SPEAKER_00 0:00

On this episode, why sleep is critically important for every aspect of your well-being, what bad sleep is costing you, and what you can do about it. Joining me to unpack this important topic is Indira Guru Bhagavatula, a professor of medicine in the Division of Sleep Medicine at the University of Pennsylvania Medical Center. She's also the director of the Sleep Medicine Fellowship Program. She has over 30 years of experience in taking care of patients with sleep disorders. She has done research looking at screening for sleep apnea in high-risk groups, including commercial vehicle drivers, and has a special interest in sleep and public health. I'm Jake Panasevich, and this is the Yoga with Jake podcast.

SPEAKER_02 1:06

Oh my goodness, wow. Fantastic. 100%.

SPEAKER_00 1:11

Okay, good. If I could get through the name, I think I think we've gone through the toughest part. How's it going?

SPEAKER_02 1:20

Going great. Thank you for uh for the invitation.

SPEAKER_00 1:23

Oh, it's my pleasure. I was very uh thrilled to have such a quick turnaround to be able to talk to you so quickly. Sometimes there's months back and forth. So this is really nice.

SPEAKER_02 1:33

I'm glad it worked.

SPEAKER_00 1:35

I was curious if we could just start a little to to um learn a little bit about yourself and your background.

SPEAKER_02 1:42

I am a professor of medicine at the University of Pennsylvania in the division of sleep medicine. And I'm also the director of the sleep medicine fellowship at Penn, which means I'm responsible for training people who want to become sleep specialists. These are physicians who've come to us from different pathways and have done residencies in other areas. Um, and I also uh work at the Philadelphia VA Medical Center as a sleep medicine doctor. My training was actually in pulmonary and critical care medicine, and I kind of stumbled into sleep medicine as a specialty. It did not exist as a field way back a couple of years ago when I was in training. Um, but uh it came into its own and has really grown quite a bit to the point where now I just practice sleep medicine full-time.

SPEAKER_00 2:38

Okay. Was there is it a popular field? You mentioned it's grown, it sounds like relatively quickly. Um is sleep, sleep seems top of mind in my bubble of health journalism and wellness. Um, but is it um on your radar, are more people coming in with sleep troubles? Is it a a relatively um a problem that's gotten worse in our culture?

SPEAKER_02 3:09

Yeah, um, well, there are a couple of different themes in the question you ask. One is is there a true increase in the prevalence of major sleep disorders and in how common they are? And the data seems to indicate that the answer is yes. There is uh one of the most common disorders that we see in sleep centers is a medical disorder called obstructive sleep apnea. And not everyone who has obstructive sleep apnea is overweight or obese, but at least two-thirds of the patients are. And there's been a steady increase in the prevalence of obesity in not just in America but worldwide. And we think that that's contributed to an increase in the numbers of people who actually have sleep apnea. So that's one thing. And then in terms of sleep deprivation, insufficient sleep insomnia, that also seems to be getting worse. And um, there seems to be a bump up during uh the COVID pandemic. There were more people struggling. Um and then the second thing is just are people becoming more aware that they may have a sleep disorder? So now, and they know that sleep medicine exists as a specialty, so they're actually seeking more help, and that might also be a reason. There's so there's a true increase in the numbers, but there's also an increase in the numbers of people that are seeking out help and coming to medical attention. So more people with disorders are getting counted, uh, whereas they may have been undercounted before.

SPEAKER_00 4:38

Okay. And what is the are those the primary reasons um folks come in to see you for sleep apnea and just or or bad sleep, basically?

SPEAKER_02 4:51

Um, I would say those are among the most common reasons why people seek help is that um they're having trouble falling asleep, they're having trouble staying asleep, they wake up too early, they can't get back to sleep. Um, that's definitely a big reason. And a lot of people come because usually around middle age, but sometimes sooner, sometimes later, um they start having snoring. Their bed partner complains about their snoring because it's loud, it's habitual, and it's bothersome to everybody else that is also trying to get some sleep. So snoring becomes more than just an occasional nuisance, it becomes disruptive. And they're waking up, they may be choking, gasping, and they also notice that even if they're getting enough sleep, they're just not waking up rested, and that it's starting to affect their daytime performance, whether it's at work or at school or uh in their relationships. So those are probably sleep apnea and insomnia are probably among the biggest reasons. Um there are other issues too. There uh sometimes they come because they've had heart disease or heart issues. Um, they've had a heart attack, they have blood pressure that's been hard to control, um, they uh, you know, had a rhythm abnormality or some sort of a cardiac scare, and their cardiologists, a lot of them now recognize that sleep apnea could be a contributor or poor sleep can be a contributor for uh to uh heart disease. So they come in because they're referred. Um some of them come because of mental health problems, you know, depression, anxiety, post-traumatic stress, nightmares. Um a lot of mental health disorders can be they can contribute to insomnia and difficulty sleeping. Um, but at the same time, if you have a sleep disturbance for any reason, whether it's obstructive sleep apnea or another sleep disorder, if you're not sleeping well, you can experience that primary sleep disorder as a mental health problem. So some of these disorders masquerade as a uh as depression or anxiety. Um, you know, sometimes people say I just feel tired or I'm sad a lot or um, you know, I'm not mentally as resilient as I used to be. Um and so they end up, you know, seeking psychiatric help when all along the issue was was sleep apnea. Um and in children, similarly, ADHD. Uh, there are lots of kids that are getting diagnosed with ADHD, getting treated with stimulant therapy. Um and it it's been known for quite some time that one of the ways that sleep apnea shows up in in kids uh is with difficulty sustaining attention in the classroom and uh with difficulty regulating their behavior, so being hyperactive or disruptive.

unknown 7:42

Okay.

SPEAKER_02 7:43

And then when you treat the sleep apnea, the ADHD symptoms get better, the depression gets better, the anxiety gets better. So, you know, that's the really rewarding thing about being a sleep specialist is that we get to see people get better.

SPEAKER_00 7:55

Yeah, and I really do want to get into the mental health component of this because I'm curious if it's treat the mental health and the sleep gets better, or is it work on your sleep and the mental health gets better, or is it this continuous cycle, or does it be is it based on the individual?

SPEAKER_02 8:12

It's it's um often turns out to be a bi-directional thing, but for a given individual, it may be more one-sided than the other. And um, if you work with your sleep doctor, then they will help you figure out what the next steps are. And a lot of times you, if there are two different things going on, it's most effective if you if you address both. Um, but sometimes if you treat the the dominant condition, then the other one also gets better. Um and you know, uh people are struggling, they're trying on their own to cope for a long time before they finally come to us. Sometimes it's you know, they if they can't sleep, for example, they um they'll have a drink at night or they'll take a puff of uh a joint or a hit from a pipe to of a marijuana to help them relax and fall asleep. So they're trying all of these different things and um it turns out, and especially if it works the first time, it ends up becoming a habit. And over time, some of the coping behaviors actually work against you and they can make the original problem worse. So, for example, if you have a drink of alcohol, it may relax you and help you fall asleep. But as the alcohol burns off in the second half of the night, your brain is now dealing in the middle of the night with this withdrawal of alcohol. So it gets lifted up from a lighter from a deeper stage of sleep uh to a lighter stage of sleep. So the next morning, or you or you may be completely awake. Um, so the next morning you wake up and it's uh you feel like you haven't slept, or you're in this fog and you know, you're exhausted, and uh, you know, and not everybody pieces it together and realizes that it was the alcohol that left you feeling worse the next day, might have helped you in the moment, um, but it's not effective overall, and it's definitely not going to be effective in the long term because it comes with its own risks. So by the time they come to us, they've tried things, and then um, you know, it's a real uh educational session for them to understand how different things affect us and affect our sleep.

SPEAKER_00 10:21

Yeah, I I was curious about the negative effects of self-medicating with things like alcohol and cannabis. I feel like alcohol, especially, maybe we're just all more aware of these things too now, but the level of anxiety is what I call it, could last for days. I don't know if I'm just getting older. Even with light drinking, um, if you're maybe prone to maybe anxiety, is it the case that something like alcohol could um negative affect your mental health and provide anxiety when you try to go to sleep?

SPEAKER_02 10:53

Yeah, what a great term. I hadn't heard anxiety before. I've heard hangry, but oh my gosh, you're teaching me all kinds of things. Um yeah, that's uh it's a very astute observation. And it's alcohol works like Valium. It hits the same receptors in the brain as some of the medications that are used to treat anxiety. And when it's metabolized and burns off, you can have what's called rebound anxiety. And um, you know, in the middle of the night, you may not even be feeling anxious, you know, as the alcohol goes away, but you're the the state of arousal is definitely higher, you know, as the alcohol is is taken away. So um there there is a rebound wakefulness um uh or a tendency toward arousal. So it just means that um, you know, it's you you pay now or pay later when it when you it may look like a quick fix, but it but and and people are always looking for that. And um unfortunately, I wish there was a quick fix. I we'd all be rich if there was, but really it's what it requires is to build your sleep from the ground up with healthy habits. And um it it doesn't have to be perfect every night. Everybody has a bad night from time to time. Um, but if overall your health habits are consistent and um you understand how different things affect you and you have some self-awareness around how your behaviors are affecting your sleep, and you consistently choose the things that are that are helpful for you, then you can build you know healthy sleep habits and um more sleep satisfaction.

SPEAKER_00 12:33

I was I really want to go into some detail with the habits side of of this conversation, but I was wondering if we could take just a broader step back, a broader question on, you know, why why is sleep so important? You know, you brought up so many conditions that are affected by bad sleep, but what is sleep doing for us to benefit us?

SPEAKER_02 12:55

Um, so maybe it's easier to say, what is it not doing?

SPEAKER_00 12:59

It really that's that really head to toe.

SPEAKER_02 13:02

Every system, every system, every system in your body needs sleep. Your whole body needs rest, your whole body needs sleep. Um so starting with just how you feel, right? How alert you feel, how tired you feel. Um, so your level of alertness is directly impacted by how much sleep you're getting, uh, not just um just you know, both in the short term and in the long term. And if you're not getting enough, there's something called sleep debt, uh DEBT that that you end up owing. It's not that you can just get used to not getting enough sleep. The debt builds up over time, and the level of exhaustion and impairment continues to increase over time. So that's one thing is just how tired you feel. But then the lack of sleep also affects your brain's ability to function. So, really important functions like your ability to focus, um, maintain attention, remember things, learn new things, um, regulate your emotions, um, you know, make good decisions, take in large amounts of data, figure out what's important, what's not, um, stay coordinated for your muscles to work correctly, um, you know, your um, you know, uh ability to read social cues when people are talking to you, um, you know, the nonverbal cues, how to de-escalate situations, how to handle difficult conversations and communications. So, really everything, all of those functions, your brain, a motor function, speech, language, social, behavioral. Um, and then there's the um, you know, emotional health. So, mood, including, you know, your tendency to be depressed or anxious, and even suicidality can be impacted by sleep. Um, and then there are the choices we make, um, whether we're able to, like teenagers, especially if they're very sleep-deprived over long periods of time, they're more likely to engage in risky behaviors. So um, you know, indiscriminate sexual behavior, using drugs, you know, using uh excessive amounts of caffeine. Um, so some of those choices we make, the foods we choose, so we may end up, you know, choosing the foods that are not healthy for us. Um, sleep impairs the body's the brain's ability to regulate hunger and satiety. So you end up like missing the signal that you're full, and you end up having food cravings for unhealthy foods, the fried and fatty and sweet things that are not good for you over time. So then the other impact is over time, with unhealthy sleep or insufficient sleep, uh, there's weight gain, um, diabetes, um, high blood pressure, metabolic syndrome, um, blood lipid abnormalities. And then that leads to cardiovascular risk, whether it's heart attack or heart rhythm abnormalities, heart failure, stroke, um, and then other brain functions like Alzheimer's disease has even been linked to certain problems with sleep. Um, and then just general aches and pains and how well you feel, you know, headaches, stomach upsets, um, more visits to the doctor, more healthcare utilization, more likely to end up in the hospital and stay longer. Um, so you know, and then our ability to drive and perform, you know, safety-sensitive tasks. So if you're tired, you're more likely to make a mistake driving or not react in time if something happens. Um, you know, things like breaking and steering away or anticipating. And what that means is that the crashes tend to be uh a higher severity and they're more likely to result in injury or death. So sleep problems have been linked to some pretty significant public health issues and public safety issues related to accidents. Um, immune function. So if you're not sleeping, you're less likely to be able to fight off colds easily or even, you know, react to vaccines. So if you got vaccinated, your body needs to mount an appropriate immune response. And if you're underrested, there's data that shows that you're not going to generate as healthy or as robust a response to vaccination. Um and uh, you know, cancer risk. There are some studies that show that people who don't sleep enough are more likely to end up with certain types of cancers. So, again, probably there's something called immunologic surveillance where your your immune system is on the lookout for cells that don't look normal and is able to get rid of them. And people that are underrested, your body is just less efficient as at doing those things. So, you know, there's sleep is not a passive state. It's not like turning off a light. You're when you go to sleep, a lot of functions come to life. So things that are not happening in the daytime. So your brain is cleaning up the metabolic waste products and all of the buildup that happens over the course of the day when you're awake. And it's removing all of those things so that the cells, the neurons can function at their best the next day. And when you sleep, you're allowing those uh waste removal functions to happen the way they're supposed to. And if it's not happening, then there's this buildup of things that shouldn't be there. Um, and that can lead to injury to neurons and it can prevent them from um um functioning the way they're supposed to. So, and we think that Alzheimer's, that that's some of the basis for that, maybe maybe around that specific function. And then emotionally, your brain is handling all of the emotional burdens of the day and uh kind of breaking them up and putting them away, if you will, when you're sleeping. And if you don't have enough opportunity for that, right, I I often tell my patients, your your grandmother probably told you before you make a big decision, sleep on it, right? Because then you can wake up, quote unquote, clear. And so if you never get the rest you need, then you're carrying all of the emotional burdens from day-to-day to day because the processing of emotions and memories occurs during sleep. And some memories get consolidated, other memories get let go if they're not important. So your brain figures out what's important, what to hold on to, and what to let go of. Um, so yeah, lots of things happening when you sleep and giving yourself time to do that the same way you would give yourself time to eat or drink water. You know, it's you would never brag about, you know, I went five days and didn't didn't drink a sip of water. I mean, it's we have sort of a funny relationship to sleep, as if not giving ourselves a chance to sleep enough is uh some sort of a badge of honor. And I think we it is important for us to relate to sleep as the essential life function that it is.

SPEAKER_00 19:46

Thank you for that thorough answer. I I'm thoroughly terrified.

SPEAKER_01 19:52

Great. Yes, thank you for that. Now the flip side is that if you get good sleep, you're look at all of the functions you're supporting.

SPEAKER_00 20:01

Yes, that is right. You gotta see that as a positive if you've got your sleep uh habit under control in a healthy spot.

SPEAKER_02 20:10

Um you're supporting heart function, brain function, your emotional functions, immune function. So you're you're doing a lot of good for yourself.

SPEAKER_00 20:19

What what is a good amount of sleep? We've heard eight hours. Um generally, I think, as growing up for me, that's what I've been told. But is it different for an individual each individual, or what do you suggest?

SPEAKER_02 20:34

So there's probably a sweet spot for everyone. And across populations, it really depends on how old you are. Um, as you know, newborn babies sleep for many, many hours over the course of the day. And then as children get older, they need less and less sleep. So one rule of thumb is 10 at 10. So a 10-year-old needs approximately 10 hours of sleep. Um, teenagers, probably around eight to 10. And then as we get older and reach adulthood, it's probably seven to nine. And not everybody falls neatly into those bins. Some people can get away with a little less, and some people really do more need more sleep. But just the way you you figured out what you need, um, you know, you can check in with yourself and and see where you feel your best. And one way to know is that if you allow yourself to go to bed at night and you're able to get up and feel fully refreshed the next morning without an alarm clock, and you're doing that steadily, and then you get a sense of how much that is. So for some people, if I'm steadily getting seven hours of sleep a night, I feel good, I'm not tired during the day, I don't fall asleep inappropriately, I don't need an extra siesta, I'm able to function and do all the things I need to do. So you can sort of figure that out for yourself. Um, some people think they don't need much, that they can get by with four or five hours. And there have been experiments done on some of these people that are quote unquote habitual short sleepers. And the data around that are have been somewhat mixed that if you take those people and you put them in a an experimental condition where you just put them in a room and say you can sleep as much as you want and you're not going to be drinking caffeine and you're not uh doing any kind of stimulants, then what you find is that a lot of people who thought they were short sleepers end up extending their sleep and they look more like everybody else. So it's possible that a lot of people who think they need very little sleep are masking their true sleep need by consuming caffeine regularly in enough amounts that it's sort of chronically suppressing their ability to get the full sleep that they need. So the way to find out is without caffeine, you're well hydrated, you're eating healthy food, and how much are you needing? And another uh marker to look for is is there a difference between work days and days off or school days and days off? And if you notice that on work days you sleep X amount and use an alarm all the time, and then on weekends or days off you're sleeping an extra two or three extra hours a day, then that tells you that you're probably not meeting your sleep need uh during your work days.

SPEAKER_00 23:19

Okay. And could we get into what are some of the sleep habits that you suggest for those who are trying to get um good sleep?

SPEAKER_02 23:32

Um so I lucky for us, there's plenty of information available. Um, the American Academy of Sleep Medicine, sleepeducation.org has tons of information. Um, National Sleep Foundation also has resources. So there are places where you can go to for reliable information. Um, but one important thing is um wake up at the same time every day and um go to bed at a consistent time every day and keep a very consistent bedtime routine. And um the other thing is uh what you eat during the day and what you drink during the day will affect what happens at night. So the things to avoid are caffeine. Um so a lot of people say, Oh, I just have two cups and it's only in the morning, or you know, and I don't drink it after one o'clock. So that might be true for you and it might be great, and you fall asleep, you know, at the very easily at night and you're sleeping through and waking up rested. But if you have any kind of insomnia, then one place to look is are you drinking, is the caffeine affecting you more than you think? So for some people, the half-life of caffeine can be very, very long. So, you know, like six hours, eight hours, ten hours. So you might have had a cup or two in the morning, but by late afternoon, there's still, quote, the equivalent of one cup still in your system. And when it's time to go to bed, a half a cup is still hanging around. So the way to know that is to gradually taper it off so you don't get a headache and then see how you do how you feel. And is your sleep more satisfying? Are you sleeping longer? So caffeine is a really important one. And then um, similarly, cigarettes, marijuana, alcohol, they all have um sort of disruptive effects on sleep. So um hydrating well and not with water and not um consuming some of these other substances is a great place, uh, a great way to get yourself to a healthy place in terms of starting sleep. The other big question is light. So our brains are wired to use light as the key that sets our biological rhythm. It's the light is the strongest rhythm setter for our biological clock, um for our sleep wake clock, at least. So the way that works is that in the back of your eye on the retina, there are cells that specifically receive blue light. They are not the rods and cones, which are the cells that help you see. This is another set of cells that exist purely for the purpose of receiving this blue light. And then when the blue light hits the retina, it sends a signal to the brain that, oh, the sun is up, so it's time to wake up. So the brain then makes sure that there's no melatonin being secreted. And melatonin, it's called a hormone of darkness, and it serves as a signal to tell the rest of the brain to prepare for sleep so that your brain then can unwind and get ready to sleep. And the way melatonin turns on is with dim light. And you want melatonin to be secreted when it's time for you to go to sleep. So it's important that there's not bright light in the area as you're trying to get ready. So we tell people try to turn off screens and lights for about an hour before bed. And that gives your brain the signal that it is time to release melatonin and for the rest of the brain to go to sleep. Now, it's really interesting, but our sensitivity to light, it's not uniform throughout the day. So, for example, in the middle of the day, if you go outside in the bright sunshine, it is not going to keep you from sleeping at night. But it's the light in the evening. So there it's the way the brain responds to light is time dependent. So if it's exposed in the evening and the closer it is to bedtime, the bigger the effect on delaying your ability to sleep. So if you're on your screen at 6 p.m., 7 p.m. when your habitual bedtime is 10 p.m., that may not um delay sleep by as much as if you're on your screen at 10 p.m. or at 9, 3 p.m. So the effect is bigger and bigger the later and later into the night that it gets. Um, and similarly, if you wake up in the middle of the night and you go on your screen, again, it'll turn off the melatonin and make it harder for your brain to get back to sleep. And if you do that over and over again, your brain now thinks, oh, I'm supposed to wake up because now it's trained by light to think it's wake up time. So managing your light sources is really important. Um, exercise is a great habit to have. It it builds up your hunger for sleep. So we know that people who exercise very regularly, so like marathon runners, they get a lot more of the really deep restorative um, the the this the uh it's called non-REM stage three, which is the uh the sleep where if you wake up out of it, you're confused, you don't know where you are. It's beautiful, gorgeous sleep. And athletes get more of that than everybody else. So we know that exercise is a great driver for for um for sleep hunger. And um, the key is don't exercise too close to bedtime. So within a couple of hours of bedtime. And the reason is that it it raises body temperature, it may release more adrenaline, and those things are counterintuitive and counter-effective. So exercise, but not too close to bedtime. Um, and then uh um things like eating too close to bedtime, you don't want to go to bed hungry, but at the same time, you don't want to eat like a huge meal right before bed because um, again, it can uh raise body temperature and it can also contribute to acid reflux. So um, so we usually tell people leave a little gap between you know when you go to bed and and and the last thing you eat or drink. Um, and then other things like make sure your health is taken care of. If you have aches or pains, that you know you're working with someone to get that handled so the pain isn't waking you up. If you have heart failure, make sure your medications are optimized so you're not waking up in the middle of the night because of heart problems or asthma or you know, any other health problem. It's it's important that that that it all has to kind of fit together. So anything that's affecting your health in one direction can also affect your sleep similarly. Um and um, you know, same for mental health. Um, make sure that you're in a good place and get the help and resources that you need. Check your medications for some people. Um, some medications have a very strong stimulant effect. Um, so you may want to work with your doctor to figure out the timing of when you should take it or and the dose, and does it need to be adjusted if it's having effects on your sleep? So these are some of the things that people can try.

SPEAKER_00 30:07

Could someone go fully in on these habits, like try to get as much light out of their bedroom as they could, keep the cell phone out of the bedroom, um, finish up dinner really early, get to bed early so you could fall asleep early, hopefully. Could you reverse engineer with all of these? Would you recommend that? Or is that often too much for folks to do all at once? Or um, you know, I've noticed even while traveling, boy, try to get a room that doesn't have any light in the room is very challenging anymore.

SPEAKER_02 30:41

Um do you have that's what eye masks are for?

SPEAKER_00 30:45

Ah, okay. Yeah. Yeah, it should. Do you yeah, do you recommend eye masks? Yeah, or just depends on the person if they're is everyone sort of different. Like, do you have to find your sweet spot, like you said, with the hours? You know, some people might be more light sensitive or food sensitive. Is it based on the individual a little bit?

SPEAKER_02 31:06

It is, and then there are people who are who can tolerate a noisy sleep environment, um, who can tolerate slightly warmer temperatures, um, who can sleep with sort of modest physical activity. But um, if you're struggling with sleep, these are some of the places where you can look that are within your control. Um the other habit that that we should talk about is that if you're in bed and you can't sleep, what do you do? And some people think that, well, I just lie here and I rest. And because they think that just staying in bed is also a form of rest. And what we recommend is that if you know that you're not gonna sleep after 15, 20 minutes and you shouldn't be staring at the clock, you know, am I asleep yet? Am I asleep yet? But just if you have a general sense that it's been about 15, 20 minutes, it doesn't look like I'm gonna go to sleep here, then don't stay in bed. Go somewhere else and you know, keep that area also dark and relax and wait until your eyelids are very heavy and until you're very, very sleepy. And while you're there, don't do anything activating, like don't start watching, you know, um action movies or whatever, or you know, freedom, doom scrolling. Like, don't do the things that you know are going to upset you or activate you. Do something calm, relaxing, meditative. And then when your eyelids are very, very heavy and you really feel like I'm definitely about to fall asleep, then just go right back to bed and lay down. And if as soon as you lay down, you're you're up again and you can't sleep, then leave and go back to this other location and go back to sleep again, go back into the bed again to sleep when you're absolutely ready to fall asleep. And this is um, this is it's just like the Pavlov's dogs, right? Where he would ring the bell and show them the meat and they would salivate. And eventually he would ring the bell without showing the meat and they would salivate anyway. So it means the brain associated the bell ring with food. So what happens with some people is that they associate the bed with worrying. So if you're wound up and you're not happy, not ready to sleep, and that's the first time you're laying down all day that you're by yourself and you're finally processing your thoughts, um, don't stay in bed to do that. Because especially if you're going through a recent stressor of some kind, that's when these the insomnia often starts for people. They're dealing with something, you know, it's a relationship problem, a job issue, a financial strain, a health problem. And they lay down at night in bed, and that's the first time they're actually processing their emotional response to what's happening. And they're they're very wound up, they're worried, they're afraid, they're, you know, um, they're definitely not relaxed. And what's happening is that your brain then is taking in that, oh, I'm worrying in this place. And it's such a miserable night that the next morning the sun finally comes up, they're they're happy to just leave the bed and go on with their day because it's just such a miserable experience being in bed. But the next day they go back to bed and then the brain remembers, oh, yeah, this is what I was thinking about. And then it picks up again. And after three or four nights of doing that, your brain now associates the bed, just like the dogs associated the bell with food. Your brain thinks the bed, oh, this is where I do my worrying. So it'll just go right back like a trick, like a trained, you know, um puppy, to just go right back to doing that. Um, and then you can have that habit persist. So whatever the stressor was is gone. You've you've handled your finances, your health is fine, and you, the problem is gone, but that habit can stay. And I have seen patients 20 years, 30 years, and and it's still a problem. And so what we do then is we separate the bedroom from where you do your worrying. So you do the worrying somewhere else, and you also set aside time during the day to process what you're dealing with. So journaling can be really helpful. So just take 30 minutes, don't do it too, too close to bedtime so that you don't get yourself activated. But I tell my patients, just make two columns. You know, for most of my patients, it's a very finite list of things that they ruminate about or think about. So just write down what are those things, and then just write down what am I gonna do about this. And it might just be talk to somebody or wait till next week or nothing to do. But but but handle it during the daytime and then give yourself freedom to not think about it once you go into the bed. Give yourself permission to let it go. And you know, they find that once they do that, and after a few days of doing that, as soon as your head hits the pillow and you see, oh, this is my bed, immediately it should be, this is where I relax. And then within 15, 20 minutes, you should be going to sleep.

SPEAKER_00 35:53

I love that. You've accurately described a recent experience I've had in trying to sleep and was always curious how you break that vicious cycle where you can't sleep, you're overthinking, try adjusting everything, or just kind of lay there and stare at the wall, what you should do. Um, I have heard of the potential benefit of having a secondary space to lay down. And um and I've I've heard of the journaling. And is there also is there any other tools that you have found effective? I've I've written down things like prayer, meditation, um, even like I don't know if you've heard of Yoga Nidra, where it's a script and you're just asked to lay down. And I've heard of counting down backwards from a high number. Um, do you have do any of those ring true that they might be helpful or for different people? Or do you have any other tools for folks?

SPEAKER_02 36:56

Um, I you're asking great questions. Some of the information specific to some of what you asked, I can't answer, but I can tell you that I have many patients who find that yoga is a wonderful way to uh manage stress, um, uh, especially if they're being meditative. And, you know, it's actually called a moving meditation, right? So um, so yes, it's a it's a way to help process some of the thoughts that we're subconsciously um holding on to that, and because they're subconscious, they're not obvious to us. And what we're doing with some of these practices you describe is creating a a time window or a space where they can come to the forefront so you can actually recognize that they're there, hold them for a while, acknowledge them, and then, you know, uh either let it go or come up with um, you know, uh like where you're basically uh restoring your sense of power around some of the things that are that are worrying you at night. Um, and you're doing it by consciously bringing them forward and actually handling them. And so for some people, yoga is fantastic. Um, any form of exercise is a great way, really, to, and it takes some time. And but every amount helps, right? If all you can do is get up from your desk, go up and down a flight of stairs three times, you know, that helps. Every bit of activity helps. Um, but being able to do some sustained activity for a good 30 minutes can help a lot with managing stress and anxiety. Um, but certainly meditation and prayer and people, uh many of my patients have rituals around bedtime that they do to help process what's going on. Um, you know, sleep is something that that happens naturally and peacefully and easily. Um, when we allow it to, when we make space for it and we invite it in, then it comes. Um, but if we're chasing it, it's it's much harder. It's not something that you can easily chase. Um, it's really uh an entire mindset shift that in order for it to happen, you have to stop chasing it.

unknown 39:11

Yeah.

SPEAKER_02 39:11

And and and that perfection, right? So the uh like give up that it has to be perfect and try not to hyper focus on it having to be, you know, to the minute or like you have to achieve a certain amount or else like you mentioned how scary it was.

SPEAKER_01 39:29

When I started listing all the ways that, you know, if you don't sleep, it can affect you.

SPEAKER_02 39:33

But at the same time, it's um your body is wired to sleep. And if you go without sleep enough days, eventually you will sleep. And it it doesn't have to be perfect night to night to night. It's just over time and on average, are you getting what you need? So um, you know, with there are a lot of people out there now that are using the wearables, the fitness trackers and exercise and activity trackers. And um they can be really helpful in building self-awareness. So the habits that you've already put in place, um, you may not be aware whether you may not even know whether caffeine affects you or not, or alcohol affects you or not. But if you could try and see, is there a change in what this tracker is telling you from night to night? Um, and do you notice that that you feel better if you, you know, if you if you let go of of the booze for a week, or you know, if you cut back on caffeine, do you notice you feel better? Um and again, the trackers are also it's it's a rough estimate. They're not perfect assessments of what's actually happened with with your sleep. They usually use motion detectors and heart rate and you know, substitute variables to guesstimate are you asleep or or are you not? So if you were just lying still very, very still for a long time in one position, it may think you're asleep when you're actually awake. So, you know, it's take it all with a grain of salt. But sometimes the the pattern of shift in response to behavior changes can be helpful. Yeah, I think just don't get locked in on perfection and chasing numbers. Yeah.

SPEAKER_00 41:14

That's what I was curious about as somebody who maybe is prone for um overanalyzing and overthinking. Um I think sometimes the wearables inspire more anxiety around sleep. And then you described very accurately um this pattern of um, you know, you become more um knowledgeable about what bad sleep is costing us, you know, sleep or die, basically. And then so you're so anxious about the fact that you're not getting sleep in that moment that it seems makes sleep seem impossible at times, I feel.

SPEAKER_02 41:54

Yeah. Yeah, exactly. And I think that just think of it as it's a gift, it's a little gift to me, me to myself. I have these few minutes or a couple of hours or however long it takes to just be with myself and think about what I want to think about. Maybe I'll listen to some soft music, but just see opportunity and everything and forget chasing anything. And you will sleep. You know, if you have one or two nights of bad sleep, eventually you will sleep. Your brain catches up. So the key is to just make sure that the things that could get in the way of that are removed. So um, you know, and and take a comprehensive approach, you know, top to bottom, of all of your behaviors. What am I eating? What am I drinking? How am I handling stress? What's my exercise like? What are my medications and my physical health? How's my mental health? So it's an opportunity to just check in with yourself and address the things that can be addressed.

SPEAKER_00 42:51

I love that. And do we know you brought up some parameters around exercise, but do we know what is most beneficial? What the most beneficial way to um handle exercise for sleep? Is it you said it's sustained about 30 minutes, ideally not close to bedtime, not in the evening ideally. Um, but are there any other I've heard HIT workouts um to help ameliorate the negative effects of bad sleep? I don't know if you could speak some to that, but do we know exactly how to exercise for for the best results?

SPEAKER_02 43:28

You know, the I I love what I've heard other doctors say this, which is the the exercise that's best is the one that you're likely to do. And so if you know, if you if you uh there are people who can't stand HIT training, they just don't like it, and they're not gonna keep it. So if it's not for you, then you know that you're gonna sleep the rest of your life, and you want to build in habits that you can also sustain for the rest of your life. And if you're going through a hit kick and that's what you love and you can Do it safely without hurting yourself, and you're you have decent enough heart health so that you can do that without you know causing heart problems, et cetera, and lung problems. So then, you know, if that works for you, then that's your that's your answer. Uh, some people find that um lifting weights is really helpful. Um and there are people who love long walks um or hikes or bikes or whatever it is, but the key is to just be physically active. And um, you know, uh we are not when we think of our ancestors, they didn't sit at a desk for 14 hours a day. Our ancestors moved, they roamed, they foraged, they wandered, they they they were on their feet. They did not stay glued to a screen. So our wiring evolutionarily is not designed for this type of lifestyle. We woke up and then we slept based on the the temperature rhythms, light rhythms, sunrise and set and and and and temperature. We're now starting to also realize that rising temperatures make us wake up and falling temperatures help us fall asleep. Um, but movement helps us. We are designed to move. So get up and move, um, stay active. There's this other term, the non-exercise activity thermogenesis, which is the idea that even if you work out for 30 minutes straight, but then you're sedentary the entire rest of the time, that that's probably not the healthiest way to to go about your life. Um but in terms of exercise, I think any all exercise, anything you can get is good for you. And um, you know, and there are people who are competitive athletes who do a lot. And for them, um, you know, a 30-minute hit class would would be nothing. And then there are other people for whom a stroll around the block is hard. So do what you need to do to feel like you you got you got value out of what you just did. Um, and do it safely. Do it in a way that it doesn't hurt um and that it doesn't stress your system. And if you are somebody who has heart disease or lung problems, check with your doctor to find out what's safe for you. And there are people that work with injuries, and um, for some of them, the only way to do exercise safely is to get in the water. So um, you know, and for others, yoga is a great practice. So um for some people, it's dance. So whatever it is, find what your passion is, what you're likely to stick with, and um and do it consistently.

SPEAKER_00 46:30

I love that. And you brought up temperature. Do you mean do we have an ideal temperature for room temperature? Or do you mean like a thermal regulatory type of temperature, like your body temperature?

SPEAKER_02 46:43

Yeah, so in the uh in the upper 60s, like around 67, 65 to 68, somewhere in there, is probably a sweet spot for most people where they tend to sleep best. Um, and uh there was a study done recently that that um that looked at because we have this Fitbit information on people in millions of people, some of these large data studies are starting to come out, and they're finding that um uh regions of the globe that are warming where the temperatures are going up, um, that the sleep patterns are showing that people are losing sleep as a result of warming temperatures. So um, which has led to discussions about, you know, what should we be doing and how do we manage that? And um, you know, it's the the people who have access to air conditioning and cooling and shelter, they'll be relatively shielded from some of that effect. But the it's the people that don't have access to air conditioning and um uh you know appropriate shelter and housing that will be affect that will be um at the mercy of environmental temperatures. So for them, there's there's an um there's some theorizing that that they're gonna end we're gonna have more and more people who are sleep deprived, um, and that that could lead to changes in when we work and when we sleep, so that we'd have to work, you know, because in very, very high temperatures, high uh tropical climates, people end up having to work at cooler parts of the day or times of the day, especially if they're doing physical labor outside. So there's a lot of talk around, you know, temperatures and what it could do in terms of public health for sleep. For us individually, it's um keep your bedroom cool, comfortable, and dark and quiet. Um, the group that I see that that get impacted a lot are women around the time of menopause who are having hot flashes and they find it really hard to um stay asleep. Um, they'll wake up and it's like they're burning up, and they just, you know, when you're hot, it's really hard to generate sleep. And that's because there's fluctuations in um uh in their ability to control their um their internal body temperature. So we tell those people wear light layers and have a fan and you know, start off with all of your layers, and as you start to warm up, start to remove some of the layers so that you can stay comfortable. Um so um, you know, some people find taking a um a warm shower about 30 minutes before bed, it heats up your body temperature. And then as you get into the bed, your body will release that heat and it's the cooling that helps you fall asleep. So that's another way to quote biohack, the um the effect of temperature on on sleep.

SPEAKER_00 49:33

Yeah, that's you know, a lot of the other tools I was going to bring up are probably in the biohack category, I imagine. Probably not, I haven't noticed any literature on like weighted blankets and those sort of things. And even like the sauna, I've heard like you mentioned a hot shower 30 minutes before. I've heard potentially if you do have a sauna or access before an hour 30 minutes before, but it has that compensatory thermal regulatory effect where your body starts to cool down naturally. Um does that make sense with a sauna.

SPEAKER_02 50:08

I mean, I I the as far as whether somebody should invest thousands of dollars investing in a sauna or not, it's not something I can tell you to do. But um um exercise when a shower will probably do that as well. And um yeah, and um, and there are people who say that that works for them. And if you can afford it, that's one way to do it. Um, but uh whether you have to do it, it's it's it's probably not a a must. Um, but uh ultimately you you want to get down to where it's cool. That means just don't do anything that's gonna overheat you for a long time, but you know, beyond the time you should be falling asleep, which means like not exercising too close to bed and uh not taking a super hot shower where it takes you know a long time to cool down, but you just want to get warm enough that then you start cooling again in time for for falling asleep. So it's just a matter of timing um, you know, these interventions so that it all prepares you for when your brain is ready to sleep.

SPEAKER_00 51:09

Okay. And are naps effective? You brought up um debt, like sleep debt. Could you potentially, I feel like a lot of guys I know who are a certain age myself, I feel like I'm getting there, I'm napping more frequently, like mid-afternoon. Is there a sweet spot for naps? And or is there are they effective?

SPEAKER_02 51:30

So um uh if there's no other sleep disorder like sleep apnea waking you up during the nap, um, then naps generally are very effective, and they're a great way to get that little power boost that you need to go on with your day. So our circadian rhythm um it relates to our level of alertness over the course of the day. So when we first wake up in the morning, we're at one level of alertness. In the next couple of hours, alertness gradually increases, actually. So if you woke up at six or seven or eight, maybe 10 o'clock, you're actually more alert than you were. You were you're more alert than you were when you first got out of bed. And then after that, there's a little bit of a dip, and by the mid-afternoon, uh you get this slump, which is like the siesta time, where everybody has sort of a dip somewhere in the like between 12 or 2 and 4, let's say, or one and three, somewhere in there. And then we get what's called a second wind, where our alertness increases again till around six, seven o'clock. And then in the evening, it gradually starts to dissipate and you get, you know, more and more and more tired until finally uh it's dark, and then your brain makes melatonin, and then you go to sleep. So you're referring to that dip in the there's one in the mid-morning and then there's one in the in the evening or in the mid-afternoon. And what happens is usually there's something that exposes the dip. So if you're just sitting at a desk and you're bored and there's nothing else to do, or you've just eaten, it's right after lunch. So if you've eaten a lot of carbs at lunch, and then uh which which stimulates an insulin spike, and then the insulin makes your blood sugar drop. So the drop in blood sugar, as well as the timing uh around the bottom of your, you know, one of your circadian slumps makes you very sleepy. So sometimes people will feel like if I eat a big starchy lunch, especially, I'll need to take a nap. The other thing that exposes that slump is if you're already a little bit underrested and you're not getting the full sleep you need every night. So that's another little bit of a stress test to figure out if that's happening. And if it is, then a short nap can be really helpful. So maybe 20, 30 minutes. If you sleep a lot longer than that, what happens is that your brain starts to get into the really, really deeper stages of sleep. And you, when you wake up out of it, you may be actually a little bit impaired. So if you took a big long two-hour nap in the middle of the afternoon, I would not tell you, well, then just get right up and go and you know, drive across the state. Um, because it takes a good 20 to 30 minutes to kind of fully wake up after something like that. And some of my patients will actually tell me, I don't like taking long naps because I wake up feeling more tired. Um so a short nap can be very um effective and rejuvenating and maybe more effective and better for you than coffee or or you know, caffeine in the middle of the day, which can spill over and make it have trouble sleeping at night. But a short power nap should be fine as long as it's not too close to bedtime.

unknown 54:32

Okay.

SPEAKER_00 54:33

Yeah, I was about to say it might be worth giving the nap a try within that time parameters rather than reaching for that afternoon coffee, it sounds.

SPEAKER_02 54:40

Yeah, yep. Or, or if you really don't want to sleep and you want to save all of that sleep hunger for nighttime, get up and move to counteract some of the um that sense of being sleepy. And when you get up and you move, you stimulate some of the adrenaline-like compounds that that then uh will help you stay awake.

SPEAKER_00 55:01

Okay. Do you is there best positions to sleep? I've heard folks say that they've woken up with pain. Um, I myself feel like, oh, I tweaked my neck a little bit during a night uh overnight sleep. Do we know best positions for sleep? I've heard, you know, on the backs um challenging for those with sleep apnea or those who are waking up gasping for air. Is that is there any truth in that?

SPEAKER_02 55:28

Yeah, so there are a couple of things that people should know about body position and sleep. The first is that um sleep in the position that's most physically comfortable for you and that keeps your spine in a neutral alignment. So make sure that the pillow is not too big and jutting your head forward and not too low and causing you to hyperextend your neck. Um make sure the mattress is firm and supportive. Um, if you sleep on your side, for women especially, you may want to have a pillow between your knees where you're sort of in a semi-uh fetal position because um the because of the shape of the hips, it's easy for the knee to fall down, and you want to make sure that the hip, the that the two knees are neutrally aligned with your hips. Um and as far as sleeping on the side versus the back, for some people with sleep apnea, the apnea is more significant when they're on their back. And they'll tell you, yeah, my spouse makes me roll over because I snore on my back, and they know who they are, um, the ones that have bed partners at least. And um for some people, sleeping on their left side is helpful in reducing reflux because the stomach is there on the left, and that way it'll be in the dependent position instead of, you know, like where gravity will keep whatever's in your stomach, you know, at the lowest part and not coming back up and refluxing. Um, using a wedge or elevating the head of the bed can be helpful with reflux. Um, the probably the most effective way to do that instead of piling up a lot of pillows, I usually recommend they use cinder blocks under the two legs at the head of the bed so the whole bed is on a tilt. Umsing extra pillows can actually crunch your upper body and uh crunch your abdomen and put pressure on the uh stomach and make it easier to reflux. So that's one thing you want to avoid. Um, a lot of people sleep best when they're on their stomach, but that can put a lot of stress on your lower back. So um you have to kind of figure out what position is most comfortable for you. Um, people with shoulder injuries find it really hard to sleep on their side because of the pressure on their shoulders. So, you know, it's it's everybody's is unique and it's whatever works best for you. But ultimately, you want your spine to be fully aligned. You don't want to put stress on any major joints. If you have reflux or sleep apnea, there may be specific positions that work better than others.

SPEAKER_00 57:56

Okay. Any suggestions?

SPEAKER_02 57:58

Yeah, pregnancy. Pregnancy is another one where as you get bigger, it's harder to stay on your back. Um, so uh the key is uh sleep on your side and take pressure off the vena cava, which is along it's a big blood vessel in the back. So um your doctor can help you with uh learning when it's time to um not be on your on your back anymore.

SPEAKER_00 58:20

Okay. Um any suggestions for those who are waking up regularly from sleep in the middle of night?

SPEAKER_02 58:28

Um if you're having recurrent wake ups, it's and you're waking up and the next day, you're tired, you're unsatisfied with your sleep, it's probably a good idea to talk to a sleep specialist. Um sleep apnea can present that way. Um you woke up and you have no idea why. It could be that uh what happens with sleep apnea is there's a brief closure of the upper airway when you sleep. And that prevents oxygen from getting through. And when oxygen doesn't get through, the oxygen in your blood drops very quickly. And your brain has a sensor for that, and your brain will release a bunch of adrenaline to force you to wake up, open those muscles back up in your throat, and get the air back in. And it's not a full awakening, it's just a brief few seconds arousal from sleep to correct the oxygen issue. And then as soon as you go back to sleep, it happens again. So it just keeps happening all night long. And initially, it may only happen like later in the night when you get into what's called REM sleep, because during REM sleep, there's actual paralysis of a lot of the muscles throughout your body, uh, including the muscles in your upper airway, like your tongue. And uh, so you may only notice that you're waking up unexpectedly, or sometimes you may experience some choking or gasping with it, but you may not, but you're just up and you don't know why. And sometimes the adrenaline surge is big enough that you just can't get back to sleep. So it's probably a good idea to get screened and make sure you don't have sleep apnea. And then there are other conditions like leg kicks and uh restless legs and other, you know, um conditions that could make you um have some sleep disruption at night. And the people with restless legs, if you if you know what they are, it's an extremely miserable condition. It it seems to happen in the evening, usually when you're sitting still and you just have this incredible urge to keep moving your your legs to um to find some sort of relief. And it can interfere with sleep. And the the two biggest things to look for are iron deficiency and the other is caffeine and alcohol intake. So as you're waiting to get evaluated, I would suggest tapering off alcohol and caffeine. And um, you know, if you think you might be anemic, making sure that you get your iron levels checked.

SPEAKER_00 1:00:49

Is that the same as getting like a jolt and like almost feels like a seizure type of movement when you're asleep, like a sudden jolt?

SPEAKER_02 1:00:59

Yeah, that you're talking about as you're getting ready to doze off or fall asleep, you get you wake up with a sudden jerk. Um that's called a hypnic jerk. And you know, you feel like you're falling and uh or that you fell and you hit the bed. Um yeah, I I wish I understood the why we have that, but that is not a medical disorder, and it's something people experience from time to time, and it's just it's just something that happens. Uh it's this transition from being awake and alert to um becoming you know not conscious and going to sleep. And it's this sudden wake up that happens, it's brief, it's momentary. You've thought that you fell and then you go back to sleep. Another, yeah, another condition is waking up paralyzed, unable to move. That happens sometimes. Um uh it lasts for a few minutes and then it it gradually goes away. And it just means that you woke up out of REM sleep. And uh, you know, if it's occasional, it's scary when it happens. But if it's occasional and happens once in a while, um, usually we just provide reassurance that you probably had an arousal or woke up from sleep when you were in REM sleep and you were paralyzed. And your brain will kind of cycle out of it and it resolves after a few minutes. But if it's happening frequently, then it's worth getting it investigated. If it's happening multiple times a week, it's very distressing. You should probably get checked out to see what's having you wake up in the middle of the night during REM sleep.

SPEAKER_00 1:02:28

Okay, I was I was hoping you'd have the answer for me being a hypnick and shark.

SPEAKER_01 1:02:34

I've never used that term to label a person before.

SPEAKER_02 1:02:40

It's a phenomenon that happens during sleep, not a name you call somebody.

SPEAKER_00 1:02:47

Um any opinion on mouth tape that has been all like the rave on TikTok and and social media culture? There's a popular um book uh called Breath by James Nestor, that I'm sure um you probably might have heard of, um, where he talks a lot about sleeping and and this mouth tape and the benefit of nose breathing. Do you have an opinion, any opinion on that?

SPEAKER_02 1:03:17

Uh well, the natural form of breathing is through the nose. Um the nose does a lot of functions. It's the uh the the cavities help moisturize the air that go in. Um there's some warming that happens. Um and it's considered to be it also if you're inhaling um viral particles or germs or particulates that it gets filtered out because um, you know, the the surface of the nostrils, there's um you know there are built-in functions to help remove things like that, whereas the mouth doesn't do those things as effectively. So if you can, you should be breathing through your nose. Um, I have concerns about mouth tape just because so many of my patients have allergies and nasal congestion, they have polyps, some of them, deviated nasal septum, and and now you're basically cutting off access to air from anything but the nose, and they find it very hard to breathe like that. And so it can be very uncomfortable and be disruptive to sleep. And um, you know, I normally people breathe through their nose anyway, and if they're breathing through their mouth and opening their mouth to breathe, then you need to address why are they doing that? And it might mean address the allergies and address the congestion and take out the things in the bed that could be making it worse. Um, and then you'll sleep through your nose, but you'll breathe through your nose anyway. You shouldn't need tape. Um, so there are some things that people can try if they are very congested, uh, because it's so common. So we should probably cover that. So, one thing is to just if you have down or feather in the bedroom, you should probably remove it and stick to hypoallergenic bedding and make sure that you're changing out your pillows and mattresses on schedule and uh or covering them in a you know hypoallergenic cover and wash the sheets, wash the linens, the pillowcases and sheets in hot water at least one and one to two weeks so that uh it's the dust mites that a lot of people are allergic to. Um and if you smoke, that's that that will make it very, very hard to breathe through your nose. So um, you know, remove cigarettes from the from the house. That's probably a really good idea. And um, people that have HVAC units, you know, check the air filters and make sure they've been changed on schedule because they can get pretty dusty and sometimes there can be mold that can be a big allergen, uh big trigger for allergies. Um and then if you have really heavy carpets or drapes, if you're having active symptoms, it's probably a good idea to not have heavy carpets or drapes in the bedroom. Um, and vacuuming, a lot of people think that it's a way to keep dust. Out of the bedroom. But it actually turns out a lot of vacuum cleaners, they're not removing the dust, they're just sort of blowing it in the air and dispersing it. So, so, and it stays in the air for up to 72 hours after the vacuuming. So you may end up see that your allergies get worse for a couple of days after you vacuum. So if you really need your good rest, that's probably not the time to stir things up. So, you know, be careful about that.

SPEAKER_00 1:06:28

It's gonna be a popular tip for my viewers. No, maybe no vacuuming for a bit.

SPEAKER_02 1:06:35

And there are medications too for um for that are over-the-counter. Um, one thing people reach for is uh diphenhydramine, which is um it's an antihistamine, it's pretty potent. And we've moved away from and people a lot of people take it as an over-the-counter sleep aid. And we've moved away from recommending that. It's it's not a great way to get sleep. There are just so many side effects with it. It's um the hangover sedation that I see from people using that, it's it's quite a few people. They're just in a comp they feel like a zombie the next day when they use it. Um, and older people, they're at risk for problems with urination and and um not able to urinate because of urinary retention from it. They can have cognitive problems and trouble focusing and getting uh sort of cloudiness in the brain and having trouble thinking. It can impair driving. Um, so yeah, it's probably not a good alternative. And we actually don't recommend recommend people not take diphenhydramine. Um, and that's also the common ingredient in a lot of over-the-counter sleep aids.

SPEAKER_00 1:07:43

And no melatonin, right? There's been recent uh developments with with that. Is that correct?

SPEAKER_02 1:07:49

They found something negative involving melatonin or um a lot of people try melatonin as a sleep aid. It's not designed to be a hypnotic. It's not so it's not actually a great sleeping pill. And it definitely does long-term effectiveness. Um, you know, it's the this the data just are not there to support melatonin use long-term. Um the thing about melatonin is that it is not an FDA-approved drug, it's considered a um a supplement, and you know, your brain already makes melatonin. So if you have a healthy brain, you just need to help your brain bring it out with dim light. And once you have dim light, your brain has healthy amounts of melatonin. So the thing about taking pills that are not FDA approved is that you don't know what's actually in it because nobody is checking. Um, so there could be other fillers in there, other ingredients that actually won't help you or may harm you. And there's no one, it's not, no one's checking how much melatonin is in the tablet or in the um the um the gummy or whatever you're using. Um, so there have been studies that measure um different bottles, and they find that even though the label says one thing, the amount that's in there can be highly variable. It could be much more, it could be much less, it could be nothing. Um, and even within one bottle, it could be very variable content from one to the one tablet to the next. So um, you know, it is not regulated. So, you know, it is not a great way to go long term. Really, the the um the evidence supports cognitive behavior therapy for insomnia. So if you're struggling, uh find a sleep center that has a trained individual that can help you. One of the great things that came out of the pandemic is that we have greatly evolved in our way of doing telemedicine visits. And a lot of these problems can be handled with um having a telemedicine visit. So you lose less time from work, you know, you don't have to, you know, leave your kids alone. You're you're it's just so much more accessible and so much easier so um for many people. So I would say get uh get set up with uh with an evaluation and get help that's been uh proven to work.

SPEAKER_00 1:10:07

And you can go directly to someone like yourself, a sleep doctor or sleep center, or would you go through your PCP?

SPEAKER_02 1:10:13

It really depends on the plan. So some people have insurance that allows them to just go straight to the specialist without a referral, and lots of people need to go through their primary care. Um, the good thing is that a lot of primary care uh doctors or providers are uh aware of sleep and they know how to get you in so they can help you. And for those looking for sleep centers, the American Academy of Sleep Medicine has a listing of accredited sleep centers. So if you go to the website and you um search for accredited um sleep centers and put in your zip code, you can find um you can find something near you.

SPEAKER_00 1:10:52

Okay, and for dire situations, is their medication you use to allow folks to find sleep if it's an emergency?

SPEAKER_02 1:11:02

There are definitely situations where um the use of sedative hypnotics is sanctioned by sleep specialists. I mean, uh one such situation is if you're um suffering jet lag and you know you get there and you're going there on a business trip and you're only there for 24 hours and you have to perform, and then you're gonna turn around and get right back. So there's no time for adaptation, then in those situations, um the the uh your doctor may prescribe something for you to be used, you know, on an as-needed basis. Um and then people who do shift work, some of them may um may need medication support to to handle the the need to stay awake at a time when your body's not wired to stay awake. So there are special conditions where um, and there are sleep disorders like narcolepsy or other conditions that leave people profoundly sleepy, and the only way to get them to function is to give them um prescribed stimulant therapy.

SPEAKER_00 1:12:03

Okay, and I've heard you speak on other platforms advocating for earlier dismissal or start times to school. Um you still stand by that sentiment? And is there any other cultural changes? I I'm thinking of shift work that you just brought up, that it seems so brutal when you start talking about the science of sleep that um it seems like they're um in a real tough position.

SPEAKER_02 1:12:30

Yeah, it's really interesting you brought those two up together. Um the kids and early start times for high school, I will never stop preaching about that. It's so important.

SPEAKER_00 1:12:42

Oh, they're gonna love you.

SPEAKER_02 1:12:44

There are kids that they need their sleep, their brains are still developing, and so many of them have this ADHD diagnosis. We have a mental health crisis in this population. And survey after survey, the Centers for Disease Control has surveyed um teenagers across the country, and we're seeing trends going in the wrong direction. And children are getting less and less and less sleep, they're not meeting the eight to 10 hour recommended amount of sleep by these um by the CDC, the AASM. So why are so few of them getting the sleep they need? Well, it turns out if you ask, you know, the the average Joe why are teens not sleeping, well, that's easy. It's because they're on their, you know, their devices. And it turns out, okay, so there is a role for personal habits, but that's not where the bang for the buck is going to come from. The biggest bang for the buck is gonna come from systemic solutions. We are starting their schools too early and we are setting them up to fail in terms of getting the sleep they need. And the reason is that in this particular age group, there is a biological drive to go to bed later and wake up later, to fall asleep later and wake up later. They are night owls. And you can take a three-year-old and put them down to bed at 8:30 and they will fall asleep. But if you put a teenager to bed, then they're not going to. And neither will most adults. And it's because they are not wired for that bedtime. But in order for them to get the adequate eight to 10 hours that they need to make uh, you know, a 7:30 bell time or a seven o'clock bell time, you're telling them, sorry, you have to fall asleep by nine o'clock. And that's just not going to happen. Even if they manage all their devices, even if they got all their homework done, they're just not going to be able to sleep to accommodate those early, early start times. So it would be no different than you and me having to get up at 4 a.m. and go and sit down and take a calculus test at five o'clock in the morning. It's just we're asking of them what they are not biologically meant to be doing. So the way around this is not just personal habits that's not going to fix this. We need to align their workday with where their biological rhythm, their sleep-wake rhythm is. And the better alignment you get between what your internal rhythm is and what the social clock we call it, which is, you know, your work or your school clock, the better that clock aligns with your internal clock, the better you will perform in every domain that we talked about. So academically, learning, emotionally, socially, behaviorally, physically, athletically, um, all of those domains improve when you delay start times. And the American Academy of Pediatrics says don't go before 8:30 a.m. for secondary schools. And California, kudos to them. They made a statewide law saying that no middle or no high school can start before 8.30. So and we have lots of data from around the country, lots of school districts that have done it. And they are noticing a big improvement in um the amount of sleep their students get. And you know, that and that's the other myth is that people think, well, if you go start school later, they'll just go to bed even later. And it's true, they do go to bed a little bit later, but they do get more sleep because there's just better alignment with when they want to sleep and when you're allowing them to sleep. So you're just give letting them finish out that that last bit of sleep before they get up and go to school. So it's um it's a very efficient way to help a lot of students all at once. It's and it's it's a policy change.

SPEAKER_00 1:16:34

It feels like we carried that habit on into university where we study late. Still a lot of us, well, I did had classes early.

SPEAKER_02 1:16:44

And you know, then you probably not at 7:30. That's right.

SPEAKER_00 1:16:48

That's true. Yeah.

SPEAKER_02 1:16:49

Yeah. So I, you know, yes, it's true. And that night owl rhythm probably continues on into your 20s and maybe even into your early 30s. But eventually it there is a little bit of correction that happens as you head toward middle age. So you're not quite the night owl you were in high school. And there's one other major policy thing, if I can add, that aligns really well with later start times for the high school, and which is this debate around we just went through switching to daylight saving time. So in the fall, we go to uh standard time, you know, where we get that extra hour of sleep. And then in the spring, we move backward and we lose an hour of sleep and we get all this light in the evening. And there's a debate, well, which is better for us. So the natural clock, the natural time is actually standard time, and it's what we have in the winter. And standard time is set so that the highest uh when the sun is highest in the sky, we call that 12 noon. So light is evenly distributed on either side of 12 noon. So that's if any state can just stay on standard time year round without going to daylight saving time in the springtime. And in fact, we do have states that do that: Arizona, Hawaii, and um Puerto Rico. So they don't do this switching switching back and forth. And uh they're quite happy with not switching back and forth because nobody wants to lose an hour of sleep in the spring, especially when we're all already sleep deprived. And so if we can stay on standard time, that would be really helpful for our teenagers, but also for all of us, health in terms of our health. We're more likely to have alignment with our internal clock and our external clocks, the solar clock, as we call it, and our work and school calendars. It's just uh better aligned under standard time than it is under daylight saving.

SPEAKER_00 1:18:43

Yeah, but I've what is the argument for not doing that? Because I think I've heard folks in certain regions of the world that it's like there's numbers of accidents or car accidents or children getting out of school, those sort of numbers in certain specific areas of the world. But I other than that, I have not heard a good argument not to do it.

SPEAKER_02 1:19:05

We actually tried it in 1973. We tried going to daylight saving year-round because people love light in the evening. And uh, you know, when you get out of work, you don't want it to be dark. And so we tried it. It lasted for one season and immediately we changed back. And it turns out, number one, when you take away uh when you add light in the evening, you're taking away light from the morning, right? There's no such thing as sunshine protection. You can't protect sunshine, you can't legislate the number of hours the sun stays in the sky. That's determined by that's determined by your latitude, longitude, and season and the axial tilt of the earth. So those aren't things that we can we can legislate, but what we can do is just say that, you know, we're gonna call this 12 noon instead of this. So we're gonna move back an hour. So what you're doing is just, you know, changing your your your clock to and you're making people wake up earlier in order to get the extra hour of sun at night or of light at night. But what happens when you take away morning light and make it dark in the morning, it turns out depression is actually even worse. Now, people say I get seasonal affect disorder when you take away light in the evening. Well, it turns out that in order to treat depression, what's most effective is morning light. So um, you know, so morning light is really important. And then the kids that are at highest risk are the elementary school kids that are out there. So it's gonna stay really dark for a longer time if you go to daylight saving. Um, what that means is that in some places, some parts of the country may be dark, you know, till after 8:30, 9:30, 10. And you have little elementary school kids outside in the dark. And that's what happened in 1973, is that some children died waiting for the school bus in the morning. Um, and then what we also see with the switch in the spring is that there are more admissions to the hospital for cardiovascular events, for atrial fibrillation, there are more car accidents during that first week when uh when daylight saving happens. So, from a public health perspective, it's not what's helpful for us. And to set our to align and set our internal sleepwake rhythm with what's happening with the sun, our brain and bodies work best under standard time because morning light is the most powerful way to set your sleepwake rhythm. And under daylight saving, you're taking away morning light and you're giving it back in the evening. And evening light, as I said earlier, if you have bright light in the evening when you should be preparing for bed, it just keeps delaying and delaying your bedtime. Um, but then you still have to get up and go to work or school. So daylight saving is the opposite. The light distribution, taking it away from the morning and putting it in the evening ends up making it um harder to align ourselves. And some people never really adapt under daylight saving time. And uh, you know, try telling a bunch of parents with young kids and they're trying to put them to sleep at 8:30 and it's bright light outside until nine o'clock. You know, so um it's tough. And uh, you know, people who work early shifts, so uh, you know, emergency medical workers, it's really tough to get up super early and you know, health workers, nurses whose shift start really early in the morning, knowing it's pitch black till 8:30. Um, so it's really tough to align with that type of a schedule.

SPEAKER_00 1:22:29

Is there any other misconceptions or misinformation about sleep that you see that um are most egregious that you'd like to address?

SPEAKER_02 1:22:41

Um, well, there's I I think there are probably plenty of misconceptions because the the fact that we have a crisis of on um insufficient sleep um among so many people, uh it tells me that we don't have a great understanding. I think people have a general understanding, but I think people think it's something that they can get away with without. And um, you know, I I would encourage you to think about sleep the same way you think about air, the way you think about food, and the way you think about water. It's just another really basic need. And um it's good for you.

SPEAKER_00 1:23:19

Excellent. Well, is there anything else you want to bring up before I let you go? I'm just curious if you have any personal habits that you'd like to share for your own self around sleep. Or I it seems like we covered a lot, but is there anything in particular for you and as someone who's made this their livelihood that you found particularly helpful?

SPEAKER_02 1:23:45

Yeah, the answer is with you. The um there are specific times when medications may be needed. Let your doctor decide. If you're thinking that you may need that your answer may lie in a bottle, um reconsider and consider that it may actually lie with you and with the habits that you choose. And, you know, just believe in the science and believe in the habits and start with one, start with the one you can stick with and keep adding those good habits to to the habit that you started and give it time and um you know, give yourself a little grace, and um it'll pay off. Investing in yourself and in your health is uh is always a great thing.

SPEAKER_00 1:24:28

Wonderful. Well, that's a great way to to wrap up this conversation. Thank you so much for being so gracious with your time and your information. Um, so uh great at disseminating scientific information in a way that I could understand and everyone could could relate to. So I know that's a a real skill set to communicate the science in that way. And so thank you a lot so much for for this. Appreciate it.

SPEAKER_02 1:24:54

Thank you for having me. It was really honor uh it was an honor to be with you. And I wish you and all of your listeners good sleep.

SPEAKER_00 1:25:02

Absolutely. My pleasure. Take care.

SPEAKER_02 1:25:05

Take care, bye-bye.

SPEAKER_00 1:25:06

Thanks for tuning in. If you found my conversation with Indira to be helpful, informative, if it got you thinking, please leave the podcast a review and share it with everyone you know. You can find me on all social media platforms, especially Instagram at Yoga with Jake, and on my website, yoga with jake.com. Until next time, take care.