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

0:00 Michael: The first thing to know about sleep apnea is it is shockingly common.

0:04 One out of three people in the US has some sort of sleep complaint or problem.

0:09 Untreated sleep apnea can lead to liver problems, kidney problems,

0:14 brain problems, because every cell

0:16 that relies on oxygen starts getting stressed.

0:19 Rhonda: So I was wondering if you had any

0:22 tips on some more advanced type of sleep hygiene.

0:25 Michael: The enemy of sleep is effort.

0:27 Sleep is something that happens to you when the situation allows for this.

0:33 Rhonda: Let's talk about a couple supplements.

0:34 The top of mind supplement people think about when they think about sleep,

0:38 they think melatonin.

0:39 Michael: Melatonin.

0:39 Some people, when they take melatonin,

0:41 they might be taking the wrong dose at the wrong time.

0:44 Rhonda: Best evidence-based way to fall asleep and stay asleep.

0:47 Michael: I'll give you two cuz one is cheating,

0:50 which is the— Rhonda: I'm pretty excited to be sitting here with Dr.

0:55 Michael Grandner, who is one of the, I would say,

0:58 foremost experts in sleep science, behavioral medicine,

1:01 and he directs the sleep and health

1:04 research program at the University of Arizona.

1:07 His research focuses on—I couldn't even tell you everything.

1:10 It focuses on all things sleep.

1:12 But, you know, even I think you're probably—some

1:14 some of your research is some of the first

1:17 to really kind of throw out this idea as using sleep as a performance enhancer,

1:21 both athletic performance, cognitive performance.

1:22 So, I'm super excited to get into that today

1:25 as well as a lot of other topics on sleep.

1:28 So, thank you for coming to the show, Michael.

1:31 Michael: Yeah.

1:31 No, thanks for having me.

1:33 Um, I— Rhonda: As we were talking about earlier,

1:35 I kind of wanted to start this episode talking about sleep problems.

1:39 Um, you know, you've got a lot of patients

1:41 that come into your your clinic with sleep problems,

1:45 insomnia being probably one of the most prevalent ones.

1:48 Um, Michael: yes.

1:50 Rhonda: When someone comes into your clinic and says,

1:54 "I have insomnia," what sort of data points or clinical

1:58 features do you kind of look at to dis— to distinguish

2:01 whether or not this person actually has insomnia versus all

2:05 the other things that could just be causing poor sleep?

2:07 Michael: Right.

2:08 That's a great question.

2:09 The way I think about it is that there's really two kinds of insomnia.

2:14 Uh, I call it sort of insomnia with a lowercase I and insomnia with a capital I.

2:18 Think of it, it's kind of like depression, too, where it's a word.

2:21 It's a word that we use to mean a lot of different things,

2:25 but in a clinical context, it means something specific.

2:28 So, a lot of people will say, "I have trouble sleeping,

2:32 um, and I have insomnia," but is this an insomnia disorder?

2:35 Is that how we would call it?

2:38 We'd call it an insomnia disorder.

2:40 And the way to tell the difference is how they're presenting.

2:45 So an insomnia disorder is defined as a persistent

2:51 difficulty initiating or maintaining sleep or waking up too early.

2:54 So it can happen anywhere in the night.

2:57 The difficulty has to be there.

2:59 Um, it has to occur at least three nights per week.

3:03 It has to have gone on for at least 3 months to be considered,

3:08 uh, a chronic insomnia.

3:10 It has to cause some sort of daytime functioning problem.

3:14 Could be almost anything, but it's got to cause problems.

3:17 You have to give yourself adequate opportunity to sleep.

3:20 So just sleep depriving yourself isn't insomnia.

3:22 Um, and when you think about what

3:26 that means in terms of difficulty falling asleep, there's no hard and fast rule,

3:31 but a good rule of thumb we use is about 30 minutes.

3:35 So, if it's taking you at least 30 minutes to fall asleep or you're or you're

3:39 awake for at least 30 minutes during the night trying to sleep and you can't,

3:43 that's a good sign that maybe what you have is an insomnia disorder,

3:48 where a lot of people will have occasional sleep difficulties sometimes.

3:53 But, but that's really the difference where it crosses

3:55 the line to where it's really interfering with your function.

3:58 Rhonda: And how do you just determine, um,

4:02 you know, what is the underlying cause of someone's insomnia?

4:05 I would imagine, you know,

4:07 hyperaroused nervous system being one of them, but there's probably others.

4:11 Michael: Yeah, there's—so there's actually something really

4:13 interesting about chronic insomnia versus acute insomnia.

4:17 So acute insomnia, there are an almost unlimited number of things

4:23 that can cause acute insomnia for a very good reason.

4:26 I mean, evolution figured out a long time ago that when when

4:30 we're under periods of stress and our survival is questioned and it's bedtime,

4:34 we kind of should just keep going until we're safe.

4:38 Rhonda: Right?

4:38 Michael: And we have all these systems in place to protect ourselves.

4:42 So under any kind of period of of hyperarousal or stress or anything,

4:47 whether it's mental, physical, or both, we have systems in place

4:51 that can prolong wakefulness relatively safely, especially in the short term.

4:57 And so there are a million causes of short-term insomnia,

5:03 but there's only really one cause of chronic insomnia.

5:08 And and that's—there's a switch that flips

5:12 from short-term insomnia to chronic insomnia.

5:14 And that switch is all around the concept of a conditioned arousal.

5:20 That's why when someone comes into the insomnia clinic,

5:24 often the thing that caused their acute insomnia is actually no longer relevant.

5:30 It's sort of like a ball is rolling, right?

5:33 And if the ball is rolling down a hill and with the ball was pushed,

5:39 shoved, kicked, leaned on heavily,

5:41 whatever caused the ball to start moving is important

5:44 because you want to prevent that in the future.

5:47 But if you want to stop the ball from rolling,

5:49 knowing what that is and doing anything about that is largely irrelevant.

5:53 The problem you're dealing with now is gravity and momentum.

5:56 And that's what happens with chronic insomnia.

5:59 It takes on a life of its own because of this concept of conditioned arousal.

6:04 Rhonda: Can you can you give an example of that?

6:07 So let's say, you know, someone has work-related stress or something, right?

6:13 And maybe it's a project related or maybe

6:16 there's emotional related related stress from a relationship

6:19 and and it does eventually kind of get better

6:22 and yet they're still kind of having problems fall asleep.

6:25 Now why—what what would be the conditioned stimulus?

6:28 Michael: So this is what happens.

6:30 Something causes you to lose sleep, right?

6:33 And what ends up happening is you exert effort to get that sleep back.

6:39 Now when you lose your keys, what do you do?

6:42 You go looking for it.

6:43 Where do you look for it?

6:45 The last place you had it.

6:46 And if you're losing sleep, where are you looking for it?

6:49 You're looking for it in bed.

6:50 But what's happening is you have this activation going on.

6:55 You have this cortical or cognitive or physiologic

6:59 or any combination of these arousal systems engaged.

7:03 And when those are engaged, it is just physically harder to fall asleep.

7:08 So even if you are tired,

7:09 even if your natural sleep-wake drive is working just fine,

7:12 you have this counterweight sort of keeping

7:15 your mind and body sort of activated.

7:18 So what ends up happening is the act of trying to fall asleep,

7:23 whether it's the beginning of the night,

7:25 middle of the night, or wherever, becomes predictably stressful.

7:29 Rhonda: Hmm.

7:30 Michael: You—the brain's a pattern recognition machine.

7:33 You feed it the pattern of sleep is difficult,

7:37 sleep is stressful, sleep is hard to obtain, sleep is a battle.

7:42 You feed it that over and over and over again.

7:46 Even when you are exhausted and tired and sleepy,

7:50 just getting into that mode will then wake you up.

7:54 When sleep becomes predictably stressful,

7:56 think of something else in your life that's predictably stressful.

7:59 So common, um, a common analogy I like

8:01 to use is like you go to the dentist's office.

8:04 I have a friend who's a dentist who hates that I use this analogy,

8:07 but people know what I'm talking about.

8:09 Whatever that metaphorical dentist's office is for you.

8:12 You go, you're there.

8:14 Nothing has happened yet, you're already in this heightened state of arousal.

8:19 You're responding to it a stimulus that hasn't even

8:22 occurred because you're predicting that it's going to occur.

8:25 You're in the waiting room.

8:27 You're already kind of a little antsy.

8:29 You're delaying making the phone call to make the appointment 3 months

8:33 in the future because you're already responding

8:36 to that future stimulus that's causing you stress.

8:40 Like being being in a place that's predictably stressful, you anticipate it.

8:46 You can predict it.

8:48 And by predicting that stress, it creates arousal and activation.

8:53 The the difference is when you're in the dentist's office,

8:56 no matter how activated or stressed you are,

8:59 as long as you open your mouth, they can do their job, right?

9:02 But in bed, it doesn't work that way.

9:05 If you get into bed and you are dead tired, you are exhausted, you are sleepy,

9:10 you are ready, and you get into bed and all of a sudden your body is like,

9:15 "Oh, here we go again, or is this going to be a problem?" or whatever,

9:19 that automatic process starts happening.

9:21 That predictable process happens, it builds activation.

9:25 That activation makes it just a little bit harder to fall asleep.

9:31 You eventually fall asleep, maybe.

9:33 But the connection between activation

9:35 and sleep is not weakened, but strengthened.

9:37 And so, you're a little stressed, you get into bed,

9:40 have trouble falling asleep, eventually fall asleep.

9:43 Getting into bed is predictably tied with stress.

9:46 And by adding stress to it,

9:48 you strengthen the prediction and it becomes a self-perpetuating cycle.

9:51 So whatever the initial cause of the stress was,

9:55 it's the stress about not sleeping itself that creates

9:58 the very activation that makes it harder to fall asleep,

10:02 which strengthens the connection with stress,

10:04 which makes it harder to fall asleep, and it becomes a cycle.

10:07 That's why the best treatments for insomnia aren't about sedating you,

10:11 they're about reprogramming that whole cycle.

10:14 Rhonda: Wow.

10:15 You've just explained insomnia to me in a way that no one

10:19 ever has and it's like just clicked and I'm like this is— Michael:

10:22 That's what happens.

10:23 Rhonda: What happens, right?

10:24 And so now I completely understand this concept of stimulus control.

10:27 Michael: Right.

10:28 Rhonda: So let's talk about CBT-I, cognitive behavioral therapy for insomnia.

10:32 Michael: Yeah.

10:33 Rhonda: And obviously there's lots of components to it,

10:35 one of them being the stimulus control,

10:37 um, which now is like making so much more sense to me.

10:40 Michael: Yeah.

10:40 Rhonda: But let's talk about what that is,

10:42 why it does work so well for people and, you know,

10:44 and also, you know, back to this whole

10:47 like training this negative negative association,

10:48 this negative stimulus, you know, where you're like just the act of getting

10:51 into bed is is making you hyperaroused, is giving you anxiety.

10:55 Is that also true?

10:56 Then let's say you do eventually fall asleep, then you wake up,

10:59 whatever you have to repeat, whatever it is, it wakes you up,

11:02 you're hot, and then all of a sudden you're still

11:04 in that bed and it's like again that negative association, right?

11:06 And so it's like every time you wake up— Michael: And that's why some people,

11:11 they fall asleep just fine because—so something

11:14 for people to understand is that sleep-wake is

11:18 not a unidimensional line where you're sleepy

11:21 on one end and awake on the other end.

11:24 There's actually two separate dimensions.

11:26 There's—think of it like there's treble and there's bass.

11:31 And they're not—it's not just mono.

11:33 There's treble and there's bass.

11:35 You have a wakefulness signal and you have

11:38 a sleep signal that are separate from each other.

11:41 They're related, but they do function somewhat independently.

11:45 And so sedatives boost that sleepiness signal.

11:49 A lot of times with insomnia,

11:51 what happens because of the excess activation and arousal,

11:54 your sleep signal could be just fine.

11:56 It's your wake signal that might be too high.

11:59 And so when someone is taking say a sedative medication,

12:02 what you're doing is you're just—you're trying to drive up that sleepiness

12:06 signal so high it's just steamrolling over whatever activation you have.

12:09 And often that may work.

12:11 And the reason it can work long term

12:14 sometimes is if you steamroll it over enough,

12:16 you can you can maybe break that learning.

12:18 So it's not—so it isn't just the sedation,

12:21 but for a lot of people it's not sedation that's the problem.

12:25 The problem is in the activation.

12:27 And when you're doing therapy for insomnia,

12:29 it's often not about—so so patient will come in thinking like,

12:32 "How do you make me sleepier?" Actually, I've got—we've got some tools for that.

12:35 And we'll talk about that.

12:37 But often the magic isn't about making you sleepy.

12:40 It's about making you less awake.

12:43 And it's a different process.

12:44 And that's also why it doesn't work 100% of the time.

12:48 Nothing does.

12:49 But that that's why CBT-I is so effective because

12:53 it's actually targeting the problem that the person actually has.

12:58 Rhonda: Okay, let's talk about CBT-I.

13:00 Awesome.

13:01 Michael: So, so here's the deal.

13:03 A a a a few several decades ago now.

13:06 So, so stimulus control was first published in 1972.

13:10 This isn't new stuff.

13:11 Um, and it was this—it was under this idea.

13:15 The idea of stimulus control is if you're in a place

13:19 where only a very limited number of things could possibly occur there,

13:24 you will predict that they will occur and you get yourself in the zone.

13:28 So, we talked about the dentist chair,

13:29 but a great positive example is going to the gym, right?

13:31 Like if you're going to the training room or wherever,

13:33 you don't do anything else there.

13:35 So even if you're kind of tired or if you're in a bad mood or whatever,

13:40 once you start that process,

13:41 you can usually finish the workout at the end and then you go back to your life.

13:47 But when you're there, you can get in the zone.

13:51 And it's because being there creates the conditions that are

13:54 predictably tied with doing what you're going to do.

13:57 And so when you're in a place where there's a limited number of options,

14:02 those options become predictable.

14:04 On the other side of stimulus control is if

14:06 you're in a place where all kinds of options exist,

14:09 none of them become predictable.

14:10 So a great example of this I found is is

14:13 especially over the over the pandemic and as people are working

14:16 from home more is the dining room table started also becoming

14:19 where people work and it wasn't just a place where you eat.

14:22 So it used to be you sit down at the dining

14:25 room table cuz all you do is eat there.

14:27 You'd start getting hungry.

14:27 But if that's also where you work and it's also where

14:30 you watch TV and it's also where you're socializing, you sit down,

14:32 you're thinking about work and you want to put the TV

14:35 on and you may not—may or may not be hungry.

14:38 So like it it it dilutes the ability of the place to have

14:42 a response if you start increasing the number of things that occur there.

14:46 And so the way this is applied to sleep is that if in bed,

14:52 if being in bed is predictably tied to sleep, you can program that association.

14:58 But if being in bed isn't predictably tied to sleep,

15:02 um, you don't know what to predict.

15:04 So so I got to—so here's an example.

15:08 If I say bed, sleep, bed, sleep, bed, sleep, bed, sleep.

15:12 I say bed, you say— Rhonda: Sleep.

15:15 Michael: Correct?

15:16 If I say bed, sleep, bed, wake, bed, think, bed, wake,

15:21 bed, sleep, bed, wake, bed, sleep, bed, think, bed— Rhonda: Surf.

15:25 Michael: Maybe.

15:25 Rhonda: Scroll.

15:26 Michael: You have no idea, right?

15:28 You have no idea what's coming next.

15:31 You can't predict the pattern.

15:33 Human brains love patterns.

15:34 And if you can't control the sleep side of the equation yet,

15:38 at least you can control the bed side of the equation.

15:41 And stimulus control therapy,

15:43 which is one of the core components of CBT-I, was built around that.

15:47 And since that time, CBT-I has emerged as sort of this multicomponent toolbox.

15:52 Stimulus control is one of the core components,

15:56 but there's all these tools that we have that are essentially— it says therapy.

16:02 It's a lot less like psychotherapy.

16:04 It's a lot more like physical therapy where we're we're

16:08 teaching your body to do a thing it physically can do.

16:13 It just doesn't know how anymore or it forgot

16:15 or you need to build it back up again.

16:18 So, you have all—everything is there inside of you.

16:20 I mean, when a patient comes in and says,

16:22 "I'm having trouble sleeping," it's like saying,

16:26 "I'm having trouble breathing." When someone says,

16:29 "I'm having trouble breathing," it's not just because like they suck

16:33 at breathing and it's just a skill they never mastered, right?

16:36 Like, you were breathing when you were born.

16:38 No one had to teach you.

16:39 It's a part of how your body works.

16:41 The trick is why aren't you able to do

16:44 this thing you were built to be able to do?

16:46 What's in the way?

16:47 What's preventing your body from working the way it's supposed to?

16:50 And insomnia treatment is often like that.

16:53 It's like you can probably sleep just fine.

16:56 You were built with this ability.

16:58 There's a chance maybe there's something else,

17:00 but most of the time you have everything in you you need to sleep fine.

17:04 Something is in the way.

17:06 Let's get that out.

17:07 Get out of your own way and and clear that path.

17:11 Rhonda: So, do you— I was going to ask you a question

17:15 about what you think the most important mechanism behind why CBT-I works.

17:18 Michael: It's it's it's through the conditioned arousal.

17:23 It's it's teaching people that that a— they can gain

17:29 more control over their ability to sleep than they thought,

17:33 but also paradoxically,

17:34 it also teaches people how and when to surrender some control.

17:38 So like let's say you have a stomach bug

17:42 and you have no appetite for a day, right?

17:44 You're eating like toast and drinking tea or whatever.

17:46 It just—if you eat anything that would be bad.

17:49 You don't think, "What if I starve to death?" That's not a thought you have.

17:54 You don't think, "Ugh, I have this stomach bug.

17:56 What if I get a niacin deficiency

17:58 and have permanent damage because—" No, you don't.

18:01 What you think is I don't have an appetite for a couple days,

18:05 but in a couple days it'll come back and I'll be fine.

18:08 And when people deal with temporary sleep loss that same way,

18:11 it's a similar system.

18:12 The system can correct itself if you let it.

18:14 But what ends up happening is when we start stressing about it,

18:17 it starts creating these problems.

18:20 And a lot of times it's us—it's us getting in our own way.

18:25 Rhonda: Right?

18:26 Um, it—let's say you had, you know,

18:28 someone that has to work on their stimulus control.

18:31 Michael: Yeah.

18:32 Um.

18:32 Rhonda: You know, there—there's someone that likes to get into bed.

18:35 They have trouble falling asleep, so they pull out their phone.

18:38 They're scrolling.

18:38 They're looking at, you know,

18:40 social media, whatever, and maybe they're ruminating.

18:42 Michael: Yeah.

18:43 Rhonda: Like, what would be your—how would you approach that?

18:47 Like, what would you be—what would be like your two-week fix?

18:50 Michael: Great.

18:51 So first of all, um, in addition to stimulus control,

18:54 in terms of the other tools within CBT-I, a lot of them focus on this idea

18:59 that you want to drive your natural sleep drive.

19:02 Put that sleep drive in bed,

19:05 and when it's not—when bed is not really going to be used for sleep, you get up.

19:09 And so if you're going to be on your phone,

19:11 the first thing I would say is try and separate the phone from the bed.

19:15 Have the bed be the place where sleep is occurring,

19:18 not where sleep is predictably not occurring,

19:20 cuz it's not occurring when you're on your phone.

19:23 See if you can do that.

19:25 Um, if for some reason you have to be in bed when you're on your phone,

19:31 I would say the thing to do is you still want to create that separation.

19:37 The best way to do that is maybe stand next to your bed.

19:42 Because, like I say,

19:43 stand—it's silly and, and very rarely do people actually do it,

19:46 but people sometimes do.

19:47 And I do this because if you're standing, if, if,

19:50 if being in that proximity is important

19:52 for, for your ability to sort of wind down or whatever,

19:56 but at least A, you're not in bed,

19:58 but B, the standing does something very important.

20:00 And especially people in the athletic space will know

20:03 this, that you don't lose touch with your body's communication to you.

20:08 When you're standing, there will eventually come a point where you say,

20:13 "But I really want to sit down now."

20:15 That's your body telling you that you're ready.

20:18 Or you may be standing thinking like,

20:19 "What am I standing here like an idiot for?

20:21 I've been here for a half an hour.

20:23 What am I doing?" That's your other signal that you're not ready.

20:28 Sleep is not something that you do.

20:30 Sleep is something that happens to you when the situation allows for this.

20:35 And that—that's a concept I, I borrowed from a colleague of mine,

20:38 Lindsay Shaw, who's also a fantastic sleep person and sports psychophysiologist.

20:41 I learned this from her.

20:43 I use it all the time.

20:45 It, it captures it really well.

20:47 Sometimes sleep is un—is not under your—your

20:50 ability to sleep isn't under your control.

20:51 You're awake, like you need to wind down.

20:53 Maybe you're just not ready.

20:54 And if you're just not ready, laying there in bed scrolling isn’t going to help.

20:58 Go do that somewhere else.

21:00 If you are getting ready, respond to those body signals.

21:03 If you can't stand next to your bed,

21:06 if that's a little too silly for you, sit and sit up on your bed.

21:10 Don't—not like just a little propped up.

21:12 Your head's not on a pillow.

21:13 You're not under a blanket.

21:14 Sit up.

21:15 Again, you're not going to lose touch of your body's signals.

21:19 And, and worst case scenario, at least you get the head bob.

21:23 The head-bob is, is, is your friend.

21:26 The head-bob means it's your body telling you you're ready.

21:29 This is also like if you're watching TV or on the couch or whatever

21:33 and you're within that zone where you might be wanting to go to bed,

21:36 lean forward when you're watching TV or your movie

21:38 or whatever or scrolling because you'll get the head bob.

21:41 You won't get it when you're leaning back.

21:43 You get it leaning forward.

21:45 That's your signal that you're ready.

21:48 Rhonda: And what happens if, you know,

21:50 someone wakes up in the middle of the night and then they're ruminating?

21:54 Michael: Yeah.

21:54 Rhonda: Can't fall asleep.

21:55 Michael: So again, sleep is not something you do.

21:58 It's something that happens when the situation allows for it.

22:01 And if the situation is not allowing for sleep in that moment, get up.

22:05 If you're sitting there and you're eating and you have no appetite,

22:08 you don't just sit there and stare at your food

22:12 till you become hungry and it becomes more appetizing.

22:15 It actually backfires.

22:16 So often when people wake up in the middle of the night,

22:21 it's because—it's because something naturally

22:23 occurred to produce that awakening.

22:26 Whether, um, most commonly would probably be

22:29 some sort of physical discomfort like pain,

22:30 or maybe you sunk into your mattress a little

22:32 bit and, and, and it's just a little discomforting.

22:35 You need to wake up and move.

22:37 Sometimes it's untreated sleep apnea.

22:38 Super common.

22:38 You have a respiratory event that you don't know you had.

22:41 If you ever wake up suddenly for no reason

22:43 and you don't know why and can't get back to sleep,

22:45 you know, we'll talk a little bit later about sleep apnea,

22:49 but, but that can cause these awakenings.

22:51 And when you have something that causes

22:54 this awakening that arose from inside you, wasn't under your control.

22:58 And what ends up happening is that that physical activation escalates.

23:03 And just like a snow globe, you know, you shake up the snow globe,

23:07 it takes a little bit of time for it to come back down.

23:11 And when your snow globe got shaken up while you were asleep and you're awake,

23:14 you can't make it fall back down faster.

23:16 There's nothing you can do.

23:17 You can poke at it, make it go slower, but you can't make it go faster.

23:22 You just have to wait till everything settles back down.

23:24 And it often doesn't take as long as people think.

23:27 But what ends up happening is as your snow globe is settling,

23:31 then your stress starts rising again.

23:33 Slowly rising because like, why can't I sleep?

23:36 What if I can't fall asleep?

23:37 What if I'm up the rest of the night?

23:38 Blah, blah, blah, blah, blah, blah.

23:39 And then you start stressing and freaking out about it.

23:42 So now your body is ready, but your mind isn't anymore.

23:44 And now you got to wait for that to come down, and you just prolonged it.

23:48 The—because you don't have control over this part.

23:53 Surrender that control.

23:55 Recognize that you're going to get up.

23:57 You can get up.

23:59 Take a break.

24:00 Wait till you're ready.

24:01 Try again.

24:02 Just don't prolong it any more than is necessary.

24:05 So sometimes surrendering control actually shortens the awakenings.

24:08 Sometimes it doesn't.

24:08 Sometimes, you know what?

24:09 What if you're up for the entire rest

24:12 of the night and you just don't go back to sleep?

24:15 That's often people's fear.

24:16 But the truth is, A, that's unlikely.

24:18 And B, even if it does happen, you'll be fine the next day.

24:23 And guess what happens if you're halfway through your dinner and you

24:26 just lose your appetite and you just don't eat the rest of it?

24:29 What happens the next day?

24:31 You don't die.

24:31 You just are a little more hungry and you'll eat

24:34 a little more the next day and the system will correct itself.

24:37 Overcorrecting is the problem.

24:39 Rhonda: So to, to kind of, just for my understanding,

24:43 for the stimulus control— Michael: Yeah.

24:45 Rhonda: Like the most important part of it,

24:48 like for these, for these individuals that do

24:51 have this like fear of like not sleeping, right?

24:54 Or like it starts to, you know, they,

24:57 they just immediately get like anxiety about it.

24:59 The best thing is to surrender,

25:01 or is that like the, the strongest part of the stimulus control?

25:05 Michael: Yeah, it's the performance anxiety.

25:07 The fear is what's creating the activation that's getting in your own way.

25:13 So, so recognizing that it's not under your control.

25:18 Trying to control it is not going to help.

25:22 Nobody got to sleep faster by trying harder.

25:26 The enemy of sleep is effort.

25:29 If you're engaging in effort, you're adding energy into the system.

25:33 And athletes especially are vulnerable to this because, you know,

25:37 athletes are used to gaining control over

25:40 their body and learning how to control their body

25:43 in ways that most people just don't know

25:45 how to because they haven't been trained to.

25:47 So there's always a solvable problem there.

25:50 Sometimes it's like, like injury recovery.

25:52 Sometimes you can't make it go faster.

25:55 Like if you injure yourself, you got to do what you got to do to recover.

26:00 You can't—there's no like dance you can do or, or book

26:04 you can read that will make that recovery go faster.

26:07 You got to give it the time it needs.

26:10 Similarly, this is a process that's outside of your control.

26:13 Trying to control it will actually make it go slower.

26:17 Rhonda: Okay.

26:18 And so the, the next part of, you know, CBT-I that, you know,

26:22 yeah, we hear about is the sleep restriction, which sounds awful.

26:26 Michael: Worst name.

26:27 I mean, so, so if you actually look to the original publication,

26:30 they didn't, they didn't even call it sleep restriction therapy.

26:33 They called it restriction of time in bed, which is really what it is.

26:37 It's, it's a simple concept of, um, again,

26:40 a lot of these things are simple in concept, but difficult in execution.

26:44 But the concept of sleep restriction therapy,

26:46 which I hate calling it that because it doesn't—it's,

26:49 it's not about the restriction.

26:51 And that's the thing.

26:52 Sleep restriction could be part of it, but it isn't always.

26:55 The idea is, let's say you're spending 8 hours in bed but 6 hours asleep.

27:00 We know you physically can sleep 6 hours.

27:03 Okay, let me give you 6 hours time in bed.

27:05 See if you can fill it.

27:06 Let's get you to the point where you can

27:08 fill it and then we'll slowly increase it from there.

27:10 Actually, sleep restriction therapy has

27:12 more increasing of sleep than decreasing.

27:14 But there's that—there's that decrease at first.

27:16 The way I explain it to people is this.

27:18 It's actually not super complicated.

27:20 Let's say you're trying to eat your vegetables and you've

27:22 got a kid who's not eating their broccoli, right?

27:24 And you put 20 pieces of broccoli on their plate and they're not eating.

27:27 They can eat one or two and then they're like,

27:28 "Oh, I hate broccoli." Blah, blah, blah.

27:30 So then you say, "Okay, I need you to learn how to eat your broccoli.

27:34 Tonight, I'm going to give you two pieces of broccoli.

27:37 Can you eat?

27:38 I know you can eat that cuz that's what you've been eating every day.

27:40 I know you can eat that." So, you eat the two pieces of broccoli.

27:43 And then they say, "But I'm still hungry." And then you say, "Great.

27:47 You will get three tomorrow.

27:48 Let's see if you can eat those." Then they can eat the three pieces.

27:52 "But I'm still hungry." It's like, okay, hold off on—don't eat anything else,

27:56 but the next day you'll be hungry enough to eat four.

27:59 And then you slowly in—you, you start with what they can already do,

28:03 but you don't give the other stuff that, that will—so you,

28:06 you don't let them stay in bed when they're not sleeping.

28:10 At least give them the opportunity they're already able to fill.

28:14 At first, all the mental blocks and stuff will be there.

28:16 So, it might drive down their sleep a little

28:18 bit in the short term for, for several days, maybe even up to a couple of weeks,

28:22 but they eventually—eventually they get hungry enough where they can eat all

28:25 the broccoli on their plate cuz you're not giving them anything else.

28:27 Then all of a sudden,

28:28 you start introducing other foods back that they actually like,

28:31 but they've gotten over their broccoli deal.

28:33 And that's what it is with sleep.

28:35 You drive up their natural sleep pressure.

28:37 You separate out, um, the time in bed that's not wake.

28:40 You make it so that being in bed,

28:42 you're—so you go from not being able to fall asleep to not being able

28:45 to stay awake because you drive up that natural sleep pressure and it's like,

28:49 well, you have problems with your appetite?

28:51 Fast for a little bit.

28:53 That'll help a lot of problems with your appetite.

28:56 You're going to be hungry again.

28:57 Rhonda: And so this idea of not having your phone in bed, it's part of that.

29:01 Michael: Yeah, it's part of that because you don't

29:04 want to do anything in bed that is not sleep.

29:07 You want—you want—you want to make it so that when you get into bed,

29:11 you put your head on the pillow, you're under a blanket,

29:15 your eyes are closed, you're breathing through your nose.

29:19 Um, that, that, that feeling is so

29:22 predictably tied with becoming unconscious in a very

29:26 short amount of time that even when you get good at that—so this is,

29:30 this is the power of this.

29:32 When you get good at that, you're using

29:34 the prediction not just to solve a problem, but to create a benefit.

29:38 Imagine you're a little bit stressed.

29:40 You got a big day tomorrow.

29:42 But you've so trained yourself that that place

29:45 is so predictably tied with sleep that you're stressed.

29:48 You've got a big day.

29:49 You've got stuff you're working on.

29:51 You get into bed, close your eyes,

29:53 head on pillow, under blankets, start breathing.

29:55 Then all of a sudden, you fall asleep.

29:58 You've—you can, you can train yourself to get

30:00 the outcome you want and that gives you control.

30:03 So let's say you got to wake up super early one day because you're,

30:06 you're, you're going somewhere, you got to practice or something.

30:09 You need to go to bed an hour or so earlier than you really are used to.

30:14 If you've got yourself well trained,

30:16 you can use the environment as a conditioned

30:19 stimulus for sleep when you want it to be.

30:22 Rhonda: So when—so how long does it take to, to for most

30:25 people to train themselves like through the stimulus control, sleep restriction,

30:29 where you know the bed is really just for—I'—I've heard sleep and sex,

30:32 but like the— Michael: Yeah, so sex is fine.

30:34 That's usually not the problem.

30:35 Right.

30:35 You know, do that in bed, out of bed, wherever you want, that's fine.

30:38 Usually that's not taking up so much time.

30:41 I mean, right.

30:41 And if it's—and it's not interfering with your ability to sleep,

30:45 sometimes it can help your ability to sleep, but that's fine.

30:48 But, um— Rhonda: It's probably the phones that are the biggest problem nowadays.

30:52 Michael: Right.

30:53 It's, it's distractions.

30:54 So distraction, the activation, all of this stuff,

30:57 it's—you're adding energy in instead of taking energy out.

31:00 Relaxation is fine to do in bed,

31:03 but if it's brief, you know, if you're spending,

31:05 you know, a half an hour meditating in bed, that might be a little too long.

31:09 If you're—I, I've known people who, like, they,

31:11 they have this whole hour long routine that they do,

31:13 like by the time that hour is done,

31:15 the bed is no longer predictably tied to sleep anymore.

31:18 So yeah, it's about—it's about getting this stuff out.

31:20 It doesn't—I'm not saying don't be on your phone, but I, I mean, I,

31:25 I actually think this, the sleep field telling

31:27 everyone get off their phone for an hour before going to bed is not a helpful

31:31 recommendation because no one's going to follow it.

31:33 We should be talking about how to do it safely

31:36 in a way that's not going to get in your way.

31:38 Rhonda: And that comes down to what you were saying earlier,

31:41 either being in another room or sitting up or standing.

31:44 Michael: Yeah.

31:45 And, and also it's what you're doing that's important.

31:48 You might want to create sort of boundaries.

31:50 So like maybe within a half an hour of when you're planning on going to bed,

31:54 maybe switch to something that's not too mentally activating.

31:58 Like if, if you're the kind of person where you watch

32:01 the news and it gets you all worked up and angry,

32:05 don't do that before going to bed.

32:07 Maybe do it the hour, you know, in the, in the earlier part of the evening.

32:10 Um, I mean, the great thing now is TV isn't live anymore.

32:13 Back when I was a kid, you had to watch it when it was on and that was it.

32:18 Now we can watch—we can,

32:19 we can gain more control over what we're exposing ourselves to media-wise.

32:23 The rule of thumb I use, and this is what I use for myself:

32:27 if an alarm went off right now and said, "Okay, time to turn it off," could I?

32:35 If the answer is yes, then it's probably okay to do within that time

32:39 frame because I can easily disconnect from it.

32:42 If the answer is no, no, no, five more minutes,

32:44 I want to see how it ends or I want to, you know,

32:48 whatever, that's probably not the thing to watch in that buffer time.

32:51 Watch it before the buffer time, but don't do that in the buffer time.

32:55 Like, if you're scrolling and you can easily put it down,

32:59 I don't know that—I don't know that that's that big of a deal.

33:02 But if you're scrolling and like half an hour will go by and you wouldn't

33:06 even notice and you lose that time and then you say you don't have time,

33:10 but you just threw away some time, you know, that you didn't need.

33:13 So like those are the sort of things you want to—you want to make

33:16 sure that you curate what you're doing so that it's not too activated.

33:19 Rhonda: Why, why are a lot of people that h—that have insomnia,

33:23 why are they prescribed, you know, these sedatives like, you know,

33:27 Ambien or— Michael: Well, they don't not work.

33:29 I mean, like, like I was saying, like what they do is they drive up that sleep

33:34 drive so much it overpowers whatever is in the way.

33:36 And it's kind of an easy solution.

33:38 The thing is, honestly, it's much easier to write a prescription.

33:42 Like you can go to any primary care anywhere and they can write a prescription.

33:48 But if you, if you look at every medical organization

33:53 that has any recommendation around in how to treat insomnia,

33:57 and for athletes, you know, this includes like NCAA and IOC who,

34:03 who've put out sleep related materials, um,

34:07 they all say CBT-I first and that's because every study that has ever

34:14 been done shows that when you compare—when you pool the data from CBT-I trials,

34:23 it works shockingly well.

34:25 Not only does it work reliably well, it works when you have other—like,

34:28 well, what about if you're in chronic pain?

34:30 Like if the pain is keeping you up.

34:32 How is that—you don't have conditioned arousal,

34:34 you have an active thing going on?

34:37 Still works in—works in fibromyalgia, works in chronic pain, works in cancer.

34:41 It actually might be better in cancer survivors than people who

34:43 aren't cancer survivors cuz they don't want to take these medications.

34:46 They're more motivated.

34:47 It works in sleep apnea.

34:49 It works before your sleep apnea is even treated.

34:52 It helps with your insomnia.

34:54 Um, find me a condition.

34:56 Works in older people.

34:57 Works in younger people.

34:58 Works in—so, like, it it's a blunt instrument.

35:01 It's retraining yourself to sleep.

35:04 It doesn't—it—and it works well by helping people gain control.

35:08 It doesn't necessarily add hours to your night,

35:11 but neither do sleeping pills either.

35:12 What it does is it removes some of those barriers about,

35:17 again, about 85% of the time, not 100%.

35:19 But it's also some people don't know how to get access to it,

35:24 or they read about it online and either

35:27 the the information they get isn't isn't great,

35:30 or they have exposure to it in that, you know, maybe, you know,

35:33 maybe they're doing it by the book,

35:35 but they might need a little flexibility with it or something.

35:37 But I mean, there's lots of adaptations.

35:39 I mean, we edited a textbook on how to adapt CBT-I to different populations.

35:42 But, you know, a lot of people just don't know it exists,

35:46 and the people who do don't really understand what it

35:48 is or how to find someone who knows what they're doing.

35:51 Rhonda: Is that the key?

35:52 Do you really have to find someone that knows what they're doing,

35:54 or can you try this yourself?

35:56 Michael: Yes and yes.

35:57 I mean, there are many people that I've talked to who've,

36:01 um, tried it, done it with themselves.

36:04 I mean, because it's not rocket science.

36:07 Um, the—there's an art to it, but the the basics of it are relatively simple.

36:12 It's bed equals sleep.

36:13 Get out of bed if you're not sleeping.

36:15 You know, compress your window

36:17 of of opport—you're giving yourself too much opportunity.

36:20 You're not filling it.

36:21 Compress your opportunity, but then expand it again once you can fill it.

36:25 Um, some basic stuff like that.

36:27 Uh, and some people could just do that on their own, and that's all it takes.

36:32 Some people, they need somebody who knows what they're doing.

36:35 The problem is there's not a whole ton of people who are trained in this.

36:39 Despite it's being around for a long time,

36:41 despite the fact that it's really well supported,

36:43 there's not a ton of people who are well trained.

36:47 There are some online versions available where

36:49 they can automate some some aspect of this.

36:51 It's a very—it'll be very by the book,

36:53 but for a lot of people, that's all it takes.

36:55 Um, you can do this over telehealth.

36:57 Any state that you're in, I can promise you there's

37:01 someone who can do this via telehealth in your state.

37:04 So, it used to be very geographically restricted.

37:07 It's not anymore.

37:08 Um, there's a couple of good

37:10 directories online of—if you're looking for somebody,

37:13 um, we have a board certification.

37:15 You could see who's board certified in this, and we—it

37:17 exists because it's not part of normal training.

37:19 So, to be able to say that you're good at it,

37:22 you have to, like, prove that you know what you're doing.

37:25 But, um, yeah, you can look online for people,

37:27 and again, there's there's telehealth options too.

37:29 So whatever state you're in, um, you can find somebody.

37:33 What— Rhonda: what percentage of, like, the US population has insomnia?

37:38 Michael: It's a great question.

37:40 Um, for decades, any population level study

37:44 has generally found kind of the same thing,

37:46 mostly, and it hasn't—doesn't seem to have mostly changed much,

37:49 that about one out of three people in the US

37:53 has some sort of sleep complaint or problem or something,

37:56 whether it's falling asleep, staying asleep, not feeling refreshed.

38:00 That seems to be about a third of the population at least,

38:04 and it seems like about 1 in 10 people probably would meet

38:08 the criteria for an ins—insomnia disorder if you if you if you assessed them.

38:13 Um, and then what ends up happening is they start trying to fix it on their own,

38:17 and they start going down paths that end up being unhelpful,

38:21 and then they get more frustrated,

38:23 and then sleep becomes more stressful, and they give up, and they say, like,

38:26 "I'm a I'm a hopeless case." I get one of these a week in clinic.

38:29 So, "I'm the worst sleeper you've ever seen.

38:32 I've tried everything.

38:32 I've had this problem forever." Then six to eight sessions, they're better.

38:36 Rhonda: Yeah.

38:37 I—one in 10 is a lot.

38:38 And you know, I definitely think we're

38:40 going to talk about some of these substances

38:42 people then turn to because they think

38:44 it's going to help treat their sleep problem,

38:46 which they don't necessarily know is even insomnia, right?

38:48 And so they're, you know,

38:50 turning to things like alcohol and um, and that doesn't really help.

38:54 So, um— Michael: Right.

38:55 Rhonda: But let's, before we get to that, um, sleep apnea you mentioned,

38:59 and that's another one that I wanted to talk about.

39:03 I've known a lot of people, it seems, that have had sleep apnea.

39:06 I wonder how—you can tell me how common that is as well.

39:09 But um, first I kind of wanted to ask you,

39:11 like, what are some of the nonobvious presentations?

39:14 Michael: Yeah.

39:14 Rhonda: That, you know, of sleep apnea that you see,

39:17 especially in people who, like, maybe don't even report feeling sleepy.

39:20 Michael: Right.

39:20 So, so the thing with sleep apnea is the first

39:23 thing to know about sleep apnea is it is shockingly common.

39:27 It is very, very, very common.

39:30 Um, the most recent data I've seen estimates that about one out of four

39:37 or five men over 30 probably has at least some sleep related breathing issues,

39:43 especially if if their BMI is over 30.

39:47 It's more like 50/50.

39:50 Um, it's really high.

39:52 Women get it less often, but it's also shockingly common in women, too.

39:55 It might be more like one out of every 15 or 20 women.

39:59 Um, and then as as BMI goes up, it gets more common.

40:04 Um, so it's it's shockingly common.

40:06 It's so common that my threshold for screening for it is very low,

40:11 especially among otherwise fit people because the normal risk factors.

40:15 So, like, as you gain weight,

40:17 it it it—you get it more because it can crowd out your airway.

40:22 Rhonda: Muscle too.

40:22 Michael: Yeah, muscle too.

40:24 It's because think of it this way.

40:26 So most mammals, their airway is a straight line, you know,

40:30 from snout all the way up and and to to to their lungs.

40:35 It's a straight line from the snout to their lungs.

40:38 Humans, by by moving upright, we solved a lot of problems,

40:42 and and we've gotten a lot of benefit from being upright,

40:46 but we—it created it created a problem with us

40:49 in that our tube now has a 90 degree angle in it.

40:54 And if you're designing a pipe and you put a 90° angle kink in your hose,

41:01 where is it—where is it going to start having problems?

41:04 It's going to have problems at that.

41:06 And that's what happens.

41:07 So, like, right around that spot here,

41:10 that's where we get narrowing of the airway.

41:13 And so, like, any mass, whether it's muscle or fat or whatever, any mass—I mean,

41:18 there are people who look at MRIs of, like, tongue fat, like like cheeks,

41:23 like anything here that—whether even skinnier people with smaller airways,

41:28 you know, where it's a little more compressed,

41:31 it just—it's it's a it's a vulnerability

41:34 in in the human physiology for breathing issues.

41:40 And it—there—it's actually mostly fine in that you can have four or five

41:47 breathing pauses per hour in the night and be in the normal range.

41:52 It's actually—sleep apnea doesn't begin at—five

41:55 is mild—begin—is the low end of mild, and it's not even till you get to 15

42:00 per hour that it becomes start becoming moderate.

42:02 So many people who are in the mild range don't

42:04 even have any symptoms and might not be causing any problems.

42:07 We have a lot of flexibility in the system,

42:11 but as you get older and neuromuscular control changes,

42:15 as we put on more pressure here in the airway by gaining weight or whatever,

42:20 it just becomes more and more common.

42:22 And my guess is it's actually been common through history.

42:26 It's just we've written it off as something else,

42:29 especially in people that don't have those obvious signs.

42:32 So, what are some of those less than obvious signs?

42:36 If I have a patient who comes in, I—and they say, "I fall asleep just fine.

42:41 Actually, if I'm anything, I'm a little tired during the day, whatever.

42:44 I fall asleep just fine,

42:45 but then I wake up in the middle of the night because of stress.

42:49 My stress wakes me up,

42:51 and then I have a hard time falling back asleep." When I hear that, I

42:56 think there's greater than 50/50 chance

42:58 in my mind that that was a respiratory event.

43:02 Stress doesn't wake you up.

43:04 What happens is if you wake up Rhonda: Mm-hmm.

43:07 Michael: and you're thinking,

43:08 "I'm stressed," your brain is reading signals like elevated heart rate,

43:12 elevated respiratory rate, um,

43:14 endor—the the the endorphins of the muscles getting tense.

43:18 It's reading these physical signs,

43:20 and then because we live in the society we live in, stress is readily available.

43:25 We can fill that space really fast.

43:28 But what what was happening was it wasn't the stress that woke you up.

43:32 It was that, you know,

43:34 your breathing was starting to get a little bit constrained.

43:37 So then what happens is your airway tries to open itself up,

43:41 and it was trying, and it wasn't it wasn't successful.

43:45 So it tried harder, still wasn't successful.

43:47 Tries a little harder, still not successful.

43:50 Worst case, you wake yourself up, and you and you can you can wake up

43:55 with a gasp because you can breathe when you're awake just fine.

43:57 It's a different neuromuscular control system.

43:58 So, as soon as you wake up,

44:01 you sort of get that that sudden awakening because you just got

44:04 that little sort of a shot of adrenaline to wake you up.

44:07 And, like, if I just shot you up

44:08 with a little bit of adrenaline during the night,

44:10 you'd wake up, and you would not be able to fall back asleep.

44:13 Your mind would start racing, and you'd have all these physical signs,

44:16 but it wasn't the stress that woke you up.

44:19 The stress got superimposed on it later.

44:21 So, when I have a patient who comes in and describes that sensation of, "I

44:24 wake up in the middle of the night either because of stress or for no reason.

44:27 I don't know why something wakes me up.

44:29 I have no idea.

44:30 But I cannot get right back to sleep immediately,

44:33 like within a few minutes." I mean, something just happened.

44:37 Some flare up just happened somewhere.

44:40 Um, that's that's what I look at in athletes.

44:43 Often what I'll look at is, "I feel like my sleep is really shallow,

44:47 and I don't know why." Because what's happening is

44:50 you might be having lots of these low-level respiratory.

44:52 That's the thing when you get the more severe sleep apnea of, like,

44:56 30 events per hour or more with with these other presentations,

45:00 but you get a lot of the mild to moderate cases in people who, you know,

45:05 don't have a lot of extra weight,

45:07 aren't older and have neuromuscular control issues, which just happens with age.

45:11 They're younger, they're healthier, but they just might have a narrow airway.

45:16 And and so, like, I'll never forget, like,

45:19 there was this—there was a, um, an Olympic level athlete I was working with.

45:24 She was she was in the trials, and she's like,

45:26 "Just not meeting the times I think I

45:28 should be." She was still faster than everybody else,

45:31 but she's like, "My inst—intuition is telling me something is

45:34 in my way from reaching what I could be doing.

45:37 I don't know what it is." And, like, "How are you sleeping?" It's like,

45:40 "I feel like my sleep is kind of shallow.

45:42 I fall asleep just fine, but I feel like I'm up a few times during the night,

45:46 and I don't really know if that's a problem or not." So, I'm like, "Well,

45:50 let's see what's going on." Turns out she had she had mild sleep apnea,

45:55 got that treated better,

45:57 and she's like, "Oh, that was it." And and in the real world,

46:00 it would have been missed.

46:01 It would have been someone just slogging through their day.

46:04 They would have just been like, "Ugh, you know, life is hard.

46:07 I'm tired.

46:07 Not sleeping as good." And then probably in 30 years she would have

46:11 gotten diagnosed by the time it was more obvious if she weren't an athlete.

46:14 Rhonda: So what should a person do?

46:15 Like, how many—is this an every night thing where people are getting woken up,

46:20 like, if they're having apnea?

46:21 Is this like an every night thing?

46:23 Um, like, what sort of sort of symptom clusters,

46:26 biomarkers can people look at, um, short of, like,

46:29 going and getting the thing on your finger

46:32 and measuring the oxygen and, you know, the whole— Michael: Yeah.

46:35 I mean, so so here's the thing.

46:37 It's normal for people to wake up in the middle of the night sometimes.

46:40 Actually, the typical adult will wake up 10

46:42 times a night or more during the night.

46:44 They just don't remember.

46:45 It's very short.

46:46 I mean, again, evolution figured this out a long time ago.

46:49 You wake up, no bear, back to sleep.

46:51 Like, that's normal.

46:52 But if you're remembering more of those awakenings,

46:55 if you're remembering three, four awakenings, if you have an awakening,

46:59 especially waking up, like, with a gasp,

47:03 like if you wake up like that, or you wake up with a snort,

47:07 like if you wake up with something like that, um,

47:09 if you if—or if you feel like you just can't get enough sleep,

47:14 like you try and sleep a little bit more, but it doesn't help.

47:19 It's like it's just it's just empty calories, you know?

47:21 Like, it's not about the amount anymore.

47:23 There's, like, something that's keeping it artificially shallow.

47:26 There's lots of things it could be.

47:28 It's just sleep apnea is so common.

47:30 Why not take tests?

47:31 Why don't you just get tested?

47:32 Just go get a referral, get tested.

47:35 You can do them at home now.

47:37 It's easy enough.

47:38 Um, in turn, it's it's—there's no real good biomarker for it yet.

47:42 I know people are working on it.

47:44 There's no real good biomarker except that that sleep is shallow.

47:49 It's fragmented, and you don't know why.

47:52 I mean, it could be something else.

47:54 Could be inflammation.

47:54 It could be pain.

47:55 It could be environmental.

47:56 There's lots of things.

47:57 It's like, if if you're not breathing, is there a problem with your lungs?

48:01 Is there a problem with your airways?

48:02 Is there a problem with the pollution in the air?

48:04 So, like, is it—is there something that's

48:06 preventing your body from being able to sleep?

48:09 Or— and and and if it is sleep apnea, it's so common.

48:13 This is why my threshold for screening is just ultra low because,

48:17 um, if it was that, and I do all the tips with you,

48:21 and I work out this, and I do all this, and you're still feeling like, "Ugh,

48:26 but my sleep just isn't good," and I knew

48:28 on day one that this was a possible reason why,

48:31 then I'd feel like an idiot for not

48:34 even checking because I—we did all this work, and maybe we didn't even need to.

48:38 Rhonda: Do those, um, at home kind of—if I remember doing one once,

48:42 like, years ago when I was in graduate school,

48:43 and I was—I think I was waking up because of stress, but, um,

48:46 the test came out negative, but I wore this, like, ox pulse thing, I think.

48:50 I don't know what it was, on my finger.

48:51 Michael: Yeah, so so there's there's a bunch of devices.

48:53 They've gotten better and smaller over the years.

48:55 Um, there's still people who do need to come into the lab.

48:59 Those are usually reserved for when there's, like,

49:02 another sleep disorder you're also looking for, like

49:04 narcolepsy or or or limb movements or thing, or if you're medically complicated,

49:09 like you need supplemental oxygen or if

49:11 you might have heart failure or something where you need to kind of be monitored

49:14 in the hospital while you're doing it for safety.

49:16 Other than that, or or or the test you did at home was negative,

49:20 but you still have a lot of symptoms,

49:22 and maybe it missed it because the the home tests aren't as sensitive.

49:25 Like, you you won't get false positives, but you might get false negatives.

49:29 That's the only time you'd really need to come into the lab most of the time.

49:33 Usually they just give you the thing to take home,

49:35 and these days you can wear it as a strap.

49:37 They have ones that just go on your wrist,

49:39 and they measure they measure, um, your oxygen levels during the night.

49:44 And what you can see is how's your respiration tied with your O2,

49:48 because respiration drops during the night too, and so does O2 a little bit.

49:52 But if if your respiration is dropping, and then your O2 starts dipping,

49:57 and then it then it opens back up again and gets recovered, like,

50:00 you look at these patterns of what's happening during the night,

50:03 and you can see in one night if someone clearly has sleep apnea or not.

50:08 Rhonda: Okay.

50:09 Michael: It's easy enough.

50:10 Rhonda: If if you're working with someone who has obstructive sleep apnea,

50:13 like, how do you go about differentiating if it's,

50:17 like, caused by allergies or positional or, you know,

50:20 something something like nasal congestion?

50:22 I don't know.

50:23 Michael: Like, yeah.

50:23 Yeah.

50:24 Especially when it's more on the mild to moderate side, right?

50:27 Where, um, so the great thing is the the the ones that are on the strap,

50:32 they usually have a gyroscope in it,

50:34 and they can measure your breathing separately on your side and on your back.

50:37 There's a lot of people where it's just that it's on their back.

50:40 That's the issue.

50:41 And, um, for those people, there's actually really simple fixes.

50:46 You can se—they sell these devices where it's really just a strap you wear.

50:50 In the old days, they used to sew a tennis ball in the back of a t-shirt,

50:54 and that's all it did.

50:55 So, like, whenever you rolled on it, you just roll off it.

50:57 And they have, like,

50:58 fancy versions of that now where that's essentially what it is,

51:01 where it's—there's one—there's a couple of them where it's a strap.

51:04 It's like a belt, but, like, the back of the belt has a little bump on it.

51:07 And so, like, whenever you roll on it, you just roll off it.

51:10 It just stays off your back.

51:11 That's it.

51:12 Um, you can't force yourself to stay off your back when you're asleep.

51:14 You're like, "Well, I'm just going to fall asleep on my side." Well,

51:16 you can't control it when you're unconscious.

51:19 So, like, you can see if it's positional easily in the diagnosis.

51:22 And if it is, then just try and treat it positionally.

51:25 And then what I would do is retest using

51:27 the positional device and see if it all goes away.

51:30 Because it might, might not.

51:31 Um, if it's allergies, um, th—this is why the the the sleep docs, you know,

51:36 we get a lot—they get a lot of training,

51:39 and and and I've gotten some of this too when I rotated in sleep medicine.

51:42 Like, you see what to look for.

51:44 So, like, you look at nostrils, you look at their nose,

51:46 you have them breathe in, You look inside the airway in the mouth

51:49 and and like you can see where their soft palate is,

51:51 you could see their tongue, you could you can see some of these things.

51:56 Um, and you know, sometimes, you know,

51:58 there's a lot of sleep medicine that's using,

52:01 you know, Flonase and and some of this stuff to sort of clear up the nose,

52:06 but remember the obstructions almost all the time are

52:09 back here in that 90° angle in your airway.

52:12 It's not up here.

52:13 It's like people think snoring is is a nose-based thing.

52:16 It really isn't.

52:16 Sometimes you get like sort of floppy nostrils or whatever,

52:19 but almost entirely it's that the issue is back here.

52:22 It's the back of your tongue.

52:24 That's also why on your back it's

52:26 worse often because gravity starts pulling stuff back

52:28 or like when you open your mouth

52:30 and your tongue falls back and can block the airway.

52:34 So, so that's so like you can do

52:36 that in the physical exam when you go to the sleep doc.

52:38 They can to take a look at your mouth and take

52:40 a look at your nose and and they'll be able to see.

52:42 But I but I'll tell you it is a vast,

52:45 vast minority of the time where that's actually the cause.

52:47 People want it to be because it's an easier fix, but um that's usually not it.

52:52 It it— Rhonda: What happens if someone has untreated sleep apnea?

52:57 So I mean what what happens to their sleep architecture?

53:00 I mean first of all maybe we should briefly mention like the sleep stages,

53:04 but like does it affect their sleep architecture?

53:07 Michael: So, so here's the different sleep stages.

53:09 Stage— so when you fall asleep you enter stage one.

53:13 Stage one is super ultralight sleep.

53:14 If you sort of like nod off and someone bangs a table and you're like, "What?

53:18 What was that?" That's stage one.

53:19 When they say you were asleep and you say, "No, I wasn't." That's stage one.

53:24 It's very light.

53:25 Um, this is also where you get hypnic jerks in you.

53:28 If you have one of those, you were in stage one sleep.

53:32 Um, totally normal, medically harmless.

53:33 Everyone gets them.

53:34 Um, so that's stage one.

53:36 It's a light transitionary stage.

53:38 Then you drop into stage two.

53:40 Now, stage two, when you first drop into it, you're in it pretty quickly,

53:44 but for most of the night, that's actually what you spend the most time in.

53:47 Stage two is sometimes called light sleep.

53:49 I don't like that name for it.

53:51 I like just calling it normal sleep.

53:53 It's regular sleep.

53:53 It's vanilla sleep.

53:54 It is more than 50% of the night.

53:57 Most of the work that your brain does in sleep is done in stage two.

54:02 Um, but then you drop into stage three, which is also, you know,

54:06 in our world we call it slow-wave sleep

54:08 because the brain waves are bigger and slower.

54:10 Um, a lot of people also call it deep sleep.

54:13 It's not called deep because it's the good one or the most restful one even.

54:19 It's called deep because your arousal threshold is

54:22 the highest and it is hardest to wake you up

54:25 from that sleep stage because the the thinking parts

54:29 of your brain are largely like detached and offline.

54:33 You're not you're not thinking during that time.

54:36 Your muscles are very relaxed.

54:37 This is for athletes.

54:39 This is super important because this is when growth hormone is

54:42 secreted in N3 sleep at stage three or non-REM stage three sleep.

54:46 Um, but it's also highly protected.

54:49 Even sleep-d deprived people are mostly getting all

54:52 of the stage three sleep their body wants.

54:55 Like it's it's actually, again, evolution figured this out a long time ago.

54:59 You— it's the hardest to wake up

55:01 from and it frontload it frontloads it into the night.

55:04 So usually within the first few hours you're done with it anyway.

55:07 So it's not a— so sleep deprivation doesn't actually

55:10 eat into slow-wave sleep or or deep sleep very much.

55:13 And people, so they don't need to worry about it so much.

55:16 So anyway, you get into that and then you

55:19 come out of that into an episode of REM.

55:22 Um, REM sleep a lot of people have heard of now, um, is weird.

55:28 REM sleep is just fundamentally weird.

55:31 So like this is where dreams and nightmares happen.

55:34 Peak blood flow in the brain is actually REM sleep.

55:37 Like the your brain is extremely active.

55:40 It's actually more like waking than many any other sleep stage.

55:44 Um, but the waves are very different from waking brain waves.

55:47 But it is it is more more like that than than um than other stages of sleep.

55:53 You're also— your arousal threshold is different in that it's

55:56 easier to wake up out of REM sleep,

55:59 but there's also a couple of other weird things that happen,

56:02 that you're paralyzed.

56:03 You're so so if if in deep in the deep sleep your muscles were very relaxed,

56:09 that's nothing compared to how mus relaxed your muscles are in REM sleep.

56:12 Not because they're recovering, but because you're actively paralyzed.

56:15 Uh, your alpha motor neurons are hyperpolarized.

56:18 You cannot move, uh, even if you wanted to.

56:21 That's because otherwise you'd be acting out your dreams

56:23 because you think they're real at the time.

56:25 It's just part of your brain has its foot on the brake

56:27 while it's jamming on the accelerator at the same time.

56:29 And that's why it's not going anywhere.

56:31 That's why sometimes you see twitches where it sort

56:33 of breaks through a little bit, but that's it.

56:36 Um, it's fascinating.

56:37 And then also that's also why you get sleep

56:40 paralysis sometimes where you wake up out of REM sleep

56:42 but you're still a little bit paralyzed but you're also

56:44 conscious and that that switch forgot to get flipped really briefly.

56:46 So anyway, so you get that in REM sleep.

56:48 You also get the eye movements which might

56:50 be looking at things but might not be.

56:53 It's the data are very mixed where when you if you

56:56 go looking to match eye movements in REM sleep to dream content,

56:59 you can sometimes find it but then sometimes you can't.

57:03 It's it's it's fascinating.

57:04 Um, what what seems to be happening in between deep sleep and REM sleep,

57:10 there's a really really interesting dichotomy where

57:13 they're both important for for different reasons, where one of the things,

57:17 the main thing that seems to be happening

57:20 in the deep sleep is synaptic pruning and synaptic homeostasis.

57:23 So what— and and in REM sleep there's a lot of synaptic strengthening

57:28 and connection building and those two things work in concert with each other.

57:32 Think of it this way.

57:34 When you're experiencing the day,

57:36 you're taking in lots of experiences and information.

57:39 Some of those experiences and information are important,

57:41 you will learn from, are related to important things.

57:44 Maybe they're not super important, but they're worth keeping.

57:46 And a lot of those are not that important.

57:49 Like that piece of equipment over there, I don't need to remember it tomorrow.

57:52 It's not— I will remember it for the next few minutes,

57:54 but it's not that important to my life.

57:56 It will get filtered out.

57:57 So what ends up happening in slow-wave sleep, in in the deep sleep,

58:03 the the the experiences from the day and all those new things floating around,

58:09 they sort of get sorted and the things that are important

58:13 are kept and everything else gets let it gets let to fade.

58:18 Interestingly, this similar thing happens where

58:21 the spaces between your brain cells actually

58:23 increases and like sort of like a like actually like a like a filter,

58:28 the it increases and actually waste products

58:30 can start clearing out of your brain.

58:32 Is it because you're thinking parts of your brain are working

58:34 a little bit less and it gives it the chance to do that?

58:38 Who knows?

58:38 But it seems to happen specifically during that time,

58:41 just very protected at the beginning of the night.

58:43 So when you're after a few hours into the night,

58:46 that cleaning out process is done.

58:47 And then the cycles toward the end of the night.

58:50 So drop down to deep, up into REM.

58:53 And then you cycle through, but the cycles change.

58:55 The second cycle, you'll have a little bit less deep

58:57 and a little more stage two and a little more REM.

59:00 By your third cycle, you might have no deep left.

59:03 It's all just stage two and REM.

59:05 Maybe a little stage one interspersed in there if you wake up.

59:08 And the REM episodes get longer.

59:09 The dreams get more interesting.

59:11 That's why the dreams in the first half of the night,

59:13 you you you probably won't remember them anyway,

59:15 but if you did, they're usually a little more boring,

59:17 where the dreams at the end of the night are the cool ones.

59:20 The ones with the stories and the characters

59:22 and then and and the bl the blurring of reality and all the and and emotion

59:26 in the the later parts of the night, like nightmares.

59:29 Nightmares— to a sleep scientist, a nightmare is a dream that wakes you up.

59:33 That's the definition of sort of a nightmare in our world.

59:35 A dream that is so where the emotion is so powerful,

59:38 it overcomes that that process.

59:39 Sorry, this is sleep stages.

59:41 You go through these during the night.

59:43 And in REM sleep, it takes those important experiences that you that you

59:47 segregated in deep sleep where you got rid of all the junk, kept the good stuff.

59:51 And REM sleep, what the dreams are doing is

59:53 you're witnessing the brain rewire itself using what was left.

59:58 So basically the dreams are, among other things.

1:00:01 Essentially, what's happening is, okay, here's what's left.

1:00:03 How do I what do I do with this?

1:00:06 How is it how does it connect to other things?

1:00:08 How do I sort it?

1:00:10 How do I file it?

1:00:11 How do I process it?

1:00:12 And the other stuff that's floating around

1:00:14 that I was thinking about during the day.

1:00:16 Where is that?

1:00:17 Where do I do with that?

1:00:19 How do I process that?

1:00:20 So, dreams are you're witnessing your brain rewiring itself,

1:00:24 speaking to itself in its native language of ideas and metaphors

1:00:30 and concepts and feelings and how they relate to each other without rules.

1:00:35 Um, and so that's why all the stages are important.

1:00:39 And in stage two, that's not happening.

1:00:41 But in stage two, it's happening.

1:00:43 It's it's a lot of a lot of the recovery

1:00:45 and repair stuff is also happening in because in REM,

1:00:48 your brain's active doing this stuff.

1:00:49 And in deep sleep, your brain's also active doing this other stuff.

1:00:51 And in stage two is when it's everything else gets to happen,

1:00:55 um, in a in a more protect.

1:00:57 So like all the stages are important.

1:00:59 You cycle through them.

1:01:00 And it's about every 90 minutes.

1:01:02 Anyone can Google that, but it's not exact.

1:01:05 It's they're different across the night.

1:01:08 Um, and that's also why it's easier to wake

1:01:10 up out of stage two and REM than deep sleep.

1:01:12 But so if you woke up and you remember a dream, it's cuz you woke up out of REM.

1:01:16 That's all that's all that means.

1:01:18 So anyway, how does sleep apnea affect this?

1:01:20 Rhonda: Can I before you get to that?

1:01:22 Michael: Sure, yeah.

1:01:23 Rhonda: It's so fascinating.

1:01:24 Um, particularly the part where you're talking about, you know,

1:01:26 all the new information that you're learning every day.

1:01:29 You know, you're during that transition between deep and and REM,

1:01:32 you kind of your brain is like sorting it out and getting rid

1:01:35 of the things that you don't really aren't really that important to remember.

1:01:38 And then during REM sleep,

1:01:40 you're like using what's left and somehow attaching it to like other memories

1:01:44 and stuff and concepts and yeah sometimes they don't even seem to make sense.

1:01:49 Like you'll like— Michael:

1:01:50 They may not make logical sense or and maybe they're wrong.

1:01:52 I mean, you're sorting through, you're you're you're playing stuff out.

1:01:55 And that's also why like when you're awake, a person is a person,

1:01:59 a house is a house, a car is a car.

1:02:03 But when you're in a dream, the rules of the universe don't apply.

1:02:07 The concept of a car can also be the concept of a person.

1:02:10 And that person can be somebody else, too.

1:02:13 And then it was me, and then it was my sister,

1:02:16 and then we were in this house that I grew up in, but actually, no, it wasn't.

1:02:21 It was really a mall.

1:02:22 Like, things can happen.

1:02:23 It's because you're not bound by the rules of the universe.

1:02:27 You're just bound by how your mind is organizing that information.

1:02:30 Rhonda: Well, based on what you just said,

1:02:33 I have now a new hypothesis for why we dream.

1:02:36 But I want to ask you, why do we why do you think we dream?

1:02:40 Michael: I think we dream because evolution figured out a long time ago

1:02:46 that you can learn a lot by reading all the words on the page,

1:02:51 but you can you can also learn some really

1:02:53 important things by reading between the lines on the page,

1:02:57 by reading things that aren't on the page and reading the concepts behind them.

1:03:01 But when you're engaging in the day, so the way the brain works,

1:03:05 which is fascinating, is the brain works by shortcuts.

1:03:10 It's extremely efficient.

1:03:12 It's extremely efficient because it makes a gazillion guesses and shortcuts

1:03:16 without actually doing any real work except when it absolutely has to.

1:03:20 So for example, it's like when you take a picture,

1:03:23 your brain doesn't store every pixel.

1:03:25 Your brain stores this line here, this line here,

1:03:29 this sort of pattern of colors and a set of instructions and fills in the gap.

1:03:34 The the your brain stores the blueprints, not the house.

1:03:37 And the blueprints are rolled up.

1:03:38 This the house takes up the building can take up a whole city block.

1:03:43 That's why the brain is super efficient.

1:03:45 It stores, it figures out what is

1:03:47 the minimum amount of information it actually needs

1:03:50 and then what are all the assumptions it

1:03:52 needs to make to fill in all the details.

1:03:55 And the good thing is the universe works that like when things go farther

1:04:00 away they get smaller and like there's all kinds of rules of the way

1:04:04 that like you are you and you will be you 5 minutes from now

1:04:08 and I don't have to assume make any assumptions that that can change.

1:04:11 There's rules to the universe.

1:04:13 And when you're engaging with the world that way, it could be really efficient.

1:04:20 But maybe there's maybe there's connections that aren't

1:04:26 explicit that might help you navigate your life.

1:04:29 So like let's say we're having this conversation now.

1:04:32 Maybe you remind me of somebody who is

1:04:35 a friend of mine from like years and years ago.

1:04:39 And but you're not that person.

1:04:41 My conscious mind knows you're not that person.

1:04:44 Um, there's no question about that.

1:04:46 But it may change how I speak or how what my body language is going

1:04:51 to look like or how much I choose to ramble when I tell these stories.

1:04:57 Like these sorts of things.

1:04:59 Dreaming is about, I think it's about taking the actual

1:05:03 written words on the page of life and sorting through

1:05:07 those connections and sorting through those unspoken and and and details

1:05:12 that don't actually exist but do and inform our life.

1:05:17 So dreams are the difference, I think,

1:05:20 between memory and experience where it's it's the difference

1:05:23 between what you did and who you are,

1:05:24 like and the dreams are what sort of make you that person who

1:05:28 reacts to things based on your own history that that forms those connections.

1:05:33 But I don't know that that's my that's my ramble of what I think.

1:05:36 Rhonda: Well, thank you.

1:05:38 Um, okay, so back to the sleep apnea.

1:05:39 Michael: Yeah, sorry.

1:05:40 Rhonda: Yeah, because you you know people having

1:05:42 these awakenings where there are multiple awakenings in the night,

1:05:45 obviously this happening during different stages

1:05:47 is um what how does sleep apnea,

1:05:49 untreated sleep apnea, affect sleep, the sleep architecture?

1:05:51 Michael: That is one of— sleep apnea is one of the few things that can

1:05:58 artificially reliably dramatically reduce your slow-wave

1:06:02 deep sleep because it it prevents you because you can't

1:06:05 detach because your bodies keep trying to get your attention.

1:06:09 The other thing it does is it

1:06:11 dramatically increases it can dramatically increase stage one.

1:06:14 Um, and it can also because your sleep is more

1:06:18 shallow and you have more of these arousals and awakenings.

1:06:20 Even if you don't wake up all the way,

1:06:22 your brain is still sort of moving around.

1:06:24 The other thing it can do, it can dramatically reduce your REM sleep because

1:06:29 remember what I said about muscles in REM sleep.

1:06:32 Even your respiratory muscles get weaker.

1:06:35 That's why snoring is worse in REM and or worse at the end

1:06:38 of the night because you have more REM at the end of the night.

1:06:41 So if you're if you're already in a floppy

1:06:43 tube trying to breathe out of this floppy

1:06:45 tube that's already having an issue and then you make the muscles go extra limp,

1:06:49 snoring is going to get worse.

1:06:50 So you're going to have more awakenings out of REM,

1:06:52 you're going to have less deep sleep

1:06:54 and your sleep's just going to be more shallow overall.

1:06:56 So that's why people with sleep apnea,

1:06:58 they wake up and they feel like it's sort of like

1:07:01 I just ate a whole meal and I'm still hungry.

1:07:04 Rhonda: Right?

1:07:05 Yeah.

1:07:05 I I wonder if anyone's or maybe you can

1:07:09 tell me if anyone's ever looked at, you know,

1:07:13 because you mentioned deep sleep is really important for this, you know,

1:07:16 cleaning out the the toxic waste.

1:07:17 These are aggregate protein aggregates, amyloid beta 42 being one.

1:07:20 Michael: Yep.

1:07:21 Rhonda: I wonder if anyone's ever looked at like people

1:07:24 with Alzheimer's disease to see if any of them have sleep apnea,

1:07:27 like the untreated sleep apnea.

1:07:29 Michael: Oh yeah, untreated sleep apnea

1:07:30 is a known risk factor for neurodegeneration, especially when it's more severe.

1:07:34 So this is the thing: mild to moderate sleep apnea is a is a gray area.

1:07:40 Severe sleep apnea seems very— and that's 30 events

1:07:42 or more an hour— seems very reliably tied to bad outcomes.

1:07:47 Mild seems like it's really only tied

1:07:50 to bad outcomes when you also have daytime symptoms,

1:07:54 like you're you're mostly treating like

1:07:56 the fatigue and the memory issues, whatever.

1:07:58 You can still get um cell death and you can

1:08:03 get neuronal problems because you're— think of it this way.

1:08:06 Every time you have one of these respiratory events and you're having it,

1:08:09 you know, maybe dozens of times per hour in the night, your oxygen drops.

1:08:14 And it's not the hypoxia that's the problem.

1:08:17 This is what a lot of people get wrong about sleep apnea.

1:08:20 It's not really the hypoxia, it's the intermittent hypoxia.

1:08:23 So, you're not hypoxic because what'll happen is you drop a few points.

1:08:28 Most people, unless you have some other lung disease,

1:08:30 most people with sleep apnea,

1:08:31 their O2 doesn't drop a lot for sustained amounts of time.

1:08:35 Unless you have like emphysema or something, It'll drop a few percentage points.

1:08:39 Then your body wakes up and then it recovers.

1:08:42 Then it drops again.

1:08:43 Then your body wakes up and it recovers.

1:08:45 Then it drops.

1:08:46 So, it's like it's constantly putting out

1:08:48 all these little fires all over the place.

1:08:51 The fires are never burning any houses down.

1:08:53 They're just sprouting up all over the place.

1:08:56 But what ends up happening is all of these cells

1:09:00 are rel—releasing reactive oxygen species every time this happens.

1:09:03 So, you're releasing these reactive oxygen species.

1:09:06 This oxidative stress is happening and then it's quelled

1:09:09 and then it's stressed and then it's quelled and then it's

1:09:12 stressed and then it's quelled and it's stressed then it's

1:09:15 all night for days or months or years or decades, usually.

1:09:21 Imagine the stress, like your cells are trying to do

1:09:26 their job and they're constantly dealing with all this nonsense instead.

1:09:30 Imagine trying to do your job and you're

1:09:32 constantly having to do all this other stuff.

1:09:33 So, you're not getting the recovery function that you're trying—that,

1:09:36 that you were built for.

1:09:38 And so, your trajectory goes slightly off.

1:09:40 So that's why sleep problems, not just sleep deprivation,

1:09:44 but also sleep—untreated sleep apnea can lead to liver problems,

1:09:50 kidney problems, brain problems, heart issues, you know, immune system problems,

1:09:56 because all of the—every cell that relies on oxygen starts

1:10:00 getting stressed and some of them are more sensitive than others.

1:10:03 Rhonda: Right, and you're also disrupting

1:10:04 your sleep architecture and not getting enough sleep.

1:10:07 So, so, so people with untreated sleep apnea

1:10:09 then probably do have problems with working memory.

1:10:12 Michael: Yeah.

1:10:12 Yep.

1:10:13 Rhonda: I mean, emotional regulation.

1:10:14 Michael: Emotion regulation, executive function, um, attention.

1:10:16 So, this is the thing.

1:10:18 When you—when your sleep is poor,

1:10:20 whether it's sleep deprivation or sleep apnea or fragmentation or whatever,

1:10:24 the first brain function to go is vigilant attention,

1:10:29 your ability to maintain focus,

1:10:32 especially when whatever you're focusing on isn't super exciting.

1:10:36 Rhonda: Hmm.

1:10:37 Michael: That is usually the first brain function.

1:10:40 That's the first warning sign that something's up.

1:10:43 And the re—and that can start creating memory issues.

1:10:47 But a lot of the memory issues are

1:10:50 memory issues because sleep is really important in memory.

1:10:53 Remember, you're taking all the stuff I

1:10:55 was talking about is all memory connected functions.

1:10:57 It's about sorting through information,

1:10:59 processing information, consolidating information, integrating information.

1:11:02 And if you're not able to do those things, you're operating inefficiently.

1:11:09 You're not performing those functions.

1:11:11 But memory—but memory is also a function of attention

1:11:15 where if you're not able to focus and attend,

1:11:18 even if your memory machinery was working perfectly,

1:11:21 you have nothing to process because it never got in there.

1:11:24 This is the thing with people taking sedating medications.

1:11:27 Sometimes it impairs memory.

1:11:28 Sometimes it impairs attention, which also impairs memory.

1:11:32 Rhonda: You mean, so it does that not while you're on it,

1:11:36 but like— Michael: It can.

1:11:37 Rhonda: Yeah.

1:11:38 Wow.

1:11:38 Michael: Um, so I mean that's why a lot of these medications and stuff, um,

1:11:43 and really anything—anything that is impairing

1:11:46 your ability to focus will have ripple effects

1:11:50 to memory and decision-making as well because

1:11:54 the information you took in informs those other processes.

1:11:58 I mean, just like, just most simply,

1:12:01 you can't recall a memory that never got stored because you,

1:12:05 you—your working memory couldn't process it because you

1:12:08 didn't attend to it in the first place.

1:12:11 Rhonda: Is this why men have a lot more attentional issues?

1:12:15 Michael: Maybe.

1:12:15 Maybe.

1:12:15 I mean, there's a lot of untreated sleep apnea out there.

1:12:19 And, and, and there's a lot of other sleep problems, too.

1:12:22 And they all—I mean, sleep does a lot.

1:12:25 Sleep.

1:12:25 You know, we live in this society

1:12:28 that sees sleep as an unproductive use of time,

1:12:31 especially people who are training,

1:12:33 especially people who are like trying to maximize their day.

1:12:36 And sleep is not an unproductive use of time.

1:12:39 Sleep is an extremely productive use of time.

1:12:42 I mean, if you're working out and you're trying to get stronger,

1:12:46 when you're working out,

1:12:47 you're stressing the system so that it rebuilds back stronger, right?

1:12:51 When do you think that other part happens?

1:12:54 Not while you're working out.

1:12:55 It's when you're recovering.

1:12:57 It's the recovery.

1:12:58 Sleep should be your number one recovery

1:13:01 protocol for any kind of performance-driven person,

1:13:05 whether it's physical performance, mental performance.

1:13:08 I mean, when you sleep deprive people,

1:13:10 they—we trade sleep for work all the time, but you actually get less done.

1:13:15 And we've actually measured this.

1:13:17 You actually accomplish more on less time

1:13:19 if you're well-rested and your brain is clear.

1:13:22 Rhonda: Right.

1:13:23 Okay.

1:13:23 Okay.

1:13:24 Well, let's talk about treating, you know, sleep apnea.

1:13:27 I know we can talk about CPAP and what that is, and it certainly works.

1:13:31 Um, Michael: Yep.

1:13:32 It's a blunt instrument.

1:13:33 It works.

1:13:34 Rhonda: Long-term adherence maybe not so great.

1:13:36 Uh, what do you find to be

1:13:38 some of the best evidence-based non CPAP interventions?

1:13:41 Yeah.

1:13:42 Michael: So, the thing about CPAP is it's

1:13:44 a blunt instrument because it's—think of it—it's just,

1:13:47 it's just a split that keeps open your airway.

1:13:49 It's, it's—it creates a pillow of air that, so

1:13:51 if your airway wants to collapse, it can't.

1:13:54 And, and CPAP, it's continuous positive airway pressure.

1:13:57 Continuous cuz it's blowing continuously.

1:13:59 Positive airway pressure as opposed to negative pressure, which is sucking.

1:14:03 Positive airway pressure is blowing.

1:14:05 So, it's just continuously blowing air in your airway

1:14:08 to create a pillow of air to keep it open.

1:14:11 That's all it is.

1:14:12 It's a blunt instrument.

1:14:13 If your airway wants to close, you, you,

1:14:15 you blow enough air in there, it won't be able to close.

1:14:18 But for some people it's too uncomfortable or whatever.

1:14:21 So there's other approaches.

1:14:22 The one I tend to use the most,

1:14:25 especially with athletes who are often presenting

1:14:27 with more mild to moderate sleep apnea anyway,

1:14:30 are what are called mandibular advancement devices.

1:14:32 What these are, that's essentially a retainer you wear at night.

1:14:36 It's mandibular, like your mandible, advancement.

1:14:38 So essentially it's a retainer that pushes your jaw forward.

1:14:41 And in a nutshell, that's all it is.

1:14:44 There's obviously a science behind it,

1:14:46 but what it does is it creates a little muscle tone

1:14:50 here even when you don't want—even when you're trying to rest.

1:14:53 So, usually that's not a good thing,

1:14:55 but it creates just not enough muscle tone to keep you awake,

1:14:58 but enough muscle tone to keep this part of your airway

1:15:00 open a little more than it normally would be.

1:15:02 And for a lot of people with especially

1:15:05 more mild sleep related breathing issues, does the trick.

1:15:07 That's, that's all it takes to knock out at least enough

1:15:12 of those events so that you don't end up noticing it anymore.

1:15:15 And you don't have to plug it in.

1:15:17 You don't have to switch out your hose every couple months.

1:15:20 Like, it's a little easier.

1:15:21 You do have to get it adjusted.

1:15:22 And as your jaw remodels, you might have to do some adjustments.

1:15:25 You do it with a—there's a whole field called sleep dentistry.

1:15:28 Rhonda: Hmm.

1:15:29 Michael: It's sleep medicine dentistry, not sedation dentistry,

1:15:32 but sleep dentistry where it's about people diagnosing

1:15:35 and treating sleep apnea with these dental devices.

1:15:38 That's a very common one.

1:15:41 Um, there's an—there's, there's also, um, muscular myofascial therapy.

1:15:47 So like you can use the musculoskeletal system and essentially

1:15:50 exercise these muscles so that they just carry more muscle tone.

1:15:54 That can work.

1:15:55 I mean, there's, there's very famous work done with like people

1:15:58 who play the didgeridoo where they have to do the cyclical breathing.

1:16:02 It ends up strengthening certain muscles that even when you're asleep,

1:16:05 they're a little stronger and they can maintain a little more tone.

1:16:08 So sometimes that can help, especially for more mild apnea cases.

1:16:12 Um, there's a device, um, called eXciteOSA, uh, where,

1:16:15 where it's—you put it on your tongue when you're

1:16:18 awake and it sort of electrically stimulates your tongue muscles.

1:16:20 So then you go to bed, it keeps a little— it's like a TENS

1:16:23 unit kind of where it like—where it stimulates

1:16:25 your tongue muscles so that when you go

1:16:27 to bed there's a little more muscle tone in there.

1:16:29 That seems to work okay.

1:16:30 Um, there's a new device people have maybe seen commercials called Inspire,

1:16:34 which just means breathe in, but um, it's,

1:16:37 it's sort of like a pacemaker that they install.

1:16:39 So it's an implantable electrical device that they do surgery,

1:16:42 but it's a sort of a pacemaker for your tongue muscle.

1:16:45 And so what it does is when it detects that your tongue is falling back,

1:16:49 it zaps it to open it up.

1:16:51 And that also, for people for whom it's a candidate for it,

1:16:54 that can also—it's, you don't have to, again, there's no equipment to replace,

1:16:58 but you do need surgery for it and, and there's complications there sometimes,

1:17:01 but seems to work okay.

1:17:03 Um, there's more options now than ever

1:17:06 and the technology is always getting better.

1:17:09 Even with CPAP, there's more than 200 different kinds of masks out there.

1:17:14 So, for people who don't like their device

1:17:17 and don't like their mask because it's uncomfortable or whatever,

1:17:20 it's rare that I find a mask problem that can't be fixed,

1:17:24 if, if what you need is one of those.

1:17:27 Rhonda: What about, um, ma—mouth taping?

1:17:30 Michael: Mouth taping.

1:17:32 So, all right.

1:17:34 Mouth taping.

1:17:35 So, mouth taping.

1:17:36 For decades in the sleep medicine field, we've been using chin straps,

1:17:41 just like an elastic band keeps your mouth closed at night.

1:17:44 For people who are snoring that don't—that where it's

1:17:48 just mild snoring and they don't have sleep apnea, um,

1:17:52 or their sleep apnea is mild or their sleep apnea is due to them opening

1:17:57 their mouth at night and their tongue falling

1:17:59 back and they can breathe through their nose.

1:18:01 Okay, chin straps have been great.

1:18:03 They're, they're—they've been, again, used for decades.

1:18:05 Mouth taping, I think, is just sort of the same thing

1:18:07 where you're essentially just keeping your mouth closed.

1:18:09 Is just keeping your mouth closed in a way that you can breathe through,

1:18:12 like it's, it's special tape where air flows through fine.

1:18:16 If the problem is that you're opening your mouth,

1:18:19 I have no problem with it and it probably—it may help those people.

1:18:22 But if the problem is that you actually have sleep apnea

1:18:25 and if you don't open your mouth then you can't breathe,

1:18:28 like, and you're opening your mouth to gasp for air,

1:18:32 then that's probably not what you want.

1:18:35 It's probably the opposite of what you want.

1:18:37 If, if you need to open your mouth to breathe or else

1:18:39 you're going to have your—your oxygen is going to plummet, don't do that.

1:18:43 But for like more mild snoring cases or for people who it's mild enough or if it

1:18:48 helps you keep—like maybe you're using a nasal device

1:18:50 or, or like a—or like strips or, or, um,

1:18:53 Rhinomed makes these, these nasal splints where you can keep your nose open.

1:18:57 Like if you're using one of those and you just need to keep your mouth closed,

1:19:01 I, I have no real problem with it.

1:19:03 I just don't think it's going to like cure cancer and save the world.

1:19:06 But I, I feel like it's—it gets overblown by people's— Rhonda:

1:19:09 Yeah, it's gotten overblown and it sounds more like maybe for snoring.

1:19:13 Michael: Yeah.

1:19:13 Rhonda: Than anything.

1:19:14 Michael: Like, and it's, it's, it's if you need—if keeping your mouth closed

1:19:17 during the night solves your problem, go ahead.

1:19:20 But if that's—but if you're hoping that keeping your mouth

1:19:25 closed during the night will solve your problem and it doesn't,

1:19:28 there are other options for you.

1:19:30 Rhonda: Are there any for people that are experimenting with some

1:19:33 of these, perhaps the retainer or, or the myofunctional training?

1:19:36 Um, Michael: Yeah.

1:19:37 Rhonda: We're going to get into sleep wearables, you know,

1:19:40 soon, but like how do they really know it's working?

1:19:44 Just what's— Michael: Yeah, it's tough.

1:19:46 The best way to know, and this is not a perfect way.

1:19:50 Um, second best way to know is, are you—how do you feel during the day?

1:19:56 How's your energy level?

1:19:57 How's your ability to focus?

1:19:58 Are you falling asleep whenever you stop moving?

1:20:00 A lot of people with sleep apnea, they,

1:20:02 they can't—they don't stop moving because then they'll, they'll fall asleep.

1:20:04 They can't watch TV.

1:20:05 They can't watch a movie.

1:20:06 They can't go to a dark movie theater without nodding off.

1:20:09 Like they have a hard time with that.

1:20:11 Or meetings.

1:20:12 They hate meetings because they have trouble keeping awake.

1:20:14 If all of a sudden that's just not a problem for you,

1:20:18 it's like your appetite isn't ramped up because you're starving all the time.

1:20:22 You're actually getting good nutrition so you're not starving.

1:20:26 That's a good signal.

1:20:29 But it's not a great signal.

1:20:30 It's not, it's not a perfect signal because there's a lot

1:20:32 of people where their sleep apnea seems to be treated just fine,

1:20:35 but they still have some of those daytime symptoms.

1:20:37 And no one really exactly knows why.

1:20:40 Um, but it see—just means we need to learn more about what this condition really

1:20:44 is and what it's doing in the brain

1:20:46 and what's permanent and what's not permanent.

1:20:48 We don't know yet.

1:20:49 And I say that's second best because the best is just get retested.

1:20:52 And a lot of people with sleep apnea,

1:20:55 if it's been a couple of years, get a—do it to do the test again.

1:20:59 Do it while you're using your treatment to see.

1:21:01 And, and for a lot of those devices,

1:21:03 insurance requires you to do that anyway to make sure it's working fine.

1:21:06 See if he needs to get adjusted because sometimes they need to get

1:21:10 adjusted and they're not working great cuz your mouth changes or something.

1:21:14 So that's one way.

1:21:15 I mean, really, really there's no other

1:21:18 way besides either looking—I mean, you can,

1:21:20 you might in the future might even be easier to look at the wearable data,

1:21:23 check your oxygen levels during the night,

1:21:25 check your heart rate during the night,

1:21:27 see if you have these spikes that you used to have or see—or,

1:21:30 and most, most importantly, see how you feel the next day.

1:21:33 Rhonda: All right, um, I kind of wanted to shift gears.

1:21:36 We're going to get into the supplements

1:21:37 because that's something everyone wants to know about.

1:21:39 But before that I kind of wanted to ask you a little bit about,

1:21:42 you know, we've—a lot of people have heard about sleep hygiene Michael: Yeah.

1:21:45 Rhonda: and the most important things for sleep hygiene.

1:21:47 Michael: Yes.

1:21:47 Rhonda: I mean, you can rapid fire.

1:21:49 Michael: I do good sleep hygiene.

1:21:50 I do all the sleep hygiene or I— Rhonda: Yes, yes.

1:21:52 Michael: or my sleep hygiene is bad.

1:21:54 Like people talk about this all the time, but yeah,

1:21:56 but there's a difference between sleep hygiene and behavioral sleep medicine.

1:22:01 They're different things.

1:22:02 Rhonda: Right.

1:22:03 Exactly.

1:22:03 I mean, obviously people need to have sleep—good sleep hygiene, too.

1:22:08 Like that's important.

1:22:09 But like, like everything you were talking about with CBT-I,

1:22:12 like that's just— Michael: It's different.

1:22:13 Rhonda: One.

1:22:14 Yeah.

1:22:14 The sleep hygiene is just something that already needs to be done.

1:22:16 Michael: Yeah, but hygiene.

1:22:18 Hygiene is hygiene.

1:22:19 Hygiene isn't medicine.

1:22:20 So like washing your hands is hygiene.

1:22:23 Everyone should wash their hands more than once.

1:22:25 You know, you should be—and if you're sick,

1:22:27 wash your hands more, but washing your hands won't cure an infection.

1:22:32 Rhonda: Right.

1:22:33 But for people that perhaps don't have insomnia, have apnea,

1:22:36 sleep apnea— Michael: But everyone should still be washing their hands.

1:22:39 Everyone should still be brushing their teeth.

1:22:41 Even if you can't brush your way out of braces,

1:22:43 doesn't mean you shouldn't be brushing your teeth.

1:22:46 So, so sleep hygiene is all about setting yourself up

1:22:49 for success or dealing with some of these more minor problems.

1:22:52 Rhonda: Right.

1:22:53 So, I was wondering if you had any

1:22:55 tips on some more advanced type of sleep hygiene,

1:22:58 like we know, we all know dark, cold, quiet, like these are important.

1:23:02 Michael: Rocket science, right?

1:23:03 Rhonda: Yeah, rocket science.

1:23:04 But like are there any other sort

1:23:06 of more advanced sleep hygiene techniques, like oh,

1:23:09 maybe your resting heart rate or respiratory rate

1:23:11 or something like that, like people could— Michael:

1:23:14 Some unconventional—the stuff this, you know,

1:23:16 if you googled—if you Google sleep hygiene,

1:23:18 what's some stuff that might not come up

1:23:20 on those initial lists that, that would still be useful?

1:23:23 One of them, one of the things that you'll see often on sleep

1:23:28 hygiene lists is keep a regular

1:23:30 schedule because predictability—the brain loves predictability.

1:23:33 So if you keep a regular schedule, time itself becomes a cue.

1:23:37 So like if you want to eat lunch at noon every day,

1:23:40 start eating at noon every day and your body

1:23:42 will learn to get hungry at that time.

1:23:45 But what if you can't keep a regular schedule?

1:23:48 Well, an alternative approach I would take is find

1:23:52 other ways of building predictability into your sleep, for example.

1:23:57 So like, so one of the groups I do a lot of work with is Major League Baseball.

1:24:03 And in Major League Baseball when they're in season,

1:24:06 they're constantly moving around and playing in different

1:24:09 time zones and sleeping in different hotels.

1:24:11 How do you keep regularity when you're constantly moving around?

1:24:15 And so like for people whose lives are like that, what do you do?

1:24:20 Well, I usually say, okay, stop trying to keep a regular schedule,

1:24:23 but, but find other ways to build predictability in.

1:24:26 So, maybe have a nighttime routine that is highly predictable

1:24:29 where you do the same things in the same order,

1:24:32 even if you do them in different places in a different hotel room or whatever,

1:24:35 especially if you can bring things with you,

1:24:39 like bring the pillowcase with you, uh, as a, as a conditioned stimulus.

1:24:45 Um, use the same toothbrush that whether it's at home

1:24:48 or on the road if you travel a lot.

1:24:51 Use—do the same things in the same order.

1:24:53 So even if they're at a different time in a different place,

1:24:57 find alternate ways to build predictability if

1:24:58 time itself is not the predictable one.

1:25:01 Um, another one is avoiding bright light at night.

1:25:06 What if you can't?

1:25:08 Um, so blue blocking glasses are great for this because,

1:25:12 and by blue blocking glasses, they have to be orange or red most of the time.

1:25:17 Some of the other ones will work.

1:25:18 Some of the yellow ones or brown ones will work,

1:25:21 but if you put the glasses on and you

1:25:23 look at something blue and you know that it's blue,

1:25:26 it's not going to do its job from a circadian perspective.

1:25:29 So, some of them block blue for eye strain, but that's a different thing.

1:25:33 So if you put on, say, orange tinted glasses and you can't see the color blue,

1:25:38 then the environmental light is not going to interfere with your sleep

1:25:43 in the same way because it's not going to send a daytime signal.

1:25:47 Another one that even fewer people know about

1:25:50 is bright light in the morning can help set your sleep up at night in three

1:25:57 ways that are that are actually a little unconventional.

1:26:02 Number one, by having that morning be

1:26:05 a regular timing and a strong daytime signal.

1:26:07 I'm talking about daylight.

1:26:08 I'm talking about, like, outdoor light,

1:26:10 not just turn on a light in my bedroom light.

1:26:13 That's a couple hundred lux.

1:26:14 Step outside, it's thousands of lux of light.

1:26:17 Getting that strong daytime signal in the morning

1:26:20 at a predictable time starts a clock.

1:26:23 And that clock, just like when you finish a meal,

1:26:26 you'll start getting hungry a certain number of hours later.

1:26:29 If you don't really have a really strong meal,

1:26:31 you're sort of hungry all over the clock.

1:26:33 You don't have that rhythm.

1:26:35 But if you have a strong morning signal

1:26:37 with some bright light at a predictable time,

1:26:40 about 16 to 17 hours later, your body will expect to be ready for sleep.

1:26:45 And if you can make that a little more regular,

1:26:49 it makes—it's like if you want to be—if

1:26:50 you want to throw—if you want someone to catch a ball downfield and you throw it

1:26:55 the same amount of—about the same distance every time,

1:26:58 but you keep moving, the person downfield doesn't know where to stand.

1:27:03 But if you stay still, they can predict where the ball's going to land.

1:27:07 So, like, by setting that timer,

1:27:09 it creates—it sets you up for success by starting that timer.

1:27:12 The second thing that it does is that it creates a circadian amplitude.

1:27:18 So your circadian rhythm, this 24-hour cycle,

1:27:20 it's like when you're on the couch in the dark all day,

1:27:23 you don't have a strong daytime rhythm.

1:27:25 So you don't have a strong nighttime rhythm.

1:27:27 But if you get a strong daytime signal

1:27:29 by being active and and getting especially outside light,

1:27:33 especially in the morning to start that curve going,

1:27:36 by the time nighttime comes, you'll have an even stronger nighttime signal.

1:27:40 And then the third thing that it does

1:27:43 that even fewer people know about is, you know,

1:27:46 everyone knows that light at night is bad and that light in the morning is good.

1:27:50 But light across the day matters where the more outdoor light,

1:27:55 the more bright light, but it mostly means outdoor light.

1:27:59 The more light you get during the day, it inoculates you against light at night.

1:28:04 Because if you got a really strong light daytime signal,

1:28:07 you can get all kinds of light from screens or whatever

1:28:11 at night and it actually won't matter for most people.

1:28:14 You can actually—you can—so you, again, it's lesser known,

1:28:17 but because the system knows where it is,

1:28:20 it's not looking for information anymore and and conflicting

1:28:23 information will get thrown out as opposed to, like,

1:28:26 "I don't know, it's it's light now,

1:28:27 but I didn't get a ton of light during the day.

1:28:29 Maybe it's daytime, I don't know." But you can inoculate

1:28:32 yourself against nighttime light by getting plenty of daytime light.

1:28:35 Rhonda: That's fascinating.

1:28:36 I've noticed that, of course, when I'm traveling and I'm I'm outside all

1:28:39 the time and then it's like being in my hotel,

1:28:42 I don't usually have my dimming light,

1:28:44 my dimmers and everything that I usually have.

1:28:46 But it doesn't matter because I am dead tired, you know, Michael: Right.

1:28:49 Rhonda: after being outside.

1:28:51 Michael: Humans lived for most of our existence

1:28:55 in equatorial bright days, dark nights,

1:28:58 relatively little seasonal variability around all around, like,

1:29:01 the Mediterranean area and and that part of the world.

1:29:05 You know, we've solved all kinds of problems by creating

1:29:09 these walls and buildings and artificial lights and everything.

1:29:11 We solved a lot of problems, but we've created some new ones, too.

1:29:15 And we're still running the same code.

1:29:17 Rhonda: Right?

1:29:18 Um, couple of questions, um, follow-up questions for that.

1:29:21 Do you think the time of of, um, morning light matters a lot?

1:29:28 Like, you wake up in the morning and, like,

1:29:30 is it like first thing you go outside,

1:29:32 and how long should you have to go outside for, 30 minutes?

1:29:36 Michael: Yeah, morning light is key.

1:29:39 The earlier the better.

1:29:41 Um, I mean, honestly, earlier the better.

1:29:44 And how much?

1:29:46 I would say 15 minutes is probably fine.

1:29:51 Um, 30 minutes is probably better.

1:29:54 Like a morning walk or a morning run is actually probably perfect.

1:30:01 Um, and because what's happening,

1:30:03 it's not only that daytime signal, the other thing it's doing,

1:30:07 and we'll talk about this more when we talk about supplements, but melatonin.

1:30:10 So melatonin naturally,

1:30:11 your your natural melatonin will drop in the morning down to, like,

1:30:15 from its peak to almost nothing.

1:30:17 Light suppresses melatonin naturally.

1:30:19 That's what it does.

1:30:21 And so the earlier, if your melatonin is still kind of high and it's dropping,

1:30:28 by getting that light, you accelerate its ability to drop.

1:30:31 Rhonda: It's like coffee.

1:30:32 Michael: Yeah.

1:30:33 Kind of.

1:30:33 And and actually this is also why, uh,

1:30:35 I don't recommend that people caffeinate as soon as they wake up.

1:30:39 I recommend people wait an hour because if

1:30:42 if you caffeinate as soon as you wake up,

1:30:45 the the amount of adenosine that that caffeine is blocking is still very low.

1:30:51 You haven't produced enough yet to really have much of an effect.

1:30:54 But if you drink caffeine as soon as you

1:30:56 wake up in the morning and you feel more alert,

1:30:59 it's probably your sleep inertia naturally coming down

1:31:01 and your melatonin naturally getting blocked and you're feeling

1:31:05 the effects of it and you're attributing it

1:31:07 to the caffeine when actually you could have skipped the caffeine.

1:31:10 You probably would have felt mostly the same.

1:31:12 It's just the caffeine is still having effects later,

1:31:15 but you've missed the caffeine peak.

1:31:17 So, like, actually time the caffeine a little bit later.

1:31:19 Rhonda: So you're saying you want to use the caffeine for, you know,

1:31:24 when when you basically more need it,

1:31:26 when you're working, maybe adenosine builds up.

1:31:28 Michael: Yeah.

1:31:29 Use the caffeine so adenosine builds across the day and you're

1:31:32 at your lowest levels as soon as you wake up.

1:31:34 Why are you going to block something that you don't—you know,

1:31:36 if caffeine works mostly by blocking adenosine and your lowest

1:31:40 levels of adenosine are first thing in the morning,

1:31:42 why would you recommend someone block it first thing in the morning?

1:31:46 Wait till—wait till it accumulates a little bit.

1:31:50 Especially if if you—for most people that natural sleep inertia will wear

1:31:55 off within 10 to 60 minutes as soon as they wake up.

1:31:59 And uh, my favorite way to tell this story is like,

1:32:02 "You know how you wake up and you smell the coffee and then

1:32:04 even that kind of perks you up a little bit?" They say,

1:32:07 "Yeah." And I say, "Did you know

1:32:09 that there's a term for that?" And they're like,

1:32:12 "Oh, there is?" And I say, "Yes, it's called placebo." Rhonda: Placebo.

1:32:16 Michael: And then and then so they laugh and like,

1:32:19 "What do you mean?" I'm like, "Coffee doesn't work olfactory.

1:32:21 It doesn't work through the nose." If if you smell it and you start perking up,

1:32:25 it's because you're predicting what its effects are

1:32:28 going to be before you even ingested it.

1:32:30 And which means when you you're drinking that coffee,

1:32:33 it's giving you a placebo effect as much as it's giving you anything else.

1:32:36 So, like, wait a little bit because you're—because you don't need it.

1:32:40 Rhonda: That's why I drink decaf coffee like, you know, at 11 11:00 a.m.

1:32:44 and I feel like it's totally working

1:32:46 and I'm totally fine with that placebo because— Michael:

1:32:48 Right, because you had it in you all along.

1:32:50 Rhonda: Right?

1:32:51 So, so it sounds like the morning routine would be wake up, Michael: Yeah.

1:32:55 Rhonda: go outside, get some water,

1:32:57 Michael: You probably dehydrate a little bit.

1:32:59 Rhonda: get some water, Michael: Yeah.

1:33:00 Rhonda: go outside, whether you're taking your puppy or dog out.

1:33:03 I just got a new puppy.

1:33:04 Um, going for a run.

1:33:06 Michael: Yeah.

1:33:06 U— Rhonda: But go outside for at least 15 minutes.

1:33:09 Michael: Yeah.

1:33:09 Rhonda: And then, you know, wait a little bit, then you make your coffee.

1:33:12 Obviously there's some people are kind of rushing to get to work,

1:33:14 but you can drink your coffee in the car on the way to work.

1:33:17 Michael: Yeah.

1:33:17 Or or wait till you get there.

1:33:18 Rhonda: Or wait till you get to work.

1:33:20 Michael: Yeah.

1:33:20 Rhonda: Okay.

1:33:21 I'm going to try that.

1:33:22 Michael: Yeah.

1:33:22 I mean, and also you got to remember caffeine—caffeine doesn't reach its peak

1:33:25 effects for at least like a half an hour after you ingest it.

1:33:29 So and then it'll last for a few hours afterwards.

1:33:33 So if you want to—if you— Rhonda: Wait, say that again.

1:33:37 So it doesn't reach its peak until 30 minutes later?

1:33:39 Michael: Until about 30 minutes later.

1:33:40 So if you feel it sort of right away,

1:33:42 that wasn't—that wasn't sort of the effect of caffeine.

1:33:45 Rhonda: Okay.

1:33:45 Um, we'll see.

1:33:46 Michael: And then and yeah, and then it'll trail off.

1:33:48 Like, it'll have some effects as it builds.

1:33:49 So it's something there, but it's actually the peak effects of caffeine,

1:33:53 uh, for alertness or are about a half an hour in.

1:33:56 So that's why what a lot of people will do is they do

1:33:58 the the whole caf nap or the nappuccino or whatever they call it where,

1:34:02 like, they drink the coffee, take a nap for 15 to 20 minutes,

1:34:05 wake up right when the coffee starts ramping up and then they then they go.

1:34:09 Rhonda: I've never heard of that.

1:34:11 Michael: Oh yeah, it's a thing.

1:34:13 Um, I mean, I don't do it,

1:34:15 but I—not because I have any moral, you know, opposition to it,

1:34:19 but it's a thing where where because they leverage

1:34:21 the delay in in the caffeine reaching its effectiveness.

1:34:24 So, and they and they use that to limit their nap time.

1:34:28 But we can talk about strategic napping a little bit later.

1:34:30 Rhonda: Yeah, let's do that.

1:34:31 Before we continue, I just want to mention something important.

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1:34:40 It's the only way to ensure you'll be notified when a new episode goes live.

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1:34:55 Now, back to the episode.

1:34:56 Okay.

1:34:57 Well, let's talk about supplements.

1:34:58 Okay.

1:34:58 I mean, obviously, we're talking about

1:35:01 behavioral interventions being absolutely the best.

1:35:03 Michael: Um, the most likely to actually help.

1:35:05 Rhonda: Okay, that's the way that's— Michael: That's the way I think about it.

1:35:09 It's like they don't always work and other things may sedate you more faster,

1:35:14 but they're the things that are most likely to solve

1:35:17 your problem long term with the least negative effects.

1:35:19 Rhonda: What about, you know,

1:35:21 you talk—you were talking about early light exposure.

1:35:24 Um, the timing of, like,

1:35:25 going to bed at the same time versus waking up in the morning at the same time.

1:35:29 How does that play a role?

1:35:31 Michael: I would say focus more on starting

1:35:34 the morning than timing your bedtime at the same

1:35:37 time because the morning will set up the evening

1:35:39 and usually people have more control over that anyway.

1:35:43 Um, and the way I like to think about the evening is I think about sleep

1:35:51 as my commute to tomorrow where instead of thinking—so if you had to go to work,

1:35:57 you don't think, "Well, I'm going to wake up when I want,

1:36:00 I'm going to do everything I need to do around the house,

1:36:02 pay all my bills, do all the dishes, do all my chores,

1:36:06 and then when I happen to be done,

1:36:08 hope that I make it into work in time." And then,

1:36:12 like, "Shoot, I ran out of time." Like, that doesn't work.

1:36:15 Instead, what you do, you think, "What time do I need to leave the house?

1:36:18 How long is it going to take me to get ready?

1:36:21 What do I want to do in the morning?

1:36:22 What do I want to go for that walk or whatever?

1:36:24 What time do I need to wake up to make

1:36:28 that happen?" And that's how we should be thinking about sleep.

1:36:32 Because then you should be thinking, keep going and think,

1:36:34 "Okay, how much sleep do I want to get?

1:36:36 How much time do I need to budget with a couple of awakenings

1:36:38 during the night or whatever that's normal to get that amount of sleep?

1:36:42 When do I want to be in bed with to to be

1:36:45 able to fall asleep when I want to be able

1:36:47 to get all the sleep I need so that I wake

1:36:49 up naturally when I want to be woken up fully refreshed?

1:36:52 So when do I need to start winding down?" So you think backwards.

1:36:56 And so the the the nighttime routine regularity I think is important,

1:37:02 but I think more important is

1:37:04 thinking strategically about it and start thinking,

1:37:07 "Based on my goals for tomorrow, when do I—when do I need to be up and when

1:37:12 do I want to go to bed?" But the morning routine,

1:37:14 building regularity will help set you up to be tired at the time you want to be.

1:37:19 But going into bed at a regular time when you're not ready for sleep,

1:37:23 that's bad stimulus control.

1:37:25 That'll set you up for problems later.

1:37:27 So, that's also why I don't stress the nighttime getting into bed,

1:37:30 cuz what if you're not ready?

1:37:31 If you're not ready, if you're not hungry, don't eat.

1:37:34 Like, if you're not ready, don't sit there and and count sheep for an hour.

1:37:39 That'll just make you stressed.

1:37:41 So, it's—that's why I focus the regularity on the morning.

1:37:43 Rhonda: So, you think people should try to have

1:37:46 a consistent wake up time in the morning?

1:37:48 Michael: It's possible, but not everyone—not everyone can.

1:37:51 And, like, maybe your wake up time during the week is

1:37:54 uncomfortably early and you want to sleep in on the weekends.

1:37:56 I got no problem with that.

1:37:59 Uh, regularity is good, but, like, if if it means you're you're getting

1:38:05 a little bit of extra recovery on the weekends,

1:38:07 you know, it's it's a it's a trade-off.

1:38:08 There might be a net positive there.

1:38:10 Rhonda: But if they do—if they are waking

1:38:12 up early in the morning during the week,

1:38:14 then you'd think they'd be—they're building up

1:38:16 enough sleep pressure to fall asleep earlier.

1:38:18 Michael: Right?

1:38:18 You'd think.

1:38:19 And it's just that they have insomnia.

1:38:21 If they—and if they—that assumes they're giving themselves permission to go

1:38:24 to sleep at a time that is ideal for them.

1:38:27 A lot of people don't give themselves permission to go to sleep.

1:38:31 You know, we have this whole concept of revenge bedtime procrastination

1:38:34 where you're only taking—you're taking revenge on your own day, right?

1:38:37 And your own resentment of your life being too full

1:38:41 of junk and crap to have no time for yourself.

1:38:46 And it's tough.

1:38:48 And and the way the way I put it, though,

1:38:50 is I I I think you're cutting off your nose to spite your face at that point.

1:38:54 When people say, "I know I should be going to bed earlier,

1:39:00 but you're asking me to give up the one hour

1:39:03 in my day that's mine that I need for my own mental health.

1:39:06 What do you say to that?" And I say, "You're right.

1:39:10 I am not going to ask you to give up time.

1:39:13 What if I could give you some more of your time back?

1:39:17 What if the reason why that is the only hour in your day

1:39:20 that you have is because you could be more efficient and productive

1:39:25 during the day and you won't need as much buffer time on stuff

1:39:29 if you were a little sharper?" And actually that's what the data show,

1:39:34 that actually instead of asking you for time.

1:39:37 So, we did this.

1:39:38 We—I went into, um, to the university,

1:39:40 into the division one athletes cross all the different sports.

1:39:43 And I said, "Look, I'm not going to ask you to sleep more,

1:39:46 but if you want to fall asleep faster,

1:39:47 here's how you do it." And we'll get into what

1:39:49 I said because I'm sure you're going to ask.

1:39:51 Um, how do you fall asleep faster if you want to?

1:39:53 If you need to wake up early,

1:39:54 how do you fall asleep earlier than your body wants to?

1:39:57 How do you get moving during the day?

1:39:58 Let me teach you how to do this so that you become your own sleep expert.

1:40:02 And if you want to get more sleep,

1:40:04 here's what some of the benefits would be if you're not getting enough,

1:40:09 especially in students, especially in athletes.

1:40:11 Um, but I'm not going to tell you what to do.

1:40:14 Like, I don't know your life and I can't control your schedule,

1:40:16 but here's how to make an informed choice.

1:40:19 On average, time in bed increased by 40 minutes.

1:40:23 Total sleep time increased by over an hour.

1:40:25 Most of the time they needed, they were already in bed anyway.

1:40:29 And and they gave—they gave up those extra 40.

1:40:33 I didn't ask for it.

1:40:34 They they found what was useful for them and they—and

1:40:38 actually they were rating themselves as their grades were better.

1:40:41 They were more productive.

1:40:43 Their social life was better after they were sleeping better.

1:40:48 Rhonda: And so what did they do?

1:40:50 What was the protocol?

1:40:51 Michael: So first of all, I hammered stimulus control.

1:40:54 Um, I normalized some things like, you know,

1:40:56 they would—what would happen is they would freak out when they wake

1:40:59 up during the night and they have trouble getting them back to sleep.

1:41:01 I said, "Don't freak out.

1:41:02 Just take a break, 5, 10 minutes, get a drink of water, whatever,

1:41:05 go back to bed." And like reducing that performance anxiety,

1:41:09 hammering stimulus control, um, wind down routine stuff like dimming lights,

1:41:13 um, gave them blue blockers, you know, we like—and in terms of morning routine,

1:41:19 talked about getting light first thing in the morning.

1:41:22 Um, a lot of that basic stuff,

1:41:25 but really it was—and it also coupled it with some

1:41:28 education of—it talked about how the different sleep stages work.

1:41:31 Talked about how sleep works, not as like a "This is sleep 101" class,

1:41:36 but it's more of a "Look, you're an athlete.

1:41:39 You're trying to do all this stuff with your body and have

1:41:42 it in peak condition and understand what's going under the hood.

1:41:44 Let me teach you what you need to know

1:41:46 about what we know about how the system works so

1:41:49 that you can make the most informed choice that you

1:41:51 can make." Teach them about how circadian rhythms work.

1:41:54 Teach them about how sleep propensity builds across the day, dissipates,

1:41:57 and when they're awake in the middle of the night,

1:41:59 it just because they haven't built up enough sleep pressure yet.

1:42:01 So, you got to give it a little bit of time before you can go back to sleep.

1:42:04 Like, teach them how these processes work so that it demystifies

1:42:08 it a little bit so even if they have an awakening,

1:42:12 it doesn't become a stressful one.

1:42:13 And if they want to fall asleep earlier,

1:42:15 they can learn to program that in and create those conditions for me.

1:42:19 Like we we hammered the don't lay down in bed.

1:42:21 So like if you're college students, their bed is also their couch and it's

1:42:25 also their desk and it's also their whatever.

1:42:27 So we had a sleeping part of the bed, wake part of the bed.

1:42:30 You know, when you're in the wake part of the bed, you're sitting up.

1:42:33 You know, you can lean back, but you're not going to lay down

1:42:35 with your head on a pillow unless you're planning it.

1:42:37 So we separated these things out.

1:42:39 Worked beautifully.

1:42:39 Rhonda: How many weeks?

1:42:41 Uh, Michael: we did it for a semester,

1:42:42 so it was like it was like eight to 10 weeks.

1:42:45 Rhonda: Eight to 10 weeks.

1:42:46 That's amazing.

1:42:46 Michael: Yeah.

1:42:47 That's like typically six to eight weeks is normal.

1:42:49 That's usually even people who come in and say,

1:42:52 "My sleep is terrible." Often, you know, and I'll say like, "Look,

1:42:57 it's extremely unusual for someone to walk in unless

1:43:00 they have some other major medical complication that's getting

1:43:02 in the way that within 6 to 8 sessions

1:43:05 they're usually sleeping way better." Often by then they're like,

1:43:09 "You know, this isn't my problem anymore." And I'll say,

1:43:11 "You know where to find me if you need me." Rhonda: Oh, that's awesome.

1:43:14 Michael: Yeah.

1:43:15 Rhonda: Okay.

1:43:15 Well, let's talk about let's talk about a couple supplements.

1:43:17 Michael: Yeah.

1:43:18 Rhonda: Um, I definitely want to get into jet

1:43:20 lag in a little bit later, but you know,

1:43:23 obviously the most the top of- mind supplement

1:43:25 people think about when they think about sleep, they think melatonin.

1:43:27 Michael: Melatonin.

1:43:27 So, melatonin is a hormone.

1:43:29 It's a very old molecule.

1:43:31 It's in plants.

1:43:31 It's in other stuff.

1:43:33 It's not a sleep hormone except by association.

1:43:38 Melatonin is the hormone of darkness.

1:43:42 Melatonin is a nighttime signal.

1:43:43 You produce it at night.

1:43:45 A great example of how it's not a sleep signal:

1:43:48 it has no sedating properties whatsoever.

1:43:51 Melatonin doesn't.

1:43:52 You give melatonin to a nocturnal animal,

1:43:55 it wakes them up because it's a nighttime signal.

1:43:58 To to the degree to which your body

1:44:01 gets a nighttime signal and that makes you sleepy, yes, it can promote sleep.

1:44:06 Melatonin can promote sleep in humans.

1:44:08 For that reason, it can help you fall asleep faster.

1:44:12 It can help you stay asleep.

1:44:14 It can help you sleep more

1:44:17 restfully because it's strengthening that nighttime signal.

1:44:21 That's what it does.

1:44:23 It's also why it is almost universally useless

1:44:27 for insomnia because if you have a conditioned arousal,

1:44:31 remember now now everyone knows what conditioned arousal is.

1:44:34 If you have a conditioned arousal,

1:44:36 your body already knows it's nighttime, still can't sleep.

1:44:42 So taking melatonin is almost never going

1:44:45 to work to treat an insomnia condition.

1:44:48 But if you don't have conditioned arousal,

1:44:51 if you don't if you just need a little bit of a boost,

1:44:54 actually melatonin probably works just fine.

1:44:56 It's also you produce it natural during the day.

1:44:59 Your levels are almost non-existent.

1:45:01 They start rising in the early evening.

1:45:03 They pick up.

1:45:04 They peak during the night and then they drop off

1:45:07 right about the time you expect the sun to come up, and light suppresses it.

1:45:11 So even if you're at peak levels during the night,

1:45:14 turn on a bright bathroom light, plummets.

1:45:16 Then you turn the off the light.

1:45:18 As long as the clock still thinks it's nighttime, it'll regenerate them again.

1:45:22 Might take a delay, especially the older you get,

1:45:25 the the less flexible the system is, but that happens naturally.

1:45:30 Now, some people when they take melatonin,

1:45:35 they might be taking the wrong dose at the wrong time.

1:45:40 So the way we started using melatonin as as a as a treatment

1:45:45 for something was our natural rhythms are about 24 hours hours, you know.

1:45:50 So so some creatures, they use light from the sun to so like when

1:45:54 you put a a a blanket over a bird's cage,

1:45:57 they'll go to sleep because their natural melatonin starts spiking as soon

1:46:00 as it's dark and then it suppresses as soon as it's light.

1:46:03 Humans, we have mammals,

1:46:05 we have our own internal clock that guesses what time it is.

1:46:08 So, we could be in a cave and still keep a roughly 24-hour cycle.

1:46:12 Otherwise, the systems in our body would get all out of whack,

1:46:15 but it's not precise 24 hours.

1:46:17 It's a biological clock that is slightly

1:46:19 longer than 24 hours in almost everybody.

1:46:22 Not quite 25 hours, but somewhere in that gray zone.

1:46:25 But what happens is so it's like if you want

1:46:27 to if every day of your life is a string

1:46:30 and every day is going to be 24 hours and you

1:46:33 had to produce the string to be the exact same length,

1:46:36 what you do is you make all the strings slightly long and trim the edges off.

1:46:40 That way you can guarantee they're all going to be the same.

1:46:43 And that's what physiology does to your rhythm.

1:46:45 It makes it slightly longer than 24 hours,

1:46:47 then resets it in the morning to start it all over again

1:46:50 with the morning light as it hits the reset on the rhythm.

1:46:55 So blind people who can't see light,

1:46:58 they get this, their natural rhythm never gets reset.

1:47:02 So it's slightly more than 24 hours.

1:47:05 So if you were living a slightly more than 24-hour rhythm,

1:47:08 you woke up at 6:00 today, you'd wake up at 6:30 tomorrow,

1:47:12 you'd wake up at 7 the next day,

1:47:14 and then eventually you're waking up at 2:00 in the afternoon.

1:47:17 It's miserable.

1:47:17 And then it cycle around.

1:47:18 It's called it's called non 24-hour circadian rhythm disorder,

1:47:21 um, where you just can't reset your rhythm with light.

1:47:25 They found is you give someone a third to a half

1:47:29 a milligram of melatonin in the evening and a blind person,

1:47:32 fixes the whole thing.

1:47:33 Sends the nighttime signal at the time when it needs

1:47:36 to see it and the system responds beautifully to it.

1:47:39 You're not trying to replace their natural melatonin.

1:47:43 That half milligram dose is the signal.

1:47:46 It's the clock signal.

1:47:48 It's it's what tells your body, "Hey,

1:47:51 nighttime now." And if you give it a little bit before

1:47:54 you're naturally going to start producing it or right around that time,

1:47:59 it sends the signal a little early.

1:48:01 So, it's sort of like your body responds of like,

1:48:04 "Oh, I didn't realize it was night time yet.

1:48:07 Better get started." And it starts your own natural process a little early.

1:48:11 So that half milligram dose in the evening, like five hours before your bedtime,

1:48:16 that's the evening signal where your evening is hasn't even really started yet.

1:48:22 You're giving your evening a little bit of boost.

1:48:24 So that's so it's basically like jetlagging yourself where you're

1:48:27 you're telling your body it's nighttime before it's actually nighttime.

1:48:30 That's not what you're really telling it.

1:48:32 You're telling it it's evening before it's actually evening.

1:48:34 Like right around dinner or like usually 2 to 3

1:48:37 hours before your typical bedtime is when you start producing melatonin.

1:48:41 You give it a couple hours before that.

1:48:44 It's in the zone where you're looking for it.

1:48:46 Like give it in the middle of the day, your body's not looking for it.

1:48:49 It's in the zone where your body is looking for it and you

1:48:52 can confuse the system and tell think it's later than it really is.

1:48:55 That also means you'll wake up a little

1:48:56 earlier because the whole thing got shifted.

1:48:58 Same thing as if you take that low dose

1:49:00 melatonin as soon as you wake up in the morning,

1:49:03 that drop gets delayed a little bit.

1:49:06 So it ends so that ball lands a little further along than it expected to.

1:49:12 So your day started a little bit later than it thought it was going to.

1:49:17 So you'll stay up a little bit later the next night.

1:49:19 So you can use that half dose, half milligram dose as a clock shifting dose.

1:49:24 So then why is everything over the counter like five and 10?

1:49:28 Well, a, people think more is more and sometimes more is less,

1:49:32 especially with melatonin.

1:49:33 Uh, if it's just a nighttime signal, more doesn't— is it more?

1:49:38 Um, five you can take closer to bedtime.

1:49:42 That's a little more of a sleep promoting dose

1:49:44 where it's more of like a "Hey body, you idiot.

1:49:47 If you didn't know it was night time already,

1:49:49 I'm going to scream it in all capital letters for you and get

1:49:52 your act together," and and it'll boost

1:49:55 that na whatever natural sleep drive you have,

1:49:58 um, that isn't interfered with by insomnia, it'll it may boost it.

1:50:01 So people who take that 3 to 5 milligrams within,

1:50:04 you know, closer to bedtime, it can have that sleep promoting effect.

1:50:09 Not because the melatonin was sedating,

1:50:11 was it sort of got was that strong enough

1:50:13 signal to kick you into gear a little bit?

1:50:15 Now, a lot of times people will feel groggy in the morning with it.

1:50:19 That's because you just couldn't metabolize it fast

1:50:22 enough that you gave yourself such a big dose.

1:50:25 You already were naturally producing it anyway.

1:50:27 So, you were you were o you overfilled your bucket.

1:50:30 And so, by the morning,

1:50:32 you still have melatonin floating around [Music] backfiring.

1:50:36 So, now you're telling your body it's night time when it's

1:50:41 daytime because you couldn't get rid of the nighttime signal fast enough.

1:50:43 And and it and it had built up over time.

1:50:46 So often when I say if you're taking melatonin at night

1:50:48 and it's helping you but you're feeling groggy during the day,

1:50:51 cut your dose in half.

1:50:52 Rhonda: And and then there's the other problem.

1:50:54 There was like a few studies that have been published where I mean

1:50:57 almost all these melatonin supplements that are

1:50:59 out on the market have huge variations.

1:51:02 Some of them have like 100 times

1:51:04 more melatonin than actually what's on the label.

1:51:06 Michael: Yeah, those.

1:51:07 So, so that's the thing where there's a lot

1:51:11 of them out there that can be unreliable,

1:51:15 especially from some of the manufacturers

1:51:17 that don't have the good quality control.

1:51:19 It is regulated by the FDA.

1:51:21 It's just, you know, there's just not enough money for enforcement.

1:51:24 So, there's not a ton of enforcement.

1:51:26 But any of the larger companies,

1:51:28 they're actually going to have pretty good quality control.

1:51:31 And they are, if you look at those, the ones

1:51:34 that are the bigger companies that are on the shelf,

1:51:36 they are almost always right on target for what they should be.

1:51:41 And I say that because what's on the bottle

1:51:44 is actually not what's supposed to be in the bottle.

1:51:46 And a lot of people don't know this, but the bigger companies

1:51:50 that have the higher quality and the higher

1:51:54 quality control are following the law.

1:51:56 And the law says that the amount on the bottle has to be within

1:52:01 a certain percentage of the amount that's in the pill at the expiration date.

1:52:07 That is the definition.

1:52:08 So, if you have a supplement that's

1:52:10 sitting on a shelf with a three-year expiration

1:52:13 date and you're working with a company that's

1:52:15 trying to do everything really well and correctly,

1:52:17 your chemists and food scientists have to calculate exactly how much they have

1:52:22 to put in that pill so that as it degrades naturally over time,

1:52:27 how much will it degrade to the point to hit the target 2 to 3 years out?

1:52:35 That's actually the calculation they're making.

1:52:37 So, in melatonin, that answer is usually 30 to 50%.

1:52:42 So, when you buy melatonin off the shelf and it says five,

1:52:49 it's probably closer to eight, seven or eight when you buy it.

1:52:54 And then two to three years later, yeah, it's five because they did their job.

1:52:59 They followed the law and they had really high standards in their manufacturing.

1:53:05 But it's still the you're probably taking a much you're probably taking a higher

1:53:08 dose and they can't tell you because the way the law is written,

1:53:11 it's like if you if you tell people what's

1:53:13 in there is different than what's on the bottle,

1:53:15 you've now changed the label and now you have to meet that.

1:53:17 It's it's complicated.

1:53:18 The law was written in in the way that I think they didn't foresee this problem.

1:53:23 But people need to know that actually if it's a good brand,

1:53:29 it's actually going to be higher than what's

1:53:31 in the bottle because they're going to calculate

1:53:33 in the overage needed to to be able

1:53:35 to degrade to the point that it hits the target.

1:53:37 Isn't that crazy?

1:53:38 Like people don't know this.

1:53:39 Rhonda: So less is more for sure with with when— Michael:

1:53:41 That's also why I say if you're still having effects,

1:53:43 actually your dose might be too high.

1:53:44 Just cut it in half.

1:53:45 Um, the other thing that's worth mentioning

1:53:47 about melatonin is it's actually a very potent, um, cellular repair molecule.

1:53:52 M, those effects don't really seem those effects

1:53:55 seem to be stronger at the higher doses actually, like closer to the 10.

1:53:59 Um, but that's where you get more side effects too.

1:54:02 So most people don't need it.

1:54:04 Like we have an immune system.

1:54:06 Melatonin as a recovery molecule is a very old molecule.

1:54:10 Uh, our immune system probably does does the trick,

1:54:13 but that's also why when people take melatonin supplements, they get sick less.

1:54:17 Um, it was seen as an adjunct treatment during

1:54:20 COVID that didn't conflict with any of the other treatments,

1:54:23 but actually made illness recovery better.

1:54:24 Melatonin is a very is a really cool molecule.

1:54:27 It's just misunderstood.

1:54:28 Rhonda: Yeah, it's a hormone.

1:54:29 I think it's a hormone.

1:54:30 It's regulating like 500 different protein encoding genes.

1:54:32 Michael: Yeah, it's a lot.

1:54:33 It is.

1:54:34 It is a hormone.

1:54:35 What other hormone do you just like buy

1:54:37 over the counter in sort of unlimited amounts?

1:54:39 Like it's weird.

1:54:40 Rhonda: Right.

1:54:40 So, when it comes to melatonin,

1:54:42 I know there's like a lot of questions I get from people is,

1:54:45 well, if you're taking a melatonin supplement,

1:54:47 are you going to then stop making endogenous melatonin?

1:54:50 Michael: Yeah, there is to my knowledge there is

1:54:54 no evidence that this that that actually ever happens.

1:54:58 To my knowledge, it's a worry,

1:55:00 but melatonin is so is so old that like you're going to produce it.

1:55:06 Like the the way to stop producing natural melatonin would be aging.

1:55:11 That reduces it.

1:55:12 But to my knowledge,

1:55:14 there is no data that shows that continual use of supplementary melatonin

1:55:20 changes or or reduces your ability to naturally produce it at night.

1:55:23 Rhonda: What about and that's also what the conclusion I came to.

1:55:26 Um, what about the ability to like your melatonin receptors?

1:55:30 Michael: Like, um, is there remodeling?

1:55:32 I don't know.

1:55:33 I I haven't seen anything that's concerning in any way.

1:55:36 I I just I just haven't like no one has there there's no finding

1:55:41 that's that when when people have looked

1:55:43 it doesn't really seem to be doing that.

1:55:45 It see it doesn't seem to change the same way other receptors do.

1:55:49 Again, it's a very old system.

1:55:51 It's an old built-in system that that isn't that is meant to adapt that that is

1:55:57 meant to be able to deal with flexibility

1:56:00 rather than respond to it super quickly.

1:56:02 Um, Rhonda: I haven't seen anything either, but I'm not sure that's the answer.

1:56:05 Michael: I haven't seen anything either.

1:56:07 I mean, maybe like maybe findings will come

1:56:08 out in the future when people look at it.

1:56:10 This is the other thing that other people need to know.

1:56:13 This is about supplements in general, that research on supplements is scarce,

1:56:18 especially really well done research in highly controlled conditions.

1:56:22 Not because, to be honest, not because there's any sort of like

1:56:26 conspiracy to keep the information out of people.

1:56:27 It's just that research is extremely expensive to do.

1:56:30 My day job is in research.

1:56:32 That research is extremely expensive to do in pharma.

1:56:36 It's because, you know, you can do some of that basic stuff,

1:56:42 um, with with research and pharma has the deep pockets to do this.

1:56:46 And the reason they do is because they have

1:56:48 IP wrapped around this, why drugs are so expensive,

1:56:51 because it costs about $2 billion to bring

1:56:53 a drug to market in 10 years at least.

1:56:57 In supplements, you don't have that IP protection.

1:57:00 You can't patent a supplement that naturally occurs.

1:57:03 You might be able to patent a molecule as an as an additive or something,

1:57:07 but that's extremely rare in the supplement space.

1:57:09 So, supplement companies have no,

1:57:11 they can't a they can't charge what drug companies can charge.

1:57:15 They don't have the deep pockets to pay for this research.

1:57:17 They don't have the IP protection around it, which would incentivize them.

1:57:20 Why would why would a manufacturer spend a spend $2 million on a clinical

1:57:25 trial that their competitor could just take

1:57:26 the results from and claim as their own?

1:57:28 Like and NIH who funds,

1:57:31 I mean people need to understand how absolutely fundamental

1:57:36 NIH is to all health research in the US.

1:57:40 I mean every every bit of health research

1:57:43 in the US absolutely depends on a healthy NIH.

1:57:47 And NIH, as much as they fund whatever,

1:57:50 I mean they're they're dramatically underfunded already compared to the need,

1:57:56 but supplements don't seem to ever rate as high

1:58:00 enough priority where like they're dealing with trying

1:58:04 to cure cancer and Alzheimer's disease and and other

1:58:08 and sleep apnea and other major health conditions,

1:58:11 and supplements by definition don't treat medical conditions.

1:58:13 They promote health, but they don't treat conditions.

1:58:15 Rhonda: They might prevent, help prevent.

1:58:16 Right.

1:58:16 Michael: They might could, they could.

1:58:19 It's just it's it's people don't understand

1:58:23 how competitive grant applications are for NIH.

1:58:27 And so to survive that competition studying supplements is really hard.

1:58:31 So that's why like the the deep pockets don't

1:58:34 have as much of an incentive to study it.

1:58:36 So it's not that it's not that anyone's trying to hide the research,

1:58:39 it's that it's really expensive to do and no

1:58:41 one's stepped up willing to pay for it.

1:58:43 Rhonda: Yeah.

1:58:43 It it's why there's not a lot of high quality studies out there

1:58:46 on supplements and you always have to take it with a grain of salt.

1:58:48 Michael: Right?

1:58:49 Rhonda: And it's like— Michael: It's not the supplement's fault.

1:58:51 It's not the company's fault.

1:58:52 It's just, you know, I would love for there I would there love for there to be

1:58:55 more investment or or or if there was a public outcry that like,

1:58:58 "Look, we need these studies." We hopefully we'll get them.

1:59:01 Rhonda: Well, with that said, are there any other,

1:59:04 I mean I've heard of a variety of supplements.

1:59:07 Like magnesium, lavender, glycine.

1:59:09 L-theanine.

1:59:09 Any, I mean, yeah, you know, moderate evidence that some of these work?

1:59:13 Michael: So a lot a lot of them

1:59:16 have evidence that they are definitely not nothing.

1:59:19 Um, none of them have beaten placebo to treat insomnia.

1:59:22 The closest that came was valerian, um,

1:59:24 but when you pool the data it still doesn't beat Insomnia,

1:59:28 uh, placebo for insomnia.

1:59:30 It can, but it is sedating.

1:59:32 It can be calming.

1:59:34 Um, magnesium also does seem to promote sleep in a number of different ways,

1:59:40 actually more than just one way.

1:59:43 Um, doesn't treat in—doesn't usually treat insomnia,

1:59:45 but it can help promote sleep.

1:59:48 Glycine, also great data on glycine showing that people who take glycine,

1:59:52 it can help, um, fall asleep, help stay asleep a little bit better.

1:59:56 Um, a lot of these supplements,

1:59:57 it can help you fall asleep and stay asleep a little bit better.

2:00:01 Some of them don't do anything to sleep per se,

2:00:03 but they work in terms of calming.

2:00:05 So, calming isn't sleepinducing.

2:00:07 Though for people who don't have insomnia,

2:00:10 because if you have conditioned arousal, you can be calm and still not sleep.

2:00:14 But for people for whom a little

2:00:16 bit of calming and relaxation is really helpful,

2:00:18 that's where things like the L-theanine

2:00:19 and some of these other more calming thing,

2:00:22 like the chamomile and some of that stuff that can be calming,

2:00:25 can actually be helpful,

2:00:27 um, even if they don't actually technically do anything on the sleep side.

2:00:31 Um, other things that can help promote sleep,

2:00:35 things that have anti-inflammatory and and antioxidating properties.

2:00:38 Remember, your body's doing a lot of that healing at night.

2:00:42 And so, if you can help give it those raw materials,

2:00:45 so this is where there's c—certain supplements

2:00:46 out there that actually seem to be,

2:00:49 um, seem to have some of those those anti-inflammatory properties.

2:00:53 And when you take them, you might be sleeping better.

2:00:55 I mean, when people take ibuprofen,

2:00:56 they can also sleep a little bit better because, like,

2:01:00 it it it—those awakenings and and arousals

2:01:02 due to discomfort might be just a little

2:01:03 bit less and might help you sleep through the night a little bit more.

2:01:07 Um, there's a few things,

2:01:08 like—but that's the difference where where just because something

2:01:12 is not nothing doesn't mean it is a cure all.

2:01:14 It's like not black and white.

2:01:16 A lot of these supplements can be helpful.

2:01:18 I recommend them for all of the things that they do,

2:01:21 but I also recommend them for none of the things that they don't do.

2:01:25 And I think there's a gray area that I

2:01:28 think people have a hard time wrapping their head around.

2:01:30 Rhonda: Yeah.

2:01:31 No, we're—I'm definitely not talking about insomnia.

2:01:33 And, you know, some people just like to have a little bit of help,

2:01:38 and glycine is interesting.

2:01:39 That's one I've been interested in.

2:01:41 And have you seen any of the thermal regulation stuff on that?

2:01:44 Michael: Yeah, like,

2:01:44 I haven't seen the thermal regulation stuff, poor body temperature,

2:01:48 but it seem—so so it's unclear to me whether that's a cause or an effect.

2:01:52 Rhonda: Right?

2:01:52 Michael: But but either way, does it matter if that's what you're taking it for?

2:01:56 Rhonda: It's more of a GABA inhibit—like more of that inhibitory— Michael:

2:01:59 Yeah, it does it does seem to promote that those inhibitory— But so,

2:02:03 a lot of people who are taking workout supplements at night for recovery, like,

2:02:07 take one that's—if you're taking aminos at night,

2:02:11 branched chain amino acids in general could be good for recovery,

2:02:14 especially after training.

2:02:15 And and if it's got some extra glycine in it, all the better.

2:02:18 But if it's got a lot of glutamine in it,

2:02:20 you want to not be using that because glutamine is act—is is activating.

2:02:24 And so, I mean, I've had athletes I've worked with who,

2:02:28 like, complain—complained about their insomnia.

2:02:30 Turns out they're taking these nighttime supplements

2:02:32 with a whole bunch of glutamine in it.

2:02:34 And that's sort of what's counter—that's that's what's getting in their way.

2:02:37 So, it's not just about supplements at night that can be helpful.

2:02:41 It's avoiding stuff that can get in the way, like B12.

2:02:43 B vitamins are good to take at night because they can help with recovery.

2:02:48 B12 helps boost the ability of light to suppress melatonin.

2:02:51 You don't want to take that at night.

2:02:53 You want to take that in the morning.

2:02:55 B12 is great in the morning because it can help

2:02:57 wake you up a little more for a bunch of reasons,

2:03:00 including its ability to help me light suppress melatonin,

2:03:02 but you don't want it at night when even

2:03:04 a little bit of light can get—start getting in the way.

2:03:07 Rhonda: Fascinating.

2:03:07 So, take your multivitamin in the morning, not in the evening.

2:03:10 Michael: Yeah.

2:03:10 If if I I I have—I have this dream one day of having, like,

2:03:13 an AM vitamin and a PM vitamin where, like, some stuff might be better at night.

2:03:17 Like, you want to—if if sleep is all about recovery and repair,

2:03:20 put those raw materials in play at the time you want to use them,

2:03:25 if they're going to degrade.

2:03:26 Or you could just take them in the morning

2:03:27 if they're going to hang out all day anyway.

2:03:29 But yeah, I mean, some of some the the—that

2:03:31 multivitamin you might want to take in the morning.

2:03:34 Rhonda: Okay, let's talk about substances that affect sleep.

2:03:38 This is another one.

2:03:39 I mean, a lot of people—we'll get into CBD because that's, like,

2:03:43 the biggest thing now that—I mean, I just hear it in peer groups.

2:03:46 I hear it on the internet.

2:03:48 I hear it in just everywhere in the audience.

2:03:50 Michael: Yeah.

2:03:50 Rhonda: Um, but kind of even a step ahead of that, you know,

2:03:54 was was marijuana, right?

2:03:56 Like, which has CBD and THC.

2:03:57 Michael: Right.

2:03:58 Rhonda: They're two separate separate compounds.

2:04:00 Michael: Totally separate, yes.

2:04:01 Rhonda: Right?

2:04:02 And so I kind of want to start maybe with THC.

2:04:05 Michael: Yeah.

2:04:05 Rhonda: Like, if someone's doing the whole shebang.

2:04:08 Michael: Yeah, THC is a good place to start

2:04:10 because THC seems to have pretty reliable effects on sleep.

2:04:13 Surprises nobody who's used it when I say that, but it can help you fall asleep,

2:04:18 can help you stay asleep, can help you feel more refreshed.

2:04:20 THC does.

2:04:22 However, there's three downsides of THC.

2:04:25 Um, four, if you're an athlete.

2:04:29 Uh, one is that the sleep-promoting effects fade over time.

2:04:34 So often it works great for a for a period of maybe a few weeks,

2:04:41 but then you'll notice that it stops working in the same way.

2:04:45 And so people start escalating doses for that reason.

2:04:49 And so maybe, you know,

2:04:51 I may—short-term benefits and long-term benefits are different.

2:04:55 That's number one.

2:04:56 Number two, in a lot of people, not—doesn't seem to be everybody,

2:04:59 but in a lot of people it can be a very potent REM sleep suppressor.

2:05:03 Um, a lot of people don't realize that anti-depressants also,

2:05:06 um, most anti-depressants are potent REM suppressors.

2:05:09 Like, you can all—you can knock out 50 to 75%

2:05:12 of all your REM sleep of the night by taking,

2:05:16 like, a Lexapro or an SSRI, um, or THC.

2:05:19 Rhonda: Does that affect memory?

2:05:21 Because isn't REM important for incorporating— Michael: Isn't that weird, huh?

2:05:25 Like, why is it if REM sleep is

2:05:28 so critically important—and we'll get to this when we

2:05:31 talk about sleep stages on wearables—if REM sleep was

2:05:33 so critically important for what it seems to do,

2:05:36 why is it that when when all these people

2:05:39 who are taking anti-depressants are not falling down,

2:05:41 not being able to remember things?

2:05:44 Don't know.

2:05:45 Um, it what it me—my hypothesis is

2:05:48 these processes are way more complicated than we realize.

2:05:51 And when we see a decrease in REM sleep,

2:05:54 what we're—we're not seeing a decrease in the process itself.

2:05:57 We're seeing a decrease in an effect of the process and in a down—like,

2:06:01 REM, what we call REM sleep

2:06:03 as these these physiologic signals and brain wave patterns.

2:06:06 Maybe it's downstream of whatever is happening under the hood.

2:06:09 And just because you don't hear the downstream signal anymore

2:06:12 doesn't mean the thing wasn't still happening to some degree.

2:06:15 But then again, with depressed people,

2:06:17 if their ability to process information is fundamentally

2:06:20 flawed and because you're—and I mean this, like,

2:06:22 when people are depressed, they see a neutral stimulus,

2:06:25 it feels negative to them and it makes their life more miserable.