Sleep Doctor: If You Wake Up Between 1–3 AM, Your Body Is Trying To Warn You | Dr Michael Breus

Let's just start off by going through some of the common mistakes you see people make, perhaps inadvertently, that is getting in the way of them having a good night's sleep.

Oh, it's a great question. There's a few. I think the biggest one is people get locked and loaded with the idea that they have to get 8 hours of sleep. And what ends up happening is, for example, if they stay up late, then they just add more sleep to the end of their sleep period. So, as an example, if they normally go to bed at, let's say, 10:00 and get up at 6:00, they get 8 hours. But let's say it's Friday night or it's Saturday night, they stay up till midnight. What do they end up doing? They end up sleeping in by a couple of hours in order to try to capture that extra supposed missed sleep. And I would argue that's probably one of the worst ideas that you can possibly have.

Let me explain why. When you wake up in the morning, sunlight hits your eye, uh, and, uh, you have a special cell in your eye called a melanopsin cell. And this cell sends a signal to the back of your brain to turn off the melatonin faucet in your head. But it sets a timer for approximately 14 hours later. It's called the melatonin phase response curve, right? So what I just said was the time that you wake up directly determines when melatonin, which is your internal, you know, sleep hormone, turns on, right? So if you have a variable wake-up time because you're trying to capture that 8 hours of sleep, you end up with variable melatonin time in the evening time, and that becomes highly problematic. There is a lower level limit. I don't want people to get less than about 5 and a half to 6 hours of sleep. However, if for whatever reason one night you get 6 hours, it's not going to be the end of the world.

In, I think your latest book, Sleep, Drink, Breathe, you have these top five sleep traps, and I wonder if we could go through those because I kind of feel that people are often doing things without realizing that it's negatively affecting their sleep. So, the five you put in the book are living out of sync with circadian rhythms. That's the one we just talked about. Playing catchup, freaking out. I mean, we can go through more, but maybe let's go to those two next. What's, what's playing catchup and what's freaking out?

So playing catchup is where you only get five and a half hours during the week and then you say to yourself, "Okay, I'm just going to catch up on my sleep over the weekend and add a couple, three hours and hopefully cumulatively across the week I will get the amount of sleep that I need." And the, the truth of the matter is, we have an argument about this in sleep medicine every couple of years. Some people say you can catch up, some people say you cannot catch up. It. Quite honestly, if I was the consumer, I would be incredibly frustrated because every couple of years it seems to change one way or another. Here's what I'll tell you. You can do, you can catch up some, but what you don't want to do is sleep in for a long period of time. So, as an example, if you wanted to catch up for, let's say, 30 to 45 minutes of extra sleep in, I don't think I have a huge problem with it. It's when somebody who normally gets up at 6:00 gets up at 9. They've completely thrown off their internal circadian rhythm. And you do that more than one night in a row and you get what's called social jet lag, where your entire circadian system shifts. And now Mondays are horrible. So as an example, stay up late on Friday, sleep in on Saturday. Stay up late on Saturday, sleep in on Sunday. Monday sucks because guess what your body wants to do? Stay up late on Sunday and sleep in. And that makes it even more difficult. So the weekend catchup, I think you can catch up for some, but I wouldn't say you can catch up for all. So my official recommendation is yes, you can sleep in for between 30 and 45 minutes, but no longer than that for sure.

Okay. So circadian rhythms, very important. We're going to talk more about them throughout this conversation. We've just dealt with number two, which is, you know, be careful with how much you try and catch up at a weekend. Okay.

Correct. But then the third one I think is really interesting and perhaps I don't know if you'd agree, but perhaps might be one of the biggest ones of all, which is freaking out. What do you mean when you say freaking out is a sleep trap?

So a lot of people get really upset about their sleep, right? And so as an example, they wake up in the middle of the night, uh, which, by the way, happens regularly for them, and they get very, very upset about it. They're like, "This is unbelievable. I keep having problems." And what happens is that escalates heart rate, which makes it harder to fall asleep, right? So, there's three main ways that we can get people to fall asleep: through lowering heart rate, lowering temperature, lowering anxiety. Those are the three, right? And so, when we look at those three in particular, lowering heart rate, lowering temperature, and lowering anxiety, freaking out affects all three. [laughter] So, when people start to get really upset about their sleep, guess what happens? Their anxiety increases. When your anxiety increases, so does your core body temperature and so does your heart rate. Now, you're moving further and further away from the actual sleep. I have a saying that I tell people all the time that I think is appropriate here. I tell people all the time, sleep is a lot like love. The less you look for it, the more it shows up, right? So, when you're out there in the world trying to find your perfect relationship, right, you can never do it. But the second you stop looking so hard, that person wanders right into your universe. The same holds true with sleep. The more you think about it, the more you worry about it, the more you freak out about it, the less likely you are going to be able to get your body to sleep. Now, don't, don't get me wrong. There are environmental issues, like you need to have a good setup in your bedroom, and also there are circadian rhythm issues. You need to know what timing is. But at the end of the day, I would argue 75% of sleep is between your ears, right? It's your mental state. It's your how do you create a mental state in order to allow your body to then fall into an unconscious state?

Yeah. One thing I was hoping to talk to you about, Michael, is this. It's something I've thought about in nutrition for a number of years now, which I think we can apply to sleep, which is this idea that we never used to need nutrition experts, right? You, you would learn nutrition from your family and culture. You know, your grandmother would make great food, you would have family dinners, the whole thing.

Exactly. And I sort of feel it might be similar with sleep, like, like I'm sure in more traditional societies who haven't been as affected by modernity, like, did they have all of these sleep problems? Did they need all of these hacks? So, what, what does it say about us as a society where we actually need people like you and me to actually help them do something that's very basic?

It, well, it's such a great question, right? Is like, you know, do, do we really need a sleep expert, right? Or a sleep doctor. And the truth of the matter is, maybe for some pathology, like for sleep apnea or narcolepsy, that makes intuitive sense for me. But for the general public, no. Like, let's be fair, 90% of the time I'm reminding people about something that their mother told them or their grandmother told them, right? Like, go to bed without the television on, or go to bed at the same time, or wake up at the same time. You know, "Here's some warm milk." Like all of those things, right, are real and they all really work if we just, let me, let me say it a different way. We all used to know how to sleep until we grew up and then life seemed to get in the way.

Yeah. Right. And so I think that's what ends up happening. And when we look at these cultures that have, uh, not a level of, of modern technology like what we do, they sleep better. Like I've got news for you. Like if you look back at the data, like I'll take the ultimate piece of technology, that kind of idiot Thomas Edison, he invented that thing called the light bulb. He screwed it up for everybody. Okay? Because as soon as you could work in the dark, people stop sleeping as much. So, I think we're as a society, we have a tendency to put something in our own way, a hurdle, if you will. Whether that's caffeine abuse, whether that's using alcohol to help us relax, whether that's playing on our phones until 3:00 in the morning, whatever it is, we're putting our own hurdles in front of us. And let's be fair, dude, like the basics are very straightforward. Go to bed when you're tired, wake up when the sun comes up, you know, exercise during the day, hydrate, have a few good meals, you should be fine.

Yeah. [laughter] We just touched on there, sleep trap number four, sleep-disrupting habits. And I'm sure all of those things you mentioned, we could go into a lot more detail, which, which we will do later on. But let's just go to that fifth sleep trap that you write about in Sleep, Drink, Breathe. You know, hoping the problem will go away on its own. Are you specifically talking about sleep disorders there, or are you talking about more lifestyle-related sleep issues, or a bit of both?

I think, I think both, if I'm being super honest with you. I think both. Uh, like an example of a sleep problem that goes away on its own because there are some that do. As an example is, uh, if your child doesn't want to stay in bed at night, right? Like most children don't at college age wander into their parents' bedroom and say, "Mom, I can't sleep." Right? Like it eventually it goes away, right? But something like sleep apnea, that probably doesn't just go away on its own, type of thing. So a lot of people avoid the idea of even sleep testing.

Rang, this is also another thing I think is kind of an interesting topic to bring up, which is a lot of people come to me and they're like, they have obvious symptomatology of a sleep disorder. So the first question I have is, "Well, why haven't you gotten sleep tested yet?" And they say, "Oh, I don't want to get sleep tested." I said, "Well, why?" And they said, "Well, I'm going to end up on a CPAP." Right? And so, just for your audience members to understand, most people are fearful that if they have a sleep test, they're going to end up with the diagnosis of something called sleep apnea. Right? Now, sleep apnea, for folks who don't know, it is a situation where you stop breathing in your sleep. This is very serious. Uh, we want all of our patients to breathe. Um, but most people will say, "Oh, I don't want to do that sleep test because I'm going to end up with the treatment for sleep apnea, which is a mask, uh, that you wear on your face that helps you breathe at night." Now, I want to be clear about a couple of different things. I want to kind of double-tap on a few things here. Number one, not everybody who has sleep apnea sleeps with a mask on their face. There are a whole host of protocols that we use nowadays to treat sleep apnea that are extremely effective and do not involve sleeping with something covering your face, but the most effective treatment that's out there happens to be a CPAP machine. So, I think there's a lot of people out there who just are fearful of the answer. Um, and even more so fearful of the protocol that could follow, which would be the treatment, which by the way, would make them feel like a million bucks, right? So, it's like, it's so funny because people like, "Oh, I don't want it. I'm claustrophobic. I can't handle it." And then at the end of it all, once we get them on treatment, whether it's a CPAP machine or not, it turns out that they, they do really, really well. That's something that doesn't just go away, right? Now, I will tell you that a lot of people turn to me with sleep apnea and they say, "Well, well, what if I just lose weight, Michael?" And, you know, weight loss can definitely help, but as a general guideline, you can still lose weight and have rip-roaring sleep apnea, right? So, let me give you another example of myself, right? So I personally, Dr. Michael Bruce, I have sleep apnea. I stop breathing in my sleep 26 times an hour, which is quite a bit [laughter], if you look at it, right? And guess what? I sleep with a CPAP machine. I wore it last night. You could probably see the marks on my face still from this morning, right? And so at the end of the day, you don't want to be fearful thinking that something is just going to magically disappear because nothing in a health-related situation usually magically disappears.

Yeah, that word, sleep apnea, could you explain what exactly sleep apnea is?

Sure.

But also, what are the signs that people may be experiencing, you know, that might indicate they've got sleep apnea?

Absolutely. So, here's there's a tricky one, uh, which everybody says and I want to say it first, but I want to put a caveat on it, which is snoring. Okay. So, not everybody that snores has sleep apnea. However, if I'm honest with you, most people that have sleep apnea do snore. So, it's kind of like it's a two-way street, but the traffic is different on one side of the street than on the other side of the street. Um, but, uh, snoring is one. Waking up in the morning with a headache, that's another symptom. Uh, waking up and being tired during the day, or waking up hitting the snooze button four or five times because you just can't get your butt out of bed. Uh, mood disruption, so up and down moods, uh, where there's some irregularity there. Um, also difficulty focusing, difficulty with attention. Um, there's quite a few symptoms that are that are out there. Um, also, let's be fair, most people kind of wake up and say, "Oh my god, I got a terrible night's sleep last night." That's something that sleep apnea people report all the time. Now, what is sleep apnea in effect? When you breathe in through your nose, you form a vacuum which pulls all of the tissue slightly back, just a little bit. If you are a large person, if you have big tonsils, if you have a deviated septum, all of these different scenarios, when you pull that tissue backwards, you can push it to the back of the throat and actually close the throat. Most sleep apnea is the back of your tongue touching the back of your throat. So, what we have to do is open up the pipe. Right? Now, there's a lot of different ways to do that. One is with a mask on your face. Pushes air up your nose and when it hits that area, it just ever so slightly opens it up, keeps you breathing all night long. But that's not the only way to do things. There's also something called an oral appliance. This is like a mouthguard, like, you know, like you see the football players wear, but it's an upper and a lower. And the lower is slightly forward. And when you move the jaw slightly forward, you open up the posterior airway space. Again, opening up the pipe is another way of doing it. Most surgical interventions do something once again to open up the pipe. So that's really what we're talking about here is anything that we can do to mechanically open this area up to allow people to breathe better and, and that usually works actually quite well.

Yeah. I really appreciate how open you are sharing your own story with sleep on the air. No, because, you know, it's really interesting. You're saying a lot of people are scared, they don't want to get tested, they don't want to have a CPAP machine. But I think there's also with health sometimes like an embarrassment, a shame, a guilt, right? And what's, and you are, you know, you are the sleep doctor, right?

I know. It's kind of ironic.

But is, but it's also I think quite empowering. It's quite reassuring to go,

Yeah.

"Oh, even though he is an expert in sleep, he also has this sleep condition that requires treatment." And I think another point there, which I think is interesting, is a lot of people associate sleep apnea with people who are overweight or obese, and you, of course, are neither.

No, not at all. So let me tell you the story because it's kind of an interesting story, right? So I call, uh, my doctor. So I have a concierge doctor, the woman who takes care of me. Her name is Dr. Carrie Bordeno. And, um, uh, I call Carrie up and I said, "Carrie, God, my workouts aren't as good as they used to be. I feel like I'm slowing down. I don't feel like I'm as, I've got as much, you know, kind of piss and vinegar in me like I usually. I'm a pretty energetic guy." And, uh, she said, "Well, let's run some blood work. Let's maybe something's going on." So, we run some blood work. Maybe she thinks maybe I'm anemic. Something's going on. We get the blood work back and my testosterone was at 400. Now, for folks listening, low T is 300 or less. So, I wasn't in the low testosterone area, but I, it's not like I had high testosterone. So, she said, "Let's try some testosterone. You're 58 years old." Or actually, I was 57 at the time. Like, let's try it. Let's see. May that's probably it. So, I'm like, "Okay, fine. I'm not a big needles guy." So, I did the oral, uh, testosterone. Uh, they were little, uh, gummies, right? So, I did that for about four or five months. Notice no difference. She said, "Look, the oral doesn't work as well as the injectable. Stop being such a wimp. Just do the injectable." So, I'm like, "Okay, fine. I'll stop being such a wimp [laughter] and do the injectable." So, I start doing the injectable, go for 3 months. Only thing that happens, I lose more hair, okay? This is not the response I'm looking for, okay? Like I'm looking for libido increase. I'm looking for energy increase. I'm looking for all these things. None of it happens. And so I call her back up and I'm like, "Look, nothing's going on in the right direction." And she said, "Hey, sleep doctor, when was the last time you had a sleep study?" And I was like, "You know what? It's been a minute." Right? So, I haven't had a sleep laboratory in about 6 or 8 years. And usually when you have a sleep laboratory, you test out equipment. I'm used to testing out, I hadn't tested any equipment out in like 8 or 10 years. So, I call up, uh, my buddy who, uh, actually is over at Sleep Doctor, which is where we actually run sleep tests for people. Uh, his name's Holland, and I said, "Holland, send me a test." So, he sends me a test. I wear it overnight. Boom. I get this number back of stopping breathing in my sleep 26 times an hour. So, you know what I did then? I didn't believe the test. I didn't. I swear to God. I was like, "Something's wrong with this test. Come on. I need another test." So, I called Holland back up and I'm like, "Holland, clearly there's something wrong with this test. Send me another test." He's like, "Dr. Bruce, there's nothing wrong with the test." I'm like, "No, seriously, dude. Send me another test." So, he sends me another test. Dead on same number.

Wow. So, look, I, even me, even me as the sleep doctor, I denied my first test result. Like, I, I was, I was convinced like, "I'm not that guy. Like, I'm not a bigger person. I don't have, you know, these terrible snoring. My wife doesn't hear me waking up, stopping breathing, none of this stuff." But sure enough, I've got moderate to severe sleep apnea, right? And it came across as low energy, right? And so that becomes important for people because you need to start looking down those paths and seeing what's going on. Do I look like an apnea patient? No, of course I don't look like an apnea patient. But to be fair, what does an apnea patient look like anymore? Like, I, I feel like anybody could be a sleep apnea patient and we need to be thoughtful and, and, you know, nowadays sleep tests are so cheap. They're less than $200 to have them sent to your home and you can have it done in the privacy of your own home these days. So it's, it really is quite remarkable. But yeah, that was kind of my story is, uh, I, I was not expecting, like when I got those test results back, I was kind of upset.

Do you have any theories as to why you have sleep apnea?

I do. So, um, so I went and I, I had another physician look in my throat. Uh, and so [clears throat] there's a couple different things that we think might be going on. So there it looks like I may have some excess tissue towards the back of my throat and that's where we think is the pinch is going on. Now, one question people ask me all the time is, "Well, why did you use, why are you on CPAP machines?" So, let's talk about that for half a second because it's kind of a funny story. So, um, so I've been putting people on CPAP machines for 26 years, right? And so, I've, and I've been talking about and telling, and I even slept with one for a little while just to kind of get used to it, but it wasn't on and I didn't have apnea at the time, so I didn't really know what the experience was like.

Right? Now I have a very different, uh, understanding and appreciation for being not just the doctor but also being the patient. So here's the funny story is about, uh, a year ago, not well, maybe less than a year ago, we got a new puppy. And, um, so in our house, as people have heard me say before, there's a big screen TV that's on all night long because that's what my wife watches all night long. And both of our French bulldogs sleep in our bed. Okay? And so the puppy wanders up and he likes to fall asleep in between my pillow and my wife's pillow. That's his favorite spot. Okay? And he likes to put his head on my wife's pillow. Okay? So what does that mean? That means that I get the rear end of the dog, a bulldog who farts all night long in my face. Okay? So, when somebody said, "Hey, Michael, you want to put a mask on your face that's got filtered cool air that's coming in?" I jumped at the chance. Are you kidding me? I was like, "Let's go." I adapted to it super fast. But I had a kind of a unique situation going on for me, but I think almost anybody can adapt. I think, and, and by the way, it might not be the optimal treatment modality for you. It was what I wanted to try first. I've enjoyed it. I've, I've done well with it. You can see I've got good energy. As you mentioned before we got on the podcast, I'm more of a night owl and it, here it's, we're filming this morning at 7:00 in the morning and I've got great energy. Why? Cuz I wore my sleep last night. You know?

At some point we need to talk about the sleep doctor sleeping in a bed with bulldogs and having a big plasma screen on in in our room. Let's just park that for a minute. Right. [laughter] In, in terms of what people come in to see you with. I've heard you say that one of the commonest things people come in to see you with is they say, "Look, I can get to sleep fine." Yeah. But I wake up between 1 and 3 a.m. Yeah. Tell us about that. You know, just how common is this? What are the causes of this? And then what can you actually do about it?

Absolutely. So, this is, uh, the number one question I get asked and I think I understand the reason why. But let's talk about what is actually going on biologically and why do people wake up somewhere between 1 and 3 o'clock in the morning. So sleep follows your core body temperature cycle, right? So as your core body temperature rises, rises, rises towards the end of the evening, it will hit a peak right around 10, 10:30. Depending upon your chronotype, it can be a little earlier or a little later. But let's just for the math, let's say right around 10:00, right? Is where you hit your peak. When you hit your peak, then the core body temperature begins to drop. That drop is actually a signal to your brain to release melatonin. Your core body temperature continues to drop, drop, drop, drop, drop. At some point, if your core body temperature doesn't heat your body up, you go hypothermic and you die. Okay? Guess what time that is? Somewhere between 1 and 3:00 in the morning. So, literally every person on Earth on Earth wakes up between 1 and 3:00 in the morning. But here's what happens. Most people burp, fart, roll over, and go back to sleep, right? However, there's a group of people, believe it or not, between 10 and 20% of the population that has difficulty at that moment falling back to sleep. So, let's talk about that particular situation now that everybody understands you didn't do anything wrong. I want to be clear, nobody out there did anything wrong to wake up in the middle of the night. This is your biology. What we need is a good strategy to get you back to sleep, allow the natural sleep process to take over. So, step number one, and this is going to sound a little strange, don't go pee. Yep, you heard it here. Don't go pee. Now, you, everybody's saying, "Wait a second, Michael. Like, what if I have to go to the bathroom?" So, here's the deal is remember the three things that help us fall asleep: lowered heart rate, lowered temperature, lowered anxiety. Right? What do you think happens to your heart rate when you go from a lying position to a seated position to a standing position, and you walk across the room to go to the bathroom, right? Your heart rate goes up, right? Inevitably, by the way, so does your temperature, right? So, now you've got your body is going in the wrong direction. Here's the reason I say don't go pee. Most people actually don't have to. Most people, what they say is, "I'm up. I might as well go pee, right?" This is a terrible idea. I want to be super clear. If you got to go pee, please go pee. I, I had somebody ask me this question. It was funny. They were like, "Well, should I put on those adult diapers?" No. No. Please go to the bathroom. Okay? But if you don't actually have to go to the bathroom, there's really no reason to do so. So, go ahead and stay in bed. So, that's hint number one. Number two, don't look at the clock. Now, this is hard for most people. So, what they do is they grab their cell phone and they go to the the restroom, right? Or they hit the loop. And what happens? The second you pick up your cell phone, you see the time and then you immediately do the mental math and now you've got anxiety, right? "Oh crap, it's 3:30 in the morning. Once again, I'm awake. Sleep, sleep, sleep." And you try to force yourself. Ranging it. In the, in the history of time, nobody has ever forced themselves to sleep without like anesthesia, right? So, like when you start to think about it, people are moving in the wrong direction when they look at the clock because they immediately get that level of anxiety. So, number one, don't go pee unless you really need to. Number two, please don't look at the clock. Don't look at your phone. Okay, didn't look at the clock. I'm lying in bed. Michael, what do I do? So, we need to get your heart rate to go down, your temperature to go down, and we need to stop something called monkey mind. Now, I don't have a formal definition for monkey mind, but I have a feeling most people know what it is, right? It's this weird list of things that pops into your head in the middle of the night that you start thinking about. Maybe it's one of your kids, maybe it's your partner, maybe it's business, maybe it's what you were watching on TV, maybe it's the grocery list, I don't know, but for some reason, you just start thinking, thinking, thinking. We want to avoid that. My favorite technique for avoiding this is called 478 breathing. Now, I know you've talked about, uh, breathing techniques before on the show. And by the way, love the show. Love all the the practicality that we get from your show. And this is one of those situations where I'm going to teach everybody how to do this 478 breathing. I think you might have mentioned it to people before, but I want to do a quick double-tap on it so people can understand it.

It's exactly what it sounds like. You slowly breathe in through the nose for a count of four. You then hold for a count of seven. Then you gently push out through your mouth for a count of eight. All right? 478 breathing. Now, I'm going to be honest with you, and Rangan, you know me, so you know this is true. I have a little bit of anxiety sometimes. And so, when I first started this technique, I couldn't hold my breath for 7 seconds, and I certainly couldn't push for eight. So, I modified the technique. So, everybody out there needs to understand number one, you can modify this technique. So, this is one of those, it worked in research and now we're using it in the field type of scenarios. So instead of doing four, seven, eight breathing, start out with four, five, six breathing. So, in for four, hold for five, out for six. Do this for 2 weeks, then move to 4, 6, 7, then move to 4, 7, 8. So, then you don't have any anxiety about your breathing. So that's one thing that's really important is to change the count so that you're the most comfortable with the count because what we don't want to do is cause anxiety. We want to lower anxiety. That's number one. Number two, I lose count. So it turns out you need 20, 20, two cycles of this 478 breathing and then your heart rate dumps to around 60. By the way, that's the magic number for sleep. In order to enter into a state of unconsciousness, people need a heart rate of about 60 or below. And this technique does that. However, you need 20 cycles to get there. So, how do you remember 20 cycles? Cuz I lose count halfway through. Then I get pissed off. Now I've got anxiety. Now the technique isn't working very well for me. So what I do is I take my hands and I gently make two light fists and I put them down by my side. And when I do one, four, seven, eight, I stick out a finger. And then the second one I stick out a finger. And before I know it, I've gotten to 10 fingers. And then when I wrap them back, I've made it to 20. Most of the time I've fallen back asleep at this point. And by the way, you've noticed me saying me, I use this technique myself. Do I have problems sleeping in the middle of the night? Occasionally, sure. Like to be fair, dude, like if something's going on with my daughter or something's going on with my son, I don't sleep well, right? That's that's a pretty normal occurrence, right? So 478 can be super, super duper helpful there. Um, the other thing I tell people to do is to picture the number in their mind. Now this turns out to be the single most important aspect to the breathing technique is picture a number four, then a number three, then a number two, then a number one, then picture the seven going down, then picture the eight coming back. When you picture the number, you're using your hands, you have distracted yourself so much from any of this monkey mind thinking and if you follow your own guideline, you're lowering your heart rate. Before you know it, you're out cold. It's pretty impressive if you want to know the truth. So 478 breathing with the modifications of using the hands to keep track, right? Maybe changing the number schema just so that it works well for you. And picturing the number in your head works incredibly, incredibly well. But let's say for half a second, you've tried it all. You got through 20 cycles and it still didn't work. Michael, what should I do?

As many of you know, when glucose is relatively stable, you feel better day-to-day with steadier energy, mood, and focus. But over time, unstable and elevated glucose can also impair your metabolic health and increase the risk of type 2 diabetes and cardiovascular disease. Now, globally, more than 760 million adults are thought to have pre-diabetes, many without symptoms or a diagnosis. And the problem is that our healthcare system often waits until you get sick before taking action, when we should take a proactive approach to prevent problems before they start. Now, many of us don't have access to our own glucose data and therefore don't have clear feedback on how our everyday choices impact our glucose. That's where Lingo by Abbott comes in. Lingo is a bio-sensor and app that helps you see how food, movement, and lifestyle choices affect your glucose in real time. So you can notice patterns and build healthier habits in the moment. With Lingo, you can get to know your glucose to build healthy habits for today and tomorrow. For listeners in the US and the UK, Lingo by Abbott is offering an exclusive 10% off a 4-week plan. Just scan the QR code on screen or visit hellolingo.com/livemore for more information. Terms and conditions do apply.

Well, there's now data on something called non-sleep deep rest. Um, we used to call it yoga nidra. Okay. And what is that? That's lying in a corpse pose on the on your bed, quiet, relaxed, cool, dark room. Believe it or not, it's rejuvenative. Like it's not as good as sleep, but if you do that for an hour, it's worth about 20 minutes of sleep. So even if you're lying there not sleeping, I'm here to tell you you're doing something good for your body. That helps lower that anxiety, right?

And then finally, stay positive. Now, I know this sounds a little ridiculous. You know, stay positive. What is, what is that supposed to mean? Here's the thing. When was the last time you woke up at 3:00 in the morning for a good reason, right? [snorts] Never, right? Nobody runs into your room at 3:00 in the morning and yells, "Happy birthday. You just got a raise." You know, some good piece of news, right? When you, when your body wakes up at 3:00 in the morning, there's a problem, right? There's an emergency, there's something going wrong, there's a noise, there's a shout, whatever. And so, your body immediately is negative in the middle of the night. And so, as a cognitive behavioral therapist, one of the things that I know is it's very difficult to stop your first thought, but you can stop your second thought, right? So, if the first thought is, "Crap, I'm up. It's 3:30 in the morning." Here's what your second thought can be. Is you can turn to yourself and tell yourself, "Okay, I've been here before. It's not like my head is going to explode. I, I may have a good night. I may not have such a good night, but I know after listening to that awesome podcast that if I try my 478 breathing or if I can just relax here and let the natural sleep process take over, I'm going to be fine." Right? That lowers your anxiety, lowers your heart rate, lowers your temperature, allows the natural sleep process to come back in.

Yeah. So many helpful nuggets in what you just said, Michael, which I kind of feel apply at other times of the day as well. Like, sure, they help you if you're up in the middle of the night.

Right. Right. Right.

But they're going to help us in other aspects of our life as well. And, and one thought I had when you were just talking about, you know, acceptance and having that positive mindset. Yes. Is it possible to say in a, in a compassionate way, not not in a judgmental way, that generally people who struggle with their sleep are a little bit stressy?

Yeah. Oh, I think that's easy. I, I mean, I think you're being kind. I would argue.

I'm trying to be kind. [laughter]

I think you're kind. I think they're a hot mess. Are you kidding me? But you're, you're hitting on something that I think is important. Positive mindset works. Okay. If you always have a negative mindset, there's a very high likelihood you're not a great sleeper.

Now, what's interesting about that is we know that when you become sleep-deprived, you have a far greater likelihood of being depressed and being more negative. So, this is a, this is a cycle. This is a watching machine that you can get caught up in is you don't sleep well, you have a negative affect, then you, that negative affect makes you not sleep well, and then you just, it just kind of compounds on itself.

Yeah. And I think that's a really important point, isn't it? It may be that you started off or maybe 5, 10 years ago you were upbeat. Um, you had a positive mindset, but then you started to have what you call sleep-disrupting habits.

Too much caffeine, too much alcohol late in the evening. Um, and then your sleep gets affected and therefore because you're sleep-deprived, your mood goes down. You feel less emotionally, good and optimistic about the world and then as you say, it becomes a self-reinforcing cycle. So I think that's important to acknowledge that it does work both ways. But if we just go back to what you were talking about there, if you wake up in the middle of the night. Okay. First, the first thing you were saying was that this is entirely normal. Okay. So no need to worry. The second thing I thought about as you were explaining, you know, your process for helping people,

Yeah.

is that we as humans get good at what we practice. We get good at what we repeat, don't we? And so you say, don't pee unless you absolutely need to, right? And we're talking about this through the lens of sleep. But for the people who actually are frustrated with how much they get up to pee at night, which of course then disrupts your sleep.

Yeah.

Yes. There can be all kinds of factors going on which we can think about and go through.

But I have had so much success, Michael, with people over the years by giving them that same piece of advice. Say, look, if you think you need to pee, just wait, right? Because if you, if you do get up and then go and pee, you are reinforcing that behavior. Right. So some people, not everyone, but some people can change that behavior.

Absolutely.

Just by training themselves. No, I'm not going to go. I don't really need to go. 10 minutes later, they're falling asleep.

Yeah. And I can remember one lady, like a few years ago, who literally that's all she had to do. And suddenly she's sleeping 8 hours a night and not getting up to pee when previously she was getting up three or four times a night.

Yeah. Yeah. It's that habit. It's that habitual behavior I think is what you're tapping into that we can often times tell people is probably not the best idea, right? Um, also, I mean, for those types of patients, also the very first thing I look at on the practical side of things is like, when do you stop fluids? Yeah. You know, so many people are like, "I got to get my water in," and so it's, you know, it's 9:00 at night and, you know, and they're trying to get their water in. I'm like, "Bro, you're going to be up all night." Like, [laughter] this is a bad idea.

And it literally can be sometimes, can't it? The most basic advice. Don't be drinking a load of fluid in the two, three hours before bed, you know?

Exactly.

Yeah. The other theme that came up when you were describing what to do when you're up in the middle of the night, is this idea of a monkey mind, right? A a busy mind. And of course, that can be one of the reasons why people don't fall asleep in the first place.

You know, if I reflect on my own sleep, I would say the biggest thing that I've noticed over the last few years for me is what do I do in that one hour before bed?

Yeah. If my one hour before bed is nothing to do with work or emotionally agitating, uh, topics, if it is relaxation, I'm generally sleeping really well.

Oh yeah. How you are before bed is how you will fall asleep. So if you're frantic and crazy and that, then you will have difficulty falling asleep. What I tell people all the time is you need runway to land the plane. Okay? Like that's how I like people to think about it, right? Is you've got to have some time to yourself. Like sleep is not an on/off switch, right? It's more like slowly pulling your foot off the gas and slowly putting your foot on the brake. There's a process that should occur there. By the way, if you fall asleep really, really quickly, that's not a good sign. Um, a funny story. I was on stage with Oprah Winfrey, of all people, many, many, many years ago. And, um, she said to me, "Tman falls asleep in a minute 37 seconds." And I said, "Oh, that's not good." She said, "Really?" I said, "That means he's sleep-deprived, right?" Because again, if you fall asleep super, super fast, don't get me wrong, there's some people out there that are fast sleepers, but generally speaking, if you fall asleep really quickly, it's probably a sign that you're sleep-deprived and that you may need to get a little bit more sleep. But when we look at the time period right before bed, I've broken it down into what I call the power-down hour, right? So let's say you're going to bed at 10, starting at around 9:00, I break that last hour up into three 20-minute segments. So, 20 minutes for just stuff you've got to do, right? So maybe it's last-minute emails, maybe it's, um, you know, getting kids' backpacks together, getting lunches together, finding sports equipment, you know, lots of stuff that you'd have normally going on in your house. I like to lay my clothes out for the next morning, things like that. So, stuff that will reduce your stress the next day. Then 20 minutes for hygiene, right? So, brush your teeth, wash your face, maybe take an evening bath or shower. And then 20 minutes for some form of meditation, relaxation, prayer, whatever gets you there. Read a book, watch a show. I don't honestly care what you do in that last 20 minutes, but it doesn't, it doesn't have a big level of engagement to it. Right? So, a lot of people say, "Well, wait a second. You said people can watch a show. What about scrolling on their phone?" Well, I'll tell you, the level of engagement that you have with your electronic device directly affects how well you're able to fall asleep or stay asleep. So basically, if you're trying to get your high score on Candy Crush, you know, you ain't trying to go to bed, right? And so what we want is we want people doing something that's relaxing, that's not important in their life, that's not intrusive in their life, so that way they can kind of trail off. That's why I personally always recommend reading a book. Because what's nice about reading a book is you can just turn it over and be done with it, you know, and, and close your eyes and, and turn off the light and fall asleep. And it's, it's a very easy, simple process. But people should have some type of a routine before bed. What we don't want people doing is falling asleep on the

couch watching TV in their normal day clothes, right? Then they stagger, you know, they pull their clothes off as they're getting to their bedroom. Maybe they brush their teeth, maybe they don't, and then they just fall into bed. That's not really the the process that we really want people to be doing. And that happens a lot more often than you think.

The way I used to explain it to patients, Michael, was I would say, "Look, do do you have kids?" And if they said yes, I would say, "Okay, so when your kids were younger, I'm guessing what you did was dim the lights, lower the tone of your voice, read them a story, right? Create this ambiance to say, "Hey, you're sort of preparing, as you say, runway to land the plane."

Yeah, we we know that kids need a routine for beds. Somehow as adults we think know we're immune like we're now grown up we don't need a a routine for bed and then you look at the statistics and how many people struggle with this that you go well maybe there's something to that and I guess what I shared with you before about that 1 hour before bed for me you can think about that as a routine that is absolutely that is my well it's my evening routine and I guess going back to that theme before that we get good at what we practice I think people also forget and And I know you you're a clinical psychologist as well as a sleep expert. I I think people forget that, you know, the brain is an associative organ, right? So it associates certain behaviors with certain locations and with certain times. So if you can start to create that sort of ritual that that repeatable lifestyle each night and I and I also want to acknowledge that not everyone can for for a variety of different reasons. You're just going to start conditioning this response which is oh you know when he starts to chill out and he puts his laptop down and he reads a book now I'm about to prepare myself for sleep.

Exactly. And and here's what's great about it is any routine that you develop for yourself probably works. Now, to be fair, drinking an espresso before bed probably does not, right? But most routines that people will do, whatever it is that calms you down. That is always the goal here is some level of relaxation. Basically, we want your heart rate to go down, right? Because then your temperature goes down, then your anxiety goes down, and then you fall asleep.

One of the things I have noticed quite a bit over the past maybe 5 to 10 years is that people will often say that they fell asleep fine and they think they slept through the night, but they're waking up feeling exhausted. Now, I noticed that if patients were mentally quite stimulated before bed, even if they slept for 7 hours or 7 and 1/2 hours, they still weren't fully refreshed compared to if they'd had that power down hour. Have you seen that as well?

So, this is a fantastic observation and it's 100% correct. So what I have discovered over the course of time is that there are some people that if they're just going going going going before bed, they do not report refreshing sleep. But the people who do take some time and who do allow themselves to relax, they oftenimes report more refreshing sleep. Now I don't have any data that I can put my finger on particularly to say, hey, this is this works or this doesn't work. But what I can tell you is as a clinician, you as well as a clinician, what you've observed is definitely what we see in the field all the time. Um, is it's very difficult for people if you've got a crazy crazy world going on to close your eyes and move from like let's be fair, nobody moves from 150 mph to zero in a good way, right? Like that doesn't like you know when you're in a car and and you slam on the brakes, it's not a good feeling, right? But if you slow the car down, you can you can come to a nice casual stop and be just fine.

What is the first night effect?

So the first night effect is pretty interesting. So this is something that we see in sleep laboratories all the time, but a lot of people experience it. It's when you are in a new environment and your brain is not used to it. Right? So I have I experience this a lot when I travel. So for folks out there who do any travel. So you know summertime is coming up. a lot of people are about ready to get into the travel of it all and or or maybe they're already out there traveling and having a good time with it. When you don't have the same noises, when you don't have the same light, when you don't have the same environment, your brain, as you said, is an adaptive organ, right? It's an associative organ. So, it's saying where is my associated sleep environment, right? Because you're in a hotel or you're uh you have a different situation going on. So, that's oftenimes what happens. First night effect originally came from when we brought people into the sleep laboratory and they would have a really crappy night the first night. So sometimes we'd have to have them in for two nights.

Yeah. If and when I go to London for work, I always stay in the same hotel. It's literally about familiarity. And I tell you literally it was four weeks ago. The very first time ever I didn't stay in that hotel. Long story. I did not sleep well at all. Now there could be a number of reasons for that. Of course, this is not like a randomized control trial. This is a one of experiment. But there will be someone listening to this, Michael, who does travel regularly to the same location for work. And if you're able to and it works for you costwise and all that kind of stuff, I I definitely think it's a hack that people don't think about enough.

I I would even go one step further because I do the same thing. So, I travel roughly every six weeks to Seattle, Washington. Um, and uh, I not only do I stay in the same hotel, I stay in the same room.

Yeah. And that familiarity lowers my stress level, right? So, as an example, since I know the hotel I'm staying at and the room that I'm going to be in, if my flight is delayed, I don't it doesn't stress me out, right? Because I'm not trying to figure out where am I going. I know exactly where I'm going, right? I go into the hotel. The person who's a night person knows me because I come in every six weeks. They're like, "Hey, Michael." I'm like, "Hey, how's it going?" you know, they're like, "Oh, we got you room 245." I'm like, "Perfect. That's what I want." Like, and it just lowers my stress level. Remember, stress is one of those things that has to lower for sleep, right? Another word for stress is anxiety. What are the three things that affect our sleep? Right? Heart rate, temperature, and anxiety, right? So, what you're tapping into is a way for us to add an additional layer that lowers our anxiety with that familiarity.

Well, what's your take for people who, let's say, don't have that luxury or they travel for work, but they're constantly going to different hotels and different locations. Could they perhaps bring stuff from home like scents and things that they use at home?

You got it. Yeah, absolutely. So, if I travel for more than 3 days, I actually bring my own pillow. Um so first thing that people should understand when you travel like most of the hotels um they overst their pillows because then they have to buy them less frequently right and so what ends up happening is you've got the perfect pillow at home and it works well because you're a side sleeper you're a back sleeper and your neck is just just kind of right but most of the time when you go to a hotel the pillows are over stuffed so the loft in the pillow is very high which pushes your head forward if you're a back sleeper and that can make it difficult to breathe so I bring a pillow if I'm staying for longer than 3 days. Um, number two, I bring an eye mask, right? I actually, believe it or not, I know this sounds a little crazy, but I am a sleep doctor, so I'm allowed to be a little crazy. I bring my own sleep kits with me to almost everywhere I go. And so, what my sleep kit h So, I have different sleep kits when I travel international and then different sleep kits when I travel domestically. So, if I'm traveling just domestically, here's what I know that I I need. I usually have an eye mask. I have earplugs. I have a little clip for the drapes in the room because a lot of times the drapes will open up in the middle of the night and uh sunlight will come through. I walk into the room. I check the alarm clock first because some idiot has set the alarm for 4:00 in the morning. You know, it wakes me up. Um I uh I also ask the front desk, hey, who are my neighbors? Not their names, but like is the is the baseball team next to me? because if they are, I'd love to move into a different part of the hotel, you know, so I can have again a nice quiet, you know, environment. But, um, it it works it works surprisingly well. Um, but in also in my sleep kit, I carry um stomach like Tums, so if I have an upset stomach, but you know, you arrive at a hotel, it's late, I carry a little bit of Advil or Tylenol in case I have a headache. Uh, and I carry a nasal spray in case I have any nasal congestion. Uh, and that's my domestic sleep kit that I bring with me everywhere. And that familiarity of having those things for my routine makes it so that I can sleep almost anywhere.

If we think about you traveling with your pillow, someone [laughter] listening might think, hey, this is a little excessive, right? Right. Okay. You are, you know, you're sort of, yes, you're the sleep doctor. Yes, you like your sleep, but do you really need to travel with a pillow? I want you to sort of make the case to them, I guess, why you think that is such a good investment of your time and energy to do so.

Absolutely. So, so to be clear, if you remember, I said only if I'm staying for 3 days or longer, right? So, if it's a if it's a quick trip, I don't bring a pillow with me. But I do have a hack that I can teach people to do uh in in the hotel room as well. So, first of all, I only take my pillow if it's 3 days. If it's shorter than 3 days, here's what I do is I walk into the bathroom of the hotel and you know, there's three types of towels in the bathroom. There's the the washcloth, right? There's the hand towel and then there's the bigger towel for like, you know, when you dry yourself off in a shower. So, I take the middle towel, the hand towel, and I lay it out, and I roll it up so that I have a long like tube, and then I put it into the pillow along the horizon of the pillow, and it gives me an extra neck support. And then, because I have a pillow at home that has neck support, my whole neck starts to relax and I'm able to fall back, fall asleep pretty easily. If I want to, if I'm staying for longer than three days, then I actually check my bag and I have a bigger suitcase because I can't fit my pillow into a carry-on. So, that is a kind of a disruptor and then I bring it along. I actually bought my luggage so that I could have a pillow that I knew would fit into it. But, I'm a sleep doctor, you know, like sleep's a big deal for me. So,

Yeah, Michael, I was asking the question to sort of play devil's advocate. I actually don't have an issue with you doing that at all because I think if you are someone who needs that pillow to increase the chances of you sleeping well, I think that's a perfectly reasonable trade to make. Now, someone else may go, "That's bloody ridiculous. I'm never going to do that." Okay, fine. Fine for them. You don't have to do it. But do you know what I mean? [laughter]

Yeah. Well, the funniest thing is like if I So, if I can't fit my pillow into my suitcase and I bring it with me on the airplane, like let's say I'm doing an overnight flight, I like to bring my pillow on the overnight flights. So, like when we do part two of this and I come and visit you, I'll you'll see me walking off the plane with with my pillow underneath my arm. Here's the funny thing is it's a great conversation starter. I can't count the number of people that are like, "Wow, you're really committed to sleep." And I said, "Well, I'm a sleep doctor." Then it's game over. Now we're talking sleep, you know, we're having a whole conversation, you know, the whole thing. [laughter]

Yeah. Look, it it makes it makes me think, look, I I don't travel with my pillow. I never have done.

Maybe you should.

Yeah. Well, actually, you're making me think now. Maybe for the right trip at the right time. It might make sense.

Speaking of um people who do things a little bit differently to others, Brian Johnson came to mind early on in this conversation. Right. So, you mentioned right by me.

Yeah. Well, you mentioned before these three things that need to come down to fall asleep. Okay. Uh heart rate needs to come down, temperature needs to come down, anxiety needs to come down.

You bet.

Now, Brian, for people who don't know, is a wealthy individual who is spending a lot of money each year trying to age as well as possible. And one of the things Brian has said publicly for many years now is that his resting heart rate before bed is one of the strongest predictors of how well he's going to sleep. So the lower his resting heart rate, the better his sleep quality is. Now he says that the way he does it is he stops eating his final meal at 11 a.m. Not P.M. 11:00 a.m.

He's crazy.

Right? But okay, but to be fair to Brian, I think he would acknowledge that not everyone has to do that.

Yeah. And I learned a lot from Brian Johnson, which is just which is kind of interesting for somebody like me because he's he has no medical background whatsoever, right? He's running this experiment on himself. It seems like he's kind of gone off the deep end if I'm being super honest with you. Um, but he is the biggest sleep advocate I've ever seen. Everywhere he goes, he's like, "Sleep, sleep, sleep." And I'm like, "Let's go, brother." So, I I'm I'm a fan of his, but I agree with you. Stopping food at 11:00 in the morning would be difficult. But it it's it it shows an interesting point, right? Which is the met the metabolic process is probably increasing his heart rate, which is probably affecting his ability to fall asleep. It's also increasing his core body temperature because your body heats up when it's digesting food. So, I think what he's saying makes a lot of sense. I'm just not sure practically how we do that. So that's why I have people stop food, water, and alcohol three to four hours before bed.

So let's just talk about that then. How do you get the body calm before bed? How do you get that heart rate down? So you mentioned there food.

How important is it to stop eating hours before bed in your opinion?

I think it's huge. Um and I think it's a big big issue that a lot of people don't look at. So, a lot of people might have their dinner at a normal time, let's say 6, 6:30, 7 o'clock. But what a lot of people don't take into account is snacking, right? And so, a lot of people are late night snackers and they end up eating things that are so complex that their body is digesting and that makes it very difficult to sleep. I mean, Reagan, I've got a one patient who actually wakes up in the middle of the night to eat and then eats something and then is able to fall back asleep. We we we started to look at it and what we discovered was is they were having a blood sugar drop in the middle of the night and then their cortisol was kicking into gear and waking them up. And so we keep now a few saltine crackers by her bedside. And guess what? She wakes up, she has a little orange juice there. She's diabetic, so she has a little orange juice there, a little cracker. she takes it, she's able to fall right back to sleep. That's the extreme case. But for most people, again, let make sure you check with your doctor. You should probably stop all food three to four hours ahead of time. Alcohol for sure you want to stop 3 to four hours ahead of time. Uh and probably water at least two hours ahead of time and make sure you go to the bathroom at least once before you you lay down.

Yeah. You know, before when we were talking about people who wake up between 1 and 3:00 a.m. and that that's a natural phenomena to do with uh body temperature.

Correct.

I've also seen many patients wake up in the night. I can't say for sure between 1 and 3:00 a.m., but certainly wake up in the middle of the night and it is like you said with that patient to do with blood sugar dropping.

Yep. And so sometimes I found with patients like that that they don't always have to eat in the night, but sometimes they're having something quite high glycemic before they go to bed, right? So their their blood sugar is or their blood glucose is going up and maybe 2 3 4 hours later it's plummeting quite sharply which of course is a stress response to the body and it wakes them up. So sometimes it wasn't about you know adding more food in at night. it would say, "Hey, listen. Let's not create a blood sugar roller coaster through the night. If you really are hungry before bed, let's have some nuts or, you know, some like carrots and hummus, something that is a bit more blood sugar stable than than something that's high glycemic." And along those lines, which I think I think is something that I've started to recommend to my patients lately, but I think you would agree with is sometimes what I do is when I've got somebody that's disruptive like that, I have them get a um a continuous glucose monitor, a CGM, and then we figure out which foods spike their sugar the most. Then we avoid those in the evening time if at all possible, right? And that seems to help quite And here's what I found that I think is just so remarkable. And I I I'm a real big proponent of people going out there and getting these uh these continuous glucose monitors because here's the thing. You have no idea what spikes your sugar. Like when I did it, I had no like bananas do nothing. Like I can have a banana right before bed and I have no blood sugar spike. But if I have an apple, I'm in trouble, right?

Yeah. I completely agree. I I honestly don't think, and I've said this before, but I'll say it again. I have not seen a more powerful behavioral change tool than a CGM because you learn stuff about yourself that you can't suddenly unlearn. You know, through the lens of sleep, if you find you're waking up at the same time every night or regularly and you then look at your data, you might actually see that your sugar actually is dipping at that time. Actually, all it is is a blood sugar drop. And there are many ways that we can avoid that blood sugar drop, right? For some people and of course if you look at the rates of metabolic dysfunction that exist out there, there's a lot of people who aren't able to manage their blood sugar effectively. So for some people, of course, this this is a very quick win.

Michael, when I when I told my audience you were coming on the show, there was a lot of excitement and I have a whole ton of questions here. So

fantastic. There's other topics I wanted to discuss, but I kind of feel that they will come out of us answering these questions. So, is it okay if I put a few of them to you?

Throw it out there, brother.

Okay. Rachel says, "How accurate are the sleep scores on fitness devices and wearables?"

I love this question. So, to be clear, they are not they are not accurate. However, they're still useful. So, and that sounds like a little bit of an oxymoron, me saying they're not accurate, but they're still useful. So, let me explain to everyone. So, you can see I've got an Aura ring on. I've got an Apple Watch. You know, people have got Fitbits or Whoop straps or whatever the tracker of the day happens to be, right? So, I want to be super duper clear. Trackers, and if you look in the medical literature, you can find the studies are decent at telling you when you fall asleep and when you wake up. They're not particularly good at depth of sleep. So, they're really not good at telling you how much deep sleep you got and how muchm sleep you got. And the reason is is because we measure those from brain waves. We measure those from EEG. It's really hard to get EEG from your finger, right, from your wrist. So, what ends up happening is they take a piece of data that is accurate in those particular areas and then they approximate what they think sleep stage you might be in. And so what ends up happening is you have a bit of variability there. So what I tell people all the time is do not I repeat do not look at your tracker information every day. First of all, you're going to drive yourself crazy. Um I'd say once a week, probably Sundays is probably the best day. You want to look at across the week and you want to look for the trend. You do not want to look for individual numbers. Dude, I can't count the number of people who walk up to me and they're like, "Dr. Bruce, my ring says I got a 37 last night. Am I going to die? Well, yeah, you're going to die, but probably not from that, right? You know, like I only got 37 minutes of deep sleep. Well, what did you get the night before? 35. Okay. Well, what did you get the night before? 40. Then you're fine, right? Like it's being consistently inaccurate, right? What I want to know is if you went from 40 minutes every night to three minutes, I want to know what happened that night.

Yeah.

Right. So, I'm looking for the delta. I'm looking for the deflection in the data. If you're consistent, even if it's consistently inaccurate, I don't think I care. However, I will tell you that I think these are going to get more accurate as time goes on. Um I feel like we're starting to see um these companies are putting out bigger, better algorithms. They've got more AI, more machine learning behind it. And I think I would argue probably in 12 to 18 months we would probably start to see the accuracy level start to increase in many of these uh you know uh tracking devices. Um so I'm I'm a fan but I'm not like live or die by your data type of type of person at least this data because it's got so much variability to it.

Yeah. I spoke to Tommy Woods uh recently. He's a neuroscientist, medical doctor, and he also like you likes the approach that you look at the stuff once a week, right? You look at it for trends, not for that daytoday variation. And it can drive you crazy and it can drive certain personalities more crazy than others. And of course, going back to the three things you want lowered if you're going to sleep, right? One of them is anxiety. So, if your wearable is increasing your anxiety, it may be informing you off your sleep, but it may not be helping you get more sleep. And and again, to be clear, I like wearables, right? I personally choose not to wear them all the time because I don't ever want to become dependent on these things. But I have learned a ton. And I think one thing I'm I'm sure you found with your clients as well, Michael, is that when a wearable shows you what alcohol late in the evening is doing to your I've seen that change people's alcohol habits like nothing else. Do you know what I mean? So I think they can have value.

There's another question, right, which I think kind of relates to this. Val wrote in to say how much deep sleep anm is optimal and is it different with age. I imagine that Val's asking probably for her health wearable because otherwise how would you even know how much deep sleep and RM you're having? So you know you we have to acknowledge you're saying that the sleepstaging on these wearables at the moment is not that accurate. Correct.

Okay. So take it with a pinch of salt. But more broadly, you know, how much deep sleepm is optimal? And is that even a reasonable question? For many years, whilst working as a doctor, I saw the same thing. Modern medicine is really good at treating illness. But it was never designed to prevent you from getting sick in the first place. That's why I co-founded Do Health, a personalized health companion that will help you take control of your health and reduce the chances of getting sick in the future. It takes everything I've learned over the past 25 years and makes it personal to you. You get an initial blood test which screens you for over 50 biomarkers. But then all the focus turns to the 11 core markers that tell me the state of your metabolic health including fasting insulin, APOB and homoyine. Each week together with you, we create a personal achievable plan and several times a year we recheck your bloods to make sure that things are moving in the right direction. This for me is the future of preventative health. Now, do health are offering fixed early access pricing less than £21 per month to all those that sign up to the weight list today. This is incredible value. And don't forget that this price includes three yearly blood tests as well as 52 custom weekly plans and unlimited daily interactions with Coach Joy. Just scan the QR code on screen or click on the first link in the description box below to gain access to the weight list right now. So I can answer the question, but what I will tell you is it's not a good question, right? And nothing against Val, by the way. I want to be super clear. Val, I get asked this question all the time. Nothing against you. It's a great question, but it's not the right question to be asking because of exactly what you're saying. Here's what I'll tell you is is my firm belief is I think that we are our best doctors. I think when we wake up in the morning, we know if we've slept well or we haven't slept well. I don't I don't need a I don't need a ring or a watch to tell me if I got a good night's sleep, right? I know kind of what's going on there. um our body every night as we're falling asleep, it kind of scans itself and it determines how much of each stage you need because different things happen in different stages. As an example, we know that in stage three, four sleep, this is where something called the glimpmphatic system comes in, scoops out all the proteins uh and and washes out your brain. We know that that during uh deep sleep, this is where the largest bolus of growth hormone is is emitted and that's why deep sleep is considered your physical restoration. But to be fair, if you haven't done anything that requires a ton of physical restoration, you might not get as much deep sleep, right? Same withm sleep. RM sleep is your mental restoration. This is where we move information from our short-term memory to our long-term memory. We kind of create this like organizational substructure like like a filing cabinet in your head. So you can put data in there, right? And so what are the percentages? Roughly 25% of each of the night is what you're kind of looking for. roughly 25% REM, roughly 23% deep sleep. But I hesitate to even throw those numbers out there because somebody is going to now pick up their phone, look at their wearable data, and say, "Oh crap, I only got 13 minutes of deep sleep. Am I going to die?" No, you're not going to die. But it might be something to shoot for. The other big thing to remember is most of these parameters were uh developed on white men between the ages of 25 and 45. So to be clear, I'm not convinced that the data is accurate from a comparison standpoint. Right? Now the other thing that the other part of her question which I thought was really important was what happens when we age? Guess what? It all changes. Right? We get less deep sleep as we age. In fact, Rangan, this is kind of an interesting point is in sleep medicine, we actually have to change the scoring criteria of the EEG when people are over the age of 55 because the amplitude of the waveforms changes and it falls out of the classic criteria for a delta wave. I know I'm getting a little technical for people here, but basically what I'm saying here is sleep doctors have to change the way we look at people's sleep past age 55 because it's so different, right? It's specifically in the deep sleep area. So, one of the things I want people to know is your sleep is going to change as we get older. Unfortunately, sleep doesn't always get better. Sometimes it can get worse. Now, the question becomes why? Um, a lot of times that has to do with medical frailty, right? So look, if you've got a medical situation, it's going to affect your sleep. If you're taking medications, it's going to affect your sleep. Add stress, add caffeine, add alcohol. All of these things are going to have effects. So when I'm working with patients, so as a as a reminder, I'm 58 years old, right? So when I work with patients that are my age or older, my big thing is don't put any obstacles in your way, right? You're already, your body isn't going to be sleeping like it was when you were 25. So do yourself a favor. Stop caffeine by 10:00 a.m. or 12:00, right? Or even 2 o'clock if that's the latest you can handle it. Stop alcohol 3 hours before bed. Don't put obstacles in the way of your sleep, right? That can get in the way because you're already not going to be having as good a sleep as you once had.

Yeah. And also, I think a key point there is as we get older, sometimes we don't tolerate the things that we used to tolerate as well, right? So, that's for sure. You might have tolerated a 400 p.m. cup of tea when you were 20. Absolutely. Right. But maybe at 55 you don't. Maybe at 65 you don't. Right. So I think just understanding that our body changes with age and what we can tolerate changes. I think it's a really important point for people to remember.

Yeah. So I want to double tap on this in one particular area that we haven't had a chance to talk about yet which is menopause.

Okay. So when we look at women who are getting older, who go through the life cycle change of menopause, it's very very interesting. So here's one of the things that I tell every menopausal woman that I see. Caffeine affects menopausal women differently. Your body is different. Your body is uh metabolizing it differently. You're it's having different effects on you. It is different. Both caffeine and alcohol change in your body over time in terms of your body's reactivity to it. So menopause, perfect example. I have a lot of women who are like, "Oh my god, Michael, my day is so stressful. My hormones are all over the place. I'm just going to have a glass of wine to relax." I'm like, "Hold on a second. That glass of wine might actually do you more damage than good, right?" And they they'll say, "Well, I used to I I've always had a glass of wine." Well, as we get older, that's going to have more and more effects in the direction that you don't necessarily want. Caffeine is the same way. Now, don't get me wrong, menopause is a hormonal disruption and it causes all kinds of things. And we can talk about uh menopause and sleep if you'd like. I'm happy to do so, but using the examples of caffeine and alcohol and when our bodies change over time and it doesn't have the same reaction to us, it's a great example.

That leads me to two questions actually that we had in specifically around menopause and and permenopause. Okay, so Shimmerish wrote in and said, "Dr. Bruce, how do we overcome permenopausal sleep? Yep. And Hanukkah said, "I had to stop with my HRT since I wake up several times in the night. What should I do?" So, two sort of related questions there. I wonder if you could give us some thoughts on both.

Absolutely. So, I think there's a couple of different things here. So, the first part of the question I my answer would have been, have you considered HRT therapy? Right. So, one of the things that we know is, so I want to take a I want to take a a mini break here for half a second and say to everybody, hey, there's been some bad data out there that we all need to recognize. So, for years and years and years, doctors were telling women that hormone replacement therapy was not a good idea and that they could end up getting cancer from it. And that data is not true. Okay? Hormone replacement therapy is a perfectly acceptable, perfectly safe thing to do. Obviously, you need to have discussions with your doctor, but historically, we used to tell women never, never, never. One of the things we recognize is, guess what? When you have no progesterone in your body, your body doesn't sleep too well. Progesterone helps with sleep. There's no ifands or buts about it. So, being able to get on HRT can absolutely help people with their sleep. That's one of the first things that I recommend. Next, get tested for sleep apnea. This is such an important aspect. People don't realize this, but when women go into the menopausal state, the ratio increases by 100% in terms of apnic uh diagnosis. So before women go into menopause, every two men that have apnea, one woman has apnea. Once women hit menopause, it's a 1:1 ratio. women their hormones change they they gain weight and they end up having potentially sleep apnea. A lot of women by the way we don't have the right criteria to diagnose women with sleep apnea because we use men criteria for it. So what ends up happening with a lot of perry menopausal women is they have undiagnosed sleep apnea. They have no idea that they have it and if they had just had a sleep study at the beginning of their uh of their menopausal journey they might have learned a whole bit. So, one thing I I I recommend is hormone replacement therapy if your doctor says it's okay for you. Number two is get a sleep test. Again, you don't realize this, but your body has changed. And that's something that, by the way, isn't your fault. Like, so many women are like, "Oh my god, I'm going through menopause." Like, it's a like it's an attack. This is a natural biological change. Like, this this is nothing to be ashamed about. This is this is something that happens to your body on on the regular every single day. uh and over the course of time you you should be able to understand kind of what's happening there. The third thing that I tell people to do is to regularize your bedtime. Be careful about alcohol and caffeine are two big uh things that are going to be important for her as well.

Yeah. You shared earlier your own sleep apnea journey. Just to make it super clear for people, I imagine there's some women who just heard what you said and were thinking, "Oh, I never really considered that I may have sleep apnoa."

Correct.

Practically speaking, how does somebody get tested?

Great question. So, first of all, it depends upon what country you live in, [laughter] right? So, there's different health insuranceances and health care works differently in different countries. Here in the United States, we've got two different methodologies. We've got the athome sleep study and we've got the in laboratory sleep study. I don't know what is going on in each individual's country, but you can absolutely ask your doctor where to get a sleep study done. Your general primary care physician will know or have somebody to refer you to, and it could be in home or it could be in the lab.

Is there anything that we might see on a wearable that might give us a clue that we might have something like obstructive sleep apnnea?

Yeah, there is. So, it depends upon the wearable, but as an example, I've got an Apple Watch on. So, Apple Watch actually has the ability to measure your oxygen levels at night. And if you know how to turn it on, there's a specific place inside the Apple software where you can turn this on and it will tell you, "Hey, we have a suspicion that you might have sleep apnea and it'll tell you to go to your doctor." Now, let's say you don't you have a tracker that's not an Apple Watch and you see multiple awakenings throughout the night, like four, five, six times that it says you woke up and fell back asleep. Woke up and fell back asleep, that could be a sign of sleep apnea. The thing that I have a tendency to look at on all of the trackers because one uh metric that almost every tracker does really really well is heart rate. I look for something called brady tachicardia. So I look for because when you stop breathing in your sleep when you have sleep apnnea your heart rate slows down or does what was called brady cardia in extreme cases. Then your brain says oh crap there's no air. So your heart rate speeds up and could go into tacocardia. So, what I'm looking for is I take the most accurate thing I can find on a tracker, which is usually heart rate, and I look for speeding up and slowing down throughout the night if it doesn't already measure something that I want to uh learn about sleep apnea from.

Yeah. Okay. Thank you. Okay. Let's go to this question from Peritan, and I I really love this question because I think it will apply to so many people. this idea that there's what we should be doing if our life was perfect and optimal and then there's the reality of the situation many people find themselves in. Okay. So, Peritan's question is this. Being a full-time carer for my patient, okay, I only get 3 to four hours sleep a night.

Oh, wow.

How can I avoid the negative effects?

You can't. Um I I at 3 or 4 hours a night, you are absolutely depriving your body of sleep. And and it's an that's at an extreme. Um if I'm honest with you, you're definitely doing some level of potential damage to your body by not getting enough sleep. Now there are there's one situation one uh out there. It's a rare genetic uh problem and people can be short sleepers. So there are believe it or not people who survive just fine on 2 to three hours of sleep. I want to be clear, these are rare, rare people. I've been doing this for 26 years. I think I've met one in my entire career. Now, I have met Rangan many people who think they are short sleepers who tell me, "Oh, I'm one of those genetic shorts sleepers, Michael." No, you're not. I can assure you, you're not. Okay? But for folks like this person who says, "Hey, I can only sleep three or four hours a night because I'm taking care of people." So, number one, you've got to make sleep a priority. I can assure you that the quality of the care that you are giving somebody when you only have three hours of sleep is not your best care. Right? And depending upon the medical severity or complexity of the individual that you might be caring for, you could miss something. Right? When somebody's only had three hours of sleep, they can mix up meds very easily, right? They can uh do the wrong protocol very easily. So what I would tell somebody there is number one, if you can extend your sleep from 3 to four hours to four to 5 hours. If you cannot, napping is probably not the worst idea for you. So strategic naps placed throughout the daytime for 25 minutes here and there could definitely be helpful for you. But if you sleep longer, like a 90minute nap, you're going to feel terrible when you wake up. So, you're going to want to keep those naps short and sweet, about 25 minutes uh in length, maybe two of them in the daytime to help you make up for some of that lost sleep. But generally speaking, remember when we were talking earlier, we talked about could you make up for sleep on the weekends? This is a person I would have making up sleep on the weekends.

Yeah. What about non-sleep deep breast or yoga nidra that you mentioned before?

So, so we've got an individual definitely can help this human. Yeah, because I think a lot of people with the best intentions and you know this is one example full-time carer for her parent, right? Yes. But I'm sure there's hundreds of other examples out there of people who feel that you know what I know I should but I can't. So I guess it's what you said, you know, they can take some naps, right?

Yoga nidra um also known more recently as non-sleep deep breaths. Although some people get annoyed that an old yoga term has been called that, but that's a separate issue alto together.

But also so but but also I'd love to know your your take on even periods of downtime. So let's say someone is a carer and of course there can be a tendency when you are no longer on duty to catch up with life emails this scroll social media wherever it is and I understand all those things but of course nothing is quite the same as sleep but even if you sat in a dark room or you sat on a sofa with your eyes shut maybe with some relaxing music on for 20 minutes you're still getting some benefit aren't you

100% % 100% you're getting some level of benefit. Um the the key factor for those situations is safety. So just make sure that if you're going to do that, if you're going to put on an eye mask, you know, and and be in a dark room, number one, people should know where you are. So that way, you know, some god forbid something happens. And number two, um you need to know how much time is going on during that period of time because what you don't want to do is fall asleep and sleep for three hours type of thing. But absolutely, you can definitely have those periods of time that are what we call quiescent. They're just relaxing times. Good for your brain, good for your body for sure. You don't even have to sleep.

Okay. Then there are series of questions to do with supplements and prescription medication. Okay. So let's start with Dave's question which is since taking SSRI um a very common uh you know class of what would colloially be called anti-depressants for people who don't know that term since taking SSRIs I wake up at night a lot do you have any idea why

great question so first of all to be clear I am not your doctor so I cannot tell you what to do or not do about your medications however if you were a patient that came into my clinic and you said to me these were some of the problems. One of the very first things that I would look at is what is the timing of your administration of your medication. As an example, some SSRI are very alerting. Uh for example, something called Wellbutrin, which is actually technically an SNRI, um is one of those

Medications where if you took it in the evening time, it would be disruptive of your sleep. So in some cases, one of the first things I do is I tell the patient, "Hey, who is your prescribing doctor? Let's talk with your prescribing doctor and say, 'Can we take this medication in the morning?' Or if I'm taking it in the morning, can I take it in the evening and see over the course of a week, does that have a big effect?" So that's step number one is timing of administration. Step number two is talking with your doctor about, "Could you change to a different sleep-friendly SSRI?" Because different people react to different medications in different ways. And so you might find one that still works with your depression and anxiety but doesn't have a level of disruption to your sleep.

Right now, in the most extreme cases, um, there are situations where we would actually consider administering a sleeping tablet during that particular period of time. So, as an example, if I have somebody who's a bipolar person, right, who's on significant medication for their mental health situation, they may require a Stilnox or an Ambien or a sleeping tablet because of their mental health situation. And I want to be very, very clear, there is nothing wrong with taking a sleeping tablet. If you and your doctor have come to the conclusion that that is something that makes sense for you in your particular situation, don't beat yourself up about it. Take the medication as directed, right? Like I tell people all the time because a lot of people come to me and they're like, "I don't want to take a sleeping pill. I don't want to get addicted to sleeping pills." I'm like, "Totally understand where you're coming from. Let me give you a scenario. I believe that insomnia in a lot of ways is like high blood pressure, right? So you can eat right, you can exercise, you can still have high blood pressure and need to be on a medication to lower your blood pressure. Look, if you do all the right sleep hygiene things that we've been talking about, you get in bed at the right time and you still can't sleep, you might need a sleeping pill. Is that mean you're addicted? Is anybody addicted to their blood pressure medication? Probably not, right? So I don't want people to uh, you know, make these assumptions and necessarily go in the in the wrong direction here."

Um, but yes, there are situations where if you're taking an SSRI, I would talk with your doctor about timing of administration and maybe swapping it out to see if there's something else that could be uh more effective and less affecting on your sleep. Some uh sleep researchers, Michael, would say that if you fall asleep after taking a prescription sleeping medication, you're not getting the same quality of sleep as you might do if you were falling asleep naturally. What's your take on that?

>> So, I would argue that they're correct, but some sleep is better than no sleep. So I I I agree with you that most of the medications out there have an effect on what we call sleep architecture. So they change the amount of stages of sleep that you get. So as an example, if you're taking an older something what we call a benzodiazepine, which would be like a Restoril or a Xanax or an Ativan um, those medications actually change deep sleep. You actually get less deep sleep. uh, in in fact um, SSRIs like what we were talking about before, those decrease REM sleep. So there are many different medications out there that can have a pretty decent effect on your deep sleep or your REM sleep, and you need to just be thoughtful in understanding those.

>> Hannah is asking, "Does magnesium really help with sleep?"

>> Such a great question. So, here's what we know is if you have a magnesium deficiency, it does. If you do not have a magnesium deficiency, it's not nearly as helpful. Now, here's the thing. Most people have a magnesium deficiency. Um, and so the very first thing, and so this gets us into the topic of supplementation, which is one of my favorite topics, and my very first thing I tell everybody that talks to me is, "Go do blood work. Okay?" Like, remember the whole idea behind supplementation is if we're not getting it in our diet, then we supplement it with these powders or pills which are usually a combination of vitamins, minerals, and herbs. Right? Now, to be clear, depending upon what you're trying to supplement, you don't often times know unless you do the blood work. So blood work becomes very important. So before anybody does any supplementation, here's the three to four things I would recommend. You want to look at your magnesium. You want to look at your vitamin D. You want to look at your iron, and you want to look at your melatonin if you can. Melatonin is a little bit more difficult to from a blood work standpoint. A lot of times you have to do a saliva test and you have to do it at night because melatonin only comes out at night. But if you just did those three, which is magnesium, vitamin D, and iron, uh, if you have deficiencies in any of those areas, I would argue, dude, 15 to 20% of the time, all I do is fix those deficiencies. Sleep gets better, and I don't have to do anything else.

Yeah, I think the problem with magnesium, certainly if I look at it through a UK lens, it's not that easy. If you went to your NHS primary care doctor and asked them for a magnesium check, you you know, I don't think it's going to be easy for people to get. And also, I think with magnesium, it's not just a serum magnesium you're looking for. I think to get a really accurate idea, you got to look at red cell magnesium and >> and so I get it. At the same time, I don't think for most people supplementing magnesium is harmful.

>> I agree with you. There's only one caveat is for some people, if you have too much magnesium, you can get diarrhea, and that can be problematic as well. So, I I try to tell people, keep it within like a 200 to 250 milligram range. It may change during the summertime. One of the things that I've looked into the literature on is that if you're a heavy sweater, uh, and you do a lot of outside activity, you may need extra magnesium. Um, so as an example, when I work out every day, and I sweat a ton, and so I lose a lot of magnesium. So I only take three supplements a day. I take magnesium, I take vitamin D, and I take omegas. That's it.

>> For people who wish to try a magnesium supplement for sleep, is there a particular form of magnesium that you like to recommend?

>> So, here is the problem is there are 13 different types of magnesium out there. Yeah. [laughter] All right. And all kinds of stuff is is available in all kinds of different forms and formats. I'm going to give you some general guidelines and then I'll give you a few brands specific that I use. So, general guidelines, I like people to start with magnesium glycinate um for a couple of different reasons. Number one, magnesium glycinate is easier on the stomach. Also, the glycine is helps with temperature regulation. So, it's kind of you get a twofer. You get your magnesium which can help with your deficiency, and you can get a a thermoregulator which can be helpful in the glycine. So, I start most people on magnesium glycinate um with about 150 to 200 milligrams. If they do that well, I may move them over to magnesium citrate, or if they're fine, I just kind of leave them alone.

>> Okay, great. Are there any other supplements you recommend for sleep, just out of interest?

>> So, what I do is I do the blood work. I fix the deficiencies. If the deficiencies are gone and they still have some level of sleep disruption, then there are certain things that I look at. Um, my one of my favorites uh or one of the ones that's probably the most well-studied is Valerian root. Um, there's a lot of data on Valerian. If you include hops, like the hops you find in beer, that seems to make it even more effective. So a Valerian hops combination product I think would work really well. The problem I usually have is many of the supplements out there are multi-ingredient supplements. I call them kitchen sinks because it's like throwing everything into the kitchen sink and kind of hoping that things work. I would rather people use single to to two ingredient supplements so that way we we really have an understanding of what's happening.

>> Okay, let's get through some more of these questions. Lauren says, "What is your best tip, Michael, for a busy mind preventing you from going to sleep?"

>> So, I like 478 breathing. That's and we talked a lot about it, but I'll tell you another one that I'd use all the time for people. Now, I know this is going to sound crazy, but I promise you that it really works. Count backwards from 300 by 3s. Yeah. All right. Now, it is mathematically so complicated you can't think of anything else, and it's so damn boring, you're out like a light. It works like a charm. Uh, I use it with a lot of my, you know, uh, patients who like are trying to fall asleep on an airplane or things like that. I have them count backwards. Or if they just have a hard time falling asleep, it's it's kind of great for monkey mind. There's also something else called cognitive shuffling. This is an interesting technique where you pick a word. So let's pick the word, I don't know, sunflower. Okay? Then what you do is in your mind, you see the word sunflower. Then you come up with five words that start with the letter S. Then you come up with five words that start with the letter U. Then five words that start with the letter N. So you walk yourself spelling down the word sunflower by finding five words for each letter. It's again so complicated you can't have the monkey mind, and it's usually so damn boring, you're out like light.

>> Yeah. I guess the point is with those exercises is that if you did them in the morning after a good night's sleep, >> they're not going to send you to sleep at that point.

>> Absolutely not. Relax you.

>> Yeah. But the point is, I guess you're trying to say at night, whether it's because you've woken up at 2 am or because you can't switch your mind off just before going to bed, there are certain techniques out there that can be helpful to help switch off that monkey mind. Right. So, if you can switch it off, then the natural sleep drive that has accumulated throughout the day is allowed to run its course and help you fall asleep, right? So I think that's a key point to sort of make with those exercises. They're not sleep-inducing in and of themselves, are they?

>> No, they are anxiety-reducing in and of themselves, and then the natural sleep process can come in and take over.

>> Okay, few more questions. Uh, Prollead says, "What is the main reason for frequent wakeups during the night?" And we could do two hours on this, but what's your topline answer to that? [laughter]

>> So again, I think there's a couple of different things that can happen as a as awakening through the night. Let's let's go through the list of things that it could be. So number one could be too much fluid, right? So you've drank some water too close to bedtime. It's waking you up. Number two, it could be your digestive process. Maybe you're eating too close to bedtime, right? Number three, um is uh you could be having a very emotional discussion with your partner, right? uh, if you if you decide to have a great big talk about, you know, uh, where to go to college or whether or not you're going to get a divorce or whether or not to have kids, like big decisions, those are not reserved for the evening times. That that is not an easy way to have runway to land the plane as as we've been talking about, right? So, avoid those emotional discussions. Uh, and also, uh, you know, make sure that you're giving yourself some space. Um, but those are the things that I tell people all the time is you really you just need to I liked your idea. What do your kids do before they fall asleep? Do they run around like crazy? No. They the lights come down, it's bath time, it's story time, it's say your prayers and go to bed, right? That that that works.

>> Yeah. I tell you what I'm doing at the moment, right? And I'm pretty sure people in my family think I'm a little crazy for this, but we are in the peak of uh, well, the British spring and summer as we have this conversation. We've had glorious weather for about 3 weeks. It does not get dark >> until about 10:00 p.m. at the moment, and my son is in the middle of his GCSE examinations, which are the sort of exams you take at 15 or 16 here in the UK. Now I know how important sleep is for his performance in an exam, right? So what I'm doing, and look, instead of you know, you you know, I'll tell you what I do, and then you can tell me your opinion on this.

>> Yep.

>> Once it gets to around probably about seven, maybe sometimes quarter to seven or half six, >> I'm going around the house and I'm pulling the curtains right.

>> I love it.

>> So I go up to the all the bedrooms upstairs. I pull all the curtains. I put the bedside lights on. So, it's, you know, there's not much light um in the upstairs, and then if we're downstairs, >> you know, in the main in our in our living room, I'll pull the curtains so it it starts to feel dark, >> right?

>> I am absolutely convinced that since I started doing that, their willingness to want to go to bed has increased, and I am certain that this is having an impact on their hormonal physiology, which will then be impacting their ability to sleep, and therefore for my son, his performance in his exams. You're the sleep doctor, Michael. Tell tell me what do you think.

So I love the idea, and I think you're also being a good model. So you're showing your children, and you're showing your partner what to do, and that is a behavior that they're going to adopt over time, so it's going to be valuable. Also, I want to commend you for doing something else that I think I don't know if you even realize that you're doing it, but a lot of parents, especially when there's a big exam coming up. So, here in the United States, we have something called the SAT, uh, which is a big exam that you take at the end of high school, helps with entrances to college, things like that. So, it's it's a little bit on the similar side.

>> It's all about the sleep that you got for the two weeks before the test. It's almost nothing to do with what happened the night before the test. Because a lot of kids, they get anticipatory anxiety, right? They're like, "Oh no, I got my my test tomorrow. Am I going to do well?" And they ramp themselves up, right? But a well-prepared, well-slept child, number one, their anxiety isn't nearly as high as the children who aren't well-slept, but number two, they've been learning during a well-sleeping environment, so they have a much greater likelihood of being able to recall and and things of that nature.

>> Yeah. It reminds me of something a top running coach once said to me, which is, you know, the night before a marathon doesn't matter if you don't sleep well. It's about how did you sleep earlier on in the week, right? It's a similar principle. And I think there's a wider principle out there which we need to be conscious of >> when we talk about sleep. We've not, you know, gone into detail today on the negatives of long-term sleep deprivation. And I have done it on many podcasts over the years. So I'm pretty sure my audience will be familiar with, you know, chronic sleep deprivation, how it pretty much increases your risk of every single chronic disease that we have. Again, I say chronic, so if you're a parent of young children and you have it for a few months, that is not chronic. That is >> a short period in your life that you have to do it for. Right. So >> but but I think this wider point of resilience, I think, is so important, isn't it? Where >> yeah, >> you know what? Yeah, one night sleep deprivation, you can get research showing the impact it will have on natural killer cells, part of your immune system >> and and and all kinds of other things. And at the same time, we are pretty damn resilient. We can cope. You know, if you have a bad night's sleep, okay, it happens. It will happen. And you can still get on and do your job.

>> Of course.

>> A few more questions which we'll try and get through if possible. Judy and Balance Yogi have kind of asked the same question using different words. Okay. So, Judy says, "Why do I wake up feeling exhausted every morning?"

>> Mhm.

>> Okay. And Balance Yogi says, "Why do I never wake up feeling rested? My Garmin says I'm stressed in my sleep."

I would say in both of these cases, I would want to do a sleep study on them because if you've gotten six and a half to seven and a half hours of sleep for let's say a week, and you wake up and you're still exhausted, then there's something about the quality of the sleep that you are getting that is wrong. That could be a sleep disorder like undiagnosed sleep apnea. That could be a disorder like narcolepsy. By the way, could be depression, right? Let's not forget that mental health often times looks like exhaustion, >> right? So there's that and that's a possibility, right, as well. So there's a whole host of things, but if you wake up regularly exhausted, you definitely want to go talk to a sleep doctor.

>> No question.

>> Four more sort of quick topics I think I would like to cover if we can, which are night shifts, pregnancy, ADHD, and restless leg syndrome. Okay. So,

>> Andrea says, "I work night shifts. >> What kind of advice can you give me for improving my sleep?"

>> Super good question. So, first of all, night shift work is a whole different ballgame. And there's quite a few people who work on the night shift. I I'm not sure your audience probably knows that, but there's a tremendous number of people that work while all of us are asleep. And by the way, the body was not meant to do that. That is not like our we should not be awake when it's dark out, right? And so we're doing also by the way, most of the shift workers, they have higher incidence of depression, higher incidence of suicidality, higher incidence of all cause mortality. So shift work is not necessarily a fantastic thing for you to be doing to your body. However, you make more money at it, and sometimes you don't have a choice, right? Sometimes when you walk into a job, you end up on the night shift. So what do I do about working on the night shift? So, first of all, there are some websites that have a tremendous amount of information just about shift work. My favorite is called circadian.com. Um, I have no affiliation with them, but boy, the information is really good for people there. But there's a couple things that I tell people that they should kind of understand about shift work. So, what most shift workers try to do, and I get it, I get it, is when they're not working, they try to flip back so that way they can spend time with their family and their loved ones. So they kind of live in and out of this environment, right? This time zone, if you will, and that can be very, very disruptive. So what you want to try to do is stay as as much on the uh evening time zone as possible, which is problematic because if you want to have a relationship and and your person that you're having a relationship isn't a shift worker, that can be very, very difficult. Um, so what I have a lot of people do is when they come off their shift, um, they drive home, they get home, instead of going immediately to bed, I have them actually spend time with their families because think about it, when you get home from work, let's say it's 6:00, you don't go to bed until like 9:30, 10, right? And so you've got time to spend with your family. So they get home at 9:00 in the morning, let them spend time until, let's say, 10:30, 11:00. Everybody's gone off to school or gone off to work. Now, in their home, they should have a cave, right? They should have a place where it's dark, it's cool, it's quiet, and then they can get the the rest that they need. So, there's a lot of lifestyle adaptations that have to go on. Also, there's an app out there specifically for shift workers to tell them when to have caffeine and when to have light. It's called Time Shifter. The guy who runs it is one of my close friends, so that's an affiliation for sure.

>> Okay, Jessica says, "Any tips for sleeping during pregnancy?"

>> Oh, good luck. Um, so here's what I'll tell you is first trimester it's usually not a problem. Get as much sleep as you possibly can during your second trimester because in the third trimester, you're uncomfortable. You got baby in front of you. It's hard to get, you know, comfortable in bed. You your your whole body is reacting differently. So get as much sleep as you can in the second trimester is usually my first piece of advice. My second piece of advice is don't try to do too much. Okay. As like you're pregnant, like relax. Like you don't have to be super mom uh while you're pregnant. You can ask for help. Uh, you can do but get sleep when you can. Uh, because sleep can get very disruptive, and it's disruptive based on which trimester that you're going through, usually.

>> Yeah. Thank you. Ann says, "How do we help children with ADHD who struggle with their sleep?"

Okay, so this is a big question, and I don't I probably don't have enough time to give a complete answer here, but there's a few things that I would I would want to think about. So number one is uh if you do have a child with ADD or ADHD, um, number one, you need to have a really good relationship with their doctor who is providing uh medication support, if if in fact that's the path that you're taking. And you need to understand what medication your child or is on and what time do they take these medications. As an example, I had a patient who um was taking Adderall in the morning and Ritalin in the afternoon as prescribed by their doctor, and the Ritalin in the afternoon was having an effect on their sleep. So we had to move it earlier in terms of its timing of administration. So sometimes that is something that occurs. So medication management absolutely becomes important uh specifically to sleep. The other big thing, and this is unfortunate, but and parents usually already know this, but uh, it's true is if you have an ADHD child and they don't sleep well, the symptomatology gets much worse. And so educating the child on why sleep is so important because they don't like how they feel either. So a lot of these kids are like, "I don't understand. I can't sit still or I can't focus in school. I can't do this and I can't do that." Educating them on, "Hey, sleep is one of those things that can be helpful," because they don't know that. And once you educate them on that and you start to get into a routine, like, "Hey, you're doing something for yourself that's going to help with your ADD," giving them a responsibility within the diagnosis can be very helpful. And them understanding that a good night's sleep can be helpful for them can actually enroll them into therapy and help them out quite a bit.

>> Yeah. Thank you. Okay, last question is from Carolyn. "What is the best solution for repetitive restless leg syndrome at night?"

>> Sure. So, first of all, just so people know, what is restless leg syndrome? So, restless leg syndrome is when you uh get sedentary, either sitting down or lying down, and you get this weird creepy crawly feeling on your legs or on your arms, and the only way to get rid of it is to stand up and walk around or to move. Okay? Now, obviously, that's problematic if every time you lie down, you have to stand up because it's really hard to go to sleep standing up, right? So the first thing we do is we make sure that there's a a formal diagnosis. Second thing we do is we do blood work. So it turns out that when you have anything less than 60 of ferritin, which is a specific type of iron um, it feels like restless leg symptomatology, even though ferritin is normal from 5 to 300, anything under 60 becomes a problem. So with every person that comes to me that says, "Hey, I have a creepy crawly feeling on my legs," very first thing I do is run blood work. I look at ferritin in particular, and I make sure that it's greater than 60. If it's not greater than 60, then I I might consider some type of iron supplementation. And that often times can be super duper helpful. Let's say it's been diagnosed and it's not ferritin. What do you do about it? As of right now, we we use medication to help with a lot of that. Um, there's a lot of different medications out there that people have tried. I'm not the biggest fan because these medications are usually used for people with Parkinson's syndrome. So, these are big um uh powerful medications, not something to just be taken lightly. Um, there is also some lifestyle things that you can do to change uh your world from a in a restless leg thing. Believe it or not, doing crossword puzzles before bed and word find before bed helps lower your restless leg symptomatology. So, what does that tell us? Distraction, right? Focus on something else is definitely going to be one of those things that's helpful. And obviously avoidance of caffeine late in the day.

>> Yeah, super useful. You know, what you said about ferritin really speaks to this idea that we've covered quite a bit recently on the podcast, which is the difference between normal and optimal, right? A a you know, the normal range for ferritin can be quite large, right? You can have a ferritin of 30, and your doctor will say that that's normal, and it may well be normal, but as you're saying, if it's not 60 or above, it might be one of the reasons why you're getting these symptoms. I remember maybe 10, 12 years ago now, chatting to an expert in London on hair, and he would see a lot of patients, a lot of female patients in their 30s and 40s who were losing hair. And I remember he said to me, "Until a ferritin is above 70, it may well be the cause of that woman's hair loss." And I never forgot that.

>> Fascinating.

>> Yeah. And again, it doesn't mean it's the cause, but it means while it's under 70, you don't know if it is. So, I found that super interesting.

>> Michael, I could source you for hours, honestly. Like, I love your your energy, your enthusiasm, your passion for helping people to sleep better. There are so many topics we have not spoken about yet, which we are going to park and leave for our part two, which we're definitely going to have at some point. To finish off, Michael, listen, you you gave so much helpful advice today for someone who has been listening who has realized that perhaps they haven't given their sleep as much attention as they could have done, and they are now wanting to change things. You gave a lot of advice today. Are there some simple places for them to start?

>> Yes, I have a five-step plan that I think makes a lot of sense for everybody here. So step number one is to wake up at the same time 7 days a week. We talked a little bit about why that's so important. That's the timing of melatonin issues. So everybody out there can set an alarm and get up at the same time 7 days a week. Step number two, stop caffeine by 2 p.m. Right? This is a general guideline, but most people, caffeine has a half-life of between 6 and 8 hours. So most people, they're going to bed around 10. If they stop at two, they're going to be a lot better off. Step number three is to stop alcohol three hours before bed. Um, it would be great if you don't have any alcohol. That would be ideal, but I'm not going to be so foolish as to think that nobody's going to drink alcohol. So, if you can limit yourself to two drinks and stop 3 hours before bed. Step number four has to do with exercise. The best thing to improve sleep quality is daily exercise. But if you do it too close to bedtime, you increase core body temperature, and that makes it very difficult. So, you want to stop exercise 4 hours before bed. And then step number five is a morning wakeup routine. I call it the three 15s, right? So when you wake up in the morning, you want to take 15 deep breaths. You want to have 15 ounces of water, and you want to get 15 minutes of sunlight. All of those have got real biological consequences that can be helpful. 15 minutes is exactly the amount you need to create vitamin D. 15 ounces of water helps you hydrate, and the the sunshine in and of itself helps move that brain fog out pretty quickly.

>> Oh, amazing. Super helpful. Super practical. And last question, Michael, you've written, I believe, six books. Now, if someone at the end of this conversation wanted to choose one of your six books to get started with, >> which book would you point them to?

>> It's a great question. I think my most recent book does kind of the most holistic job. And I feel like this is a very holistic show. So, I think Sleep, Drink, Breathe is probably the best one because it goes over sleep. It goes over the importance of hydration, and then it also goes over the importance of breathwork. I'm kind of I'm kind of fanning out a little bit to get people to do more.

>> Right. I said that was the last question, and one more's popped into my head because I opened that door before and haven't closed it. You said that in your room is a plasma television which stays on at night >> and French bulldog >> and you sleep with dogs in your beds. >> I do. >> Um, I know we're at the end of the conversation. I want to be respectful to your time. We can go into these in detail in part two for sure. But top line, why does the sleep doctor have a plasma television on when he's trying to fall asleep?

>> Because sleep is flexible, right? Uh, and that's something that everybody needs to understand is you can sleep in almost any environment. The reason I have my environment the way I do is because of my bed partner. So when I met my wife, uh, she said, "Michael, if we ever have a sleepover, I need you to know that I sleep with the television on." I said, "Oh, Lauren, I'm going to I'm going to become a sleep doctor. I'm going to fix that." I don't know about you, but have you ever tried to fix something in your life partner? Yeah. It doesn't go well. So I I pulled the TV out. She said, "Michael, if you ever want to get in this bed again, I suggest you put the I put the TV right back in." And I studied her, right? Because that's what I do in my house is I look to see, okay, what are what are the different things that that she needs and why do I not need them or are they going to be disruptive to me? So, number one, I can sleep through noise that doesn't seem to bother me. For her, she listens. She avoids monkey mind by listening to an old episode of Seinfeld. Now, here's the trick that she doesn't always know is um I have a timer on the TV. So, I just set the timer. You know, most TVs have got a timer built into the software. I just set the timer, and the TV will turn off in the middle of the night, and she doesn't know it, and I'm fine. So, that's why we do it. Our dogs, we just couldn't sleep without our dogs. Believe it or not, there's data to show that people sleep better with animals in the room, not necessarily in the bed, um, but in the room seems to be uh seems to be quite helpful. Oh, and there's, you know, there's one thing that we forgot to talk about which I think is probably worthwhile, which is thermoregulation. Um, a lot of I I think about it when I think about my dogs because my dogs uh they'll lie close to me to stay warm throughout the night. And that's one of the things that people should be thoughtful about is the cooler your environment, generally speaking, the better your sleep. And believe it or not, they now have these um devices like toppers and things like that that you can have in your bed that can make you cooler or warmer based on your circadian rhythm. We'll talk about it at our next uh pod, but there's definitely some really interesting products on the marketplace that can be helpful for sleep that help you with your temperature.

>> Yeah, love it. Michael, honestly, love what you do. Love that you've been spreading the word about good and better sleep for for a number of years now, several decades. Thank you for all that you do and thank you so much for coming on to the show.

>> Thanks for having me.

>> If you enjoyed that conversation, then I think you are really going to enjoy this one. The tired brain remembers negative experiences but forgets the positive ones. So tired individuals' entire worldview is influenced by a negative salience. We're making decisions, remembering the negative stuff and not the positive.