime or you caffeinated too late. 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 um you have something something active going on. So like do you need is there 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. Um you know, there's there's all kinds of reasons for that. And then if not, what's your relaxation windown routine like? Why is your heart are you exercising too late 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? Um, or maybe you need to introduce some more relaxation 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 mindbody approach like 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 u I know we talked about the accuracy of these sleep st being able to measure sleep stages anywhere between I maybe 60 to 80% which isn't terrible. >> 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. Um, 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. 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 picking up for for other reasons or something. Um I would say the way I do this is just like the breathing 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. Let's if so, let's figure out what that is. Treat it. Okay, lungs are fine. Do you have an airway disease? Do 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 let's identify any problems there, fix them. Okay, that's fine. 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? 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, then it's like, okay, well, maybe it's environmental, do you have are is is your room too hot, is your bed too uncomfortable, is your spouse too snoring too loud, um or rolling over too much, um 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 this? Like, is there something in your environment? If we go through with somebody and their environment is 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. Um, well, this is a this kind of leads into the next question, which is the pitfalls of these 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, 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 Baron. She's at the University of Utah. She she's she's like me. She studies sleep and sleep health and wearables and stuff. And so she came up with this idea. Um 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. Um where people are obsessing over food ingredients where it's like you're you're missing 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. It'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. 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. It's not it's a net loss for you. It's not a net gain." But I want But I want like you know what? You can't handle the truth. I guess is is 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 for what it can't give you. It can't give you those answers. we don't have that level of precision. Um, so there's 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 dex. They don't care. If you have a problem with your sleep, I will ask you the questions I need to ask, do 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 whatever your wearable says. And if that wearable is what got you into the clinic in the first place and say, "Hey, I thought my sleep was okay, but this but now I'm a little worried about it." I will say, "Okay, well, I'll tell you if you need to worry." Well, I'll ask some questions. I'll figure out what's going on. Sometimes I'll say like, "You know what? you 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 d-stressing your you your sleep is is more impaired because of the stress around your sleep than anything else that you're doing. >> It sounds much like the the stimula a negative stimulus, right? >> And so often that's the case. So, like if you're if you're looking at 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 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 the normal range, a sleep clinician is probably not going to fix is not going to have anything to fix for you. um you might have to come to somebody who has a little more experience with optimization if you really want if if 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 tea leaves and say yeah no this is totally fine I I I couldn't I couldn't make these numbers better if I wanted to or yeah 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 bit so you tell me like if there's more information that you want to share about it, but like using sleep as a cognitive performance enhancement. You talked a little bit about this. >> Yeah. I mean, think of think 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. We 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 across the board people if you can sleep better your resilience will improve. You can improve your level of resilience whether it's physical or emotional or whatever it was vari it was defined however the study whatever the study defined it any study if you improve your sleep you can improve your degree of resilience you can improve your reaction time you can go from normal to better you can go from good to great um there will be a ceiling but especially athletes especially younger athletes like 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. Um, if you're 20, it's, you know, I'm not saying more is always better, but too much is very rarely a problem for adolescence and young adults. Um, there is such thing as too much sleep, especially as you get older. 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 you it's a real thing. You can 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 6, seven hours. If you get them up to like 9 10 hours, they're faster, they're stronger, they're mentally sharper. Um, 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 windown 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. So you're I mean I go to bed at midnight instead of you know. So, like when when when a typical adult looks at a clock and sees midnight, clock says midnight, their body says midnight. When a 5-year-old looks at a clock, clock says midnight, their body's like, "Oh my gosh, it's 3:00 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, their body is like, "It's only 9:00 p.m. Why are you going to bed now?" And when it when they have to wake up at 7:00, they're like, "Oh my gosh, it's 4 in the morning. Why are you trying to wake up?" So yes, they are shifted and it changes with age. Um, so yes, you can use light behavior and melatonin to physically shift that. You can do that, but they are more naturally inclined to staying up late. I mean, high school should not start before 9:00 a.m. >> totally 100%. >> Colleges shouldn't start before 9:00 a.m. >> 100%. >> Um, it's developmentally inappropriate. >> Um, >> it's it's a lot. I mean, colleges, I can't speak for that, but for like high schools, it's it's about the parents work schedule. >> Yeah. It's it's it's logistics. It's not 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, and California led the way on this. California took the step and and at least pushed it to 8:30, >> right? >> Um, no, I don't think any other states followed yet. Um, and um, there's tons of data on this. Uh, my colleague Wendy Troxell, she has a fantastic TED talk on this um, on school start times. Um, 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 asleep? You know, all these ADHD diagnoses, how many of them are just sleep deprivation? You know, mental health problems, 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 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. >> Yeah. >> And they wait, they're like, I wake up at 5 6:00 in the morning just fine, you know? So what's your problem? You're just lazy, you know? Like I'm not saying they say that. 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. >> You can give people melatonin to you can give melatonin low that lowd dose half milligram melatonin as a phase shifting dose and light as a phase shifting dose of bright light. You can you can do that if you 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 early exercise. >> Yeah, early exercise. Get them 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 get have the dim lights in the evening, um th those dim lights in the evening can help pave the way for, you know, even if their natural melatonin isn't going to rise, give a little bit of melatonin in the evening, force that rise a little early. You can I mean, you can essentially jet lag yourself on purpose um without traveling by doing that, by giving light and melatonin at the time you want. >> No, 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. Um, and actually, um, it peaks this this delay pe seems to peak in the early 20s, like 22, but then after that, like you can you can get, I mean, 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 this is called chronotype which is like sort of where in the 24 hours are you chronoype in athletes athletes maybe it's also self- selection where the the teenagers who were just super late people were less likely to survive the the training schedules to to make it to the elite level. Who knows? Or maybe they're they 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 their age, >> right? What's the most if we're talking about like athletic performance, what's the most consistent sleep hack you could, you know, that >> 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, we're not talking about 60-y old, 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 I and there's some strategies for doing this. Uh 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. So, you might want to slowly increase the amount of time you're spending in bed. Unless you're tired enough that just spending an hour in bed, you'll knock out any >> like 15 minutes a night or >> that's that's how I like to do it. I like to 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 and that 15 minutes might buy you enough productivity where you could find the next 15 minutes. And >> do you go to bed earlier 15 minutes or >> 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 it's about advancing bedtime little by little. But the point is you're ready for it by the time you do it. But anyway, so 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 it might create more arousal if you can't fill that time. So, you don't want to just I don't want to just say like get more sleep because not everyone needs it and not you don't know how much more and you don't know if you can fill that time if you have insomnia anyway. But anyway, but the data consistently show that if you can bank a little extra sleep first of all on 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 or or a stopwatch. Are you getting faster? are you being able to lift better? It might not be perceptible by your memory, but it might if if you are 5% faster, you won't notice, but the stopwatch will, for example. Yeah. >> So, that's the first thing I would say. The other the other most important sleep hack for athletes is sort of comes after that and it's sleep banking. Bank good sleep. Um, 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. Probably maybe you will, but many athletes don't. Even at the very elite level, they are not sleeping well right before competition. But if you've banked 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 you can recover pretty well. So one to two nights of short sleep does not dramatically impair performance. It might stress you out and you might psych yourself out. That might impair your 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 so it's really about the week before Yes. your your week or two. >> A week or two. Okay. Yeah. Come from that. >> It's the same for a cognitive performance 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. If they know that ahead of time, >> 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 it's 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 to make up for being sleepd deprived during the week?" I'm like, "Well, that's like saying, "How much kale do I need to eat on the weekends, but to make up for eating nothing but cheeseburgers and pizza all week?" It's 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. Um, how strong is that data that that you really do? >> So, yeah, it looks like sleep first of all, sleep is critical for recovery and everyone knows that like when you're sick or when you're injured, you 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 you you crash your car more and actually if you ask people how well-rested you think you are but you 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 that predicts drowsy driving for example 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 due 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 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 even if you feel like you're getting plenty of sleep at night, 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, 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 one 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 and and in this school every 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-risisk sport were the three biggest predictors of concussions, except for the sleep variables. insomnia having having a high insomnia severity and it's like which is which is a questionnaire we use to see like how much is your is your insomnia interfering with your functioning day during the day and how much is it stressful for you and daytime sleepiness saying at least two days uh a week I think it was a week at least two days um 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 then. And even the concussion variables um hasn't 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 and and and getting better sleep is the best way to not be sleepy. >> Yeah, that's that's very interesting. Um 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 Patensiano who's who's actually a sports person. He's a sports psychologist and he did this project and I read it when I was a posttock and I thought it was brilliant. He he worked with Major League Baseball. He still works in in in pro sports. He's a great guy. Uh but he did this project where he gave sleepiness questionnaires to a whole bunch of MLB players. Followed them up couple years later. I don't remember exactly the time frame. Just looked 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. Wow. Um, and the ones who were in the clinical range who who scored uh 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. And so that that's what gave that that gave me the idea of like, wow, what other simple questionnaires can predict just at screening um who's at risk? >> Yeah. Um I want to ask you before getting on to the rapidfire audience questions if you um >> the cognitive performance one I'm very interested in just personal reasons and I'm wondering like is there let's say someone's getting pretty goodish sleep. >> Yeah. >> Like would you have a couple of your top tips that do you do you think they could still improve cognitive performance um with a couple of sleep tips? >> Yes. Um >> and if so what are they? >> The Yes. So the first thing I'm going to say about the cognitive performance is caffeine can dramatically improve performance in some domains but not others. You can 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-m, you just make bad decisions faster. That's what happens when you caffeinate a sleep-d deprived person. Um, 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, uh, semi-pro tennis players serving in when they took them down to 5 hours of sleep impaired their serving accuracy by, if I remember correctly, something like 35%. Um, it recovered about a third of the loss was recovered when they caffeinated, but not all of it because there's other higher order stuff that's happening. 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? Um if you can pro 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 deeper sleep and get a little more benefit from it. So here's a great example of a simple example some of the best sleep technology on the market simple cloth eye mask. There was a study, I think it was in Switzerland, where they'd had a eye mask, just an 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 weren't 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. Uh, that's just one example. like IMA, IMAS and earplugs. Some of the best cheap sleep technology that exists. >> Yeah. So, darkness and >> darkness. Well, but it's not and but it's also you might need to just that extra layer of insulation. >> Extra layer. Yeah. >> Like a white noise machine could be good for something like that. >> Don't have a puppy in your room basically. >> Yeah. Something like that. 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. Okay, let's get to some of these a 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 cuz one is cheating. Uh 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 pillow, it's a conditioned stimulus, I 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. Um, rigorous highly empirically supported. Lots of data support this. The other one I would say is allowing sufficient windown 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 time, if you're having trouble or your mind's racing, it's because you're trying to go from 30,000 ft 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 hard. >> Those are cool. >> 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's so much easier to break wherever you want if you're coming in a little slower. >> I definitely do. Number two, um I'm definitely now going to I'm I'm going to be on top of this this control thing cuz I'm super interested in it. >> Bang for your buck sleep tip in the world. >> Great. Okay, awesome. Um most effective pre-bed routine you've seen 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, reading actual paper books is great before sleep, unless you're me. I 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 know it, and you'll you will tap right into your body's signals. you won't be over stimulated and and as soon as your body's ready, you'll know it and you can put stuff down. So, reading dimmer orange light um the way to go and that's that's sort of the way to go. >> All right. Uh best strategy to fall back asleep quickly after waking in the night. >> Um if if I were going to turn this into an algorithm, step one is if I wake if I wake up in the middle of 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 could and 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 control it. Let it be. And don't panic. You will fall asleep just fine. If 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. Um, good recap. Um, >> one proven method to increase deep sleep in healthy adults. >> Proven method. So there is some really not not that I think anyone really whether or not people need it I don't know but the d there is some data you could improve the deep sleep not improve 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 um 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. Um, 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 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. Um, and and actually like I said with the eye mask, the environmental bubble wrapping of your sleep because if anything's going to prevent you from getting more deep sleep, it's it's extra stimulation >> with the auditory stimulation. Is this something that you listen to while you're >> Yeah, it's like it's like the bural beats kind of a thing where like it induces it basically um sends waves that are in the waveforms that you want your brain to sort of create to to echo them. >> Okay, cool. Yeah, it's like BOF feedback but but for brain waves. >> Um, most effective way to reduce nighttime urination and wakeups. >> Um, 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. Um, 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 is like okay while you're awake might as well. Um that that usually comes afterwards. Um 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 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 till the morning. I've done this before. Um, in fact, I used to go I used to get up to go to the bathroom one time in the night. Yeah. 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 5ish 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 this. >> And that's and that's the thing. It's actually you you might have accidentally programmed yourself to do that. Remember what I said. The average person will wake up 10 times a night or more. that the awakening occurs is not the problem. That it's blossoming into something you're remembering as stressful is 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, go back to sleep." And and and if you can train yourself to do that, it's actually shockingly effective if you if you reduce that performance anxiet. >> Yeah. No, I'm 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. overall sleep quality. Um I have 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 don't sit around in the dark all day. Um humans were not built for that. Eat well. People who people who eat like crap especially late at night their their their sleep is more disturbed at night. um reduce systemic inflammation in your body, your sleep will feel better. If you're sharing a bed with somebody and that somebody has sleep issues, drag them kicking and screaming to get tested for whatever it is they have and get it treated. Or get two twin XL's, put them next to each other, sleep in a se, 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 um we have our own separate blankets. >> Yes. On our bed because >> there's nothing wrong with that. I I there 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 environment where you get to be under control and not have it be it's best of both worlds, >> right? Where I'm not feeling the movement as much. >> Exactly. >> For sure. Um, okay. How can you quickly assess if you're getting enough sleep without a lab test? >> Uh, you couldn't even do that with a lab test. We don't have a good test of are you getting enough sleep. Um, 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's not might not be amount. It might be about quality. Because for people with a sleep disorder like apnea, more isn't always better. 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 multi-dimensional. 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 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 might why are you so hungry that like you put if you 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 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. Um 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 my plate in 30 seconds as soon as it was put in front of me." Should have taken a little bit of time. So So maybe you're going to bed too late. Maybe you're waiting a little too long. Um, yeah, that that's 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. >> Do you really need eight hours of sleep? >> No. Um, 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. 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. Um, are there people who are sleeping 5 hours and are fine? Possibly. Is it you? Probably not. Um, think of it as a bell curve where you're probably somewhere in the middle. The chances that you're on an extreme outlier are low. Um, just because you're an outlier in one part of your life doesn't mean you're an outlier here. And 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? 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 to be optimally functioning? >> Yeah. Optimally functioning. >> 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. 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. Um, but if you could control your day such that maybe you're doing certain things at certain 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 s, 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, 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 um >> today. So, thank you so much for coming on the show. Um, you have a book coming out in I think October of this year. It's it's planned. It's a textbook. So, it's an academic book, but it's all about So, it's a wearables book. We also have >> It's all about wearable sleep technology. >> Yeah. Yeah. We have we also have a I've also edited a few other text books. There's one on sleep health, another one on sleep and sports um and and another one on adapting CBTI for like I'm an academic, you know, like this is what I've got. But, um >> uh if people are interested in them, uh they're not priced like a regular book. They're priced for libraries and for academics. But so if people have any questions about anything in them, just shoot me an email. I'm actually easy to find. Um and and I'm happy to be responsive. >> Yeah, I'm I mean I'm looking forward to it. And a book on wearable sleep technology written by an academic who actually knows about it. Sounds interesting. It'll be fun. >> Um so great. So people can look you up. You got your your lab at the University of Arizona. Yep. >> Um thank you so much for coming on the show and sharing all this really really knowledgeable um you know important information with everyone and thank you for everything that you do. >> No, you're very welcome. Thanks for having me on.