The Peter Attia Drive - #221 ‒ Understanding sleep and how to improve it

Episode Date: September 5, 2022

View the Show Notes Page for This Episode Become a Member to Receive Exclusive Content Sign Up to Receive Peter’s Weekly Newsletter In this special episode of The Drive, we have pulled together a variety of clips from previous podcasts with sleep expert Dr. Matthew Walker to help listeners understand this topic more deeply, as well as to identify which previous episodes featuring Matt may be of interest. In this episode, Matt gives an overview of why we sleep, the stages of sleep, and sleep chronotypes, and he provides tips to those looking to improve their total sleep and sleep efficiency. Additionally, Matt discusses the pros and cons of napping, and gives his current thinking on the effects of blue light and caffeine on sleep. Finally, Matt explains the dangers of sleeping pills and reveals what he believes are the most useful alternatives for someone struggling with sleep, such as those with insomnia. We discuss: Evolutionary reasons to sleep [2:15]; Stages of sleep, sleep cycles, and brainwaves [10:00]; Understanding sleep chronotypes and how knowing yours could help you [25:45]; Defining sleep efficiency and how to improve it [36:15]; Correcting insomnia: a counterintuitive approach [38:45]; Pros and cons of napping, and insights from the sleep habits of hunter-gatherer tribes [41:30]; Sleep hygiene, wind-down routine, and tips for better sleep [50:15]; The optimal room temperature and body temperature for the best sleep [59:30]; Blue light: how Matt shifted his thinking [1:08:30]; Caffeine: how Matt has adjusted his hypothesis [1:14:45]; The dangers of sleeping pills, useful alternatives, and cognitive behavioral therapy for insomnia [1:19:45]; More. Connect With Peter on Twitter, Instagram, Facebook and YouTube

Hey everyone, welcome to the Drive Podcast. I'm your host, Peter Atia. This podcast, my website, and my weekly newsletter, all focus on the goal of translating the science of longevity into something accessible for everyone. Our goal is to provide the best content in health and wellness, full stop, and we've assembled a great team of analysts to make this happen. If you enjoy this podcast, we've created a membership program that brings you far more in-depth content if you want to take your knowledge of this space to the next level. At the end of this episode, I'll explain what those benefits are, or if you want to learn

more now, head over to peteratia MD dot com forward slash subscribe. Now without further delay, here's today's episode. Welcome to another episode of The Drive. As we've released so many episodes over the past four years, we realized we've covered a lot of topics in detail. Sometimes it can be hard to kind of keep up and try to piece it together. We also realized that there are listeners today who weren't exactly listeners a year ago or three years ago or four years ago. So we did a test of this idea back in May of 2022 where we did an episode that pulled

a variety of clips from previous podcasts, but all on one topic, which was exercise. The feedback we received from that episode was overwhelmingly positive and people asked for more. So this week we're going to do it again. And of course, we're going to pick a different topic. This topic is going to be sleep, probably something we get just as many questions on as frankly anything else. We put these clips in the order of what we think is the best way to listen from top to

bottom. But in between some of the clips, I'm going to provide a little bit of commentary to set the stage. Our hope is that this will not only allow you to understand the topic of sleep better, but also help identify some of the previous episodes in case you actually want to go back and listen to those in more detail. In each of these clips, I'm going to be joined by Sleep Expert Matt Walker. Matt has been on the podcast several times, including three AMAs. One thing to note is that some of these

clips are from AMAs, so if you're not a subscriber, you'll actually get a sense of what we cover during those episodes. This is still a new concept, and this is only our second time doing this, so we really do want the feedback. If you like this, tell us we'll keep doing it if you don't, we'll scrap it. So without further delay, I hope you'll enjoy this special episode of The Drive. Firstly, you know, it took Mother Nature 3.6 million years to put this 8-hour thing called a night of sleep in place. And within the space of 70 years, if you look at the data, we've locked off almost 20-25%

of that. Imagine coming along and saying, in the next 100 years, I think what I'm going to do is for the entirety of human society, I'm going to reduce their oxygen saturation by about 20 to 25 percent. Do you think that's a good idea? And the answer is no. It's such a great example. I'll pause for a moment just to tell a funny story that you and I have talked about off-mic, which is up until about 2012, I was in the I'll sleep when I'm dead camp and I know what led to that. It wasn't, it was a very deliberate decision at the end of medical school when a good friend of mine with all the best intentions, who was a year ahead of me.

So he was now in, that the end of his internship as I was about to begin mine. He said, and this is in the days when we didn't have the 80 hour work week requirement in residency. So we averaged, I think, about 114 hours a week in the hospital. So he said to me, look, Peter, you're signing up for, you know, whatever, five, seven years of this thing. If you spent every moment outside of the hospital sleeping, you would still be tired. And when difference is you wouldn't have any fun.

So make sure you live every moment that you're not in the hospital to the fullest. And so for me, that basically meant if I wasn't in the hospital, I was swimming. I was going out with my friends. I was trying to meet girls like and I was doing anything and everything such that during that period of my life, I just know because I was pretty adamant about recording how much time, like I was very wed to this idea. There's 168 hours in a week if I'm spending, you know, 114 of them here, and I spend this many driving, and I spend this many getting groceries, and I spend this many swimming, and blah, blah, blah, blah. I think I was about 28 hours a week of sleep.

So it wasn't for every night because you'd have none and then six and then three and then eight. Like you could binge sleep from time to time, but it was pretty much 28 a week. I'll come back to some of the implications of that, but fast forward a few years, I'm talking to a good friend of mine who's a physician who, like you, is adamant about, you know, the importance of sleep. And we're having dinner one night. And he says, he's challenging me on this. And he says, so let me get this straight. You just decided that you're going to sleep half of what is evolutionarily programmed.

And I said, yeah. Because does it strike you as odd that evolution would have designed us to spend a third of our life, not mating, not watching out for predators, not hunting for food, but doing this thing for some other purpose. You think that thing must have been important. And it was such an obvious argument, but it really overnight changed the way I thought about this, which was evolution went to great lengths to do this.

And superficially, at great cost to us, right? I mean, you could argue, well, imagine you didn't need to sleep and you could spend 24 hours a day foraging for food or a mate or some other thing, but it didn't. So it's sort of, it's sort of like there's probably a reason we are not anaerobic to your point about reducing oxygen saturation by 25%. You know, if you were to think about that, you know, during sleep, just as you said, you're not eating, you're not finding food, you're not finding a mate, you're not reproducing, you're not caring for your young, you're vulnerable to predation on any one of those grounds,

but especially all of them put together as a collective, completely anti-evolutionary. It sounds like the dumbest thing. And, you know, often said, and it has been said before, if sleep doesn't serve an absolutely vital set of functions, it's the biggest mistake that the evolutionary process has ever made. And we now realize from this constellation of evidence that Mother Nature did not make a spectacular blender

in putting this thing called an eight hour sort of need of sleep in place. It is the greatest life support system that you could ever wish for. It is a remarkable health insurance policy. And what's great is that it's largely democratic. It's mostly free. And in terms of a prescription from a doctor,

it's largely painless. So I almost wanted to title a book, Consciousness is Overrated, or just sometimes, . . . Consciousness is overrated. But when you really look at the evidence in terms of risk, de-risking, just about every disease that is killing us in the developed world, it's very hard to look no further than sleep. And that's why I don't want to trivialize diet and I don't want to trivialize movement and activity.

But what I would say is that if you want to put sleep up against either one of those two and kind of play the whole head-to-head game, which I don't think we need to do here, I would simply say that sleep is the foundation on which those two are the things sit. It's not the third pillar of good health. I think it is the foundation. That's a really interesting way to think about it, because I typically describe four pillars or five if you include all of the exogenous molecules that you could lump together. But another way to think about it, which again, I don't think is necessarily the right way to think about it,

but sometimes it makes the point. If you deprive yourself of food, how long can you survive? Well, we have one person up to 382 days. Even someone who's as lean as you could survive 30 days with no food, how long could you survive without water? Depends greatly on the temperature, et cetera. But you could make the case that deprivation of sleep would result in the quickest reduction of health.

Certainly more than not eating or not exercising for a period of time. And those studies have been done in rats. And actually, we know some of this from humans who have been trying to, in fact, didn't the Guinness Book of World Records, I can't remember if I read this in your work, they've actually banned attempts at longest period of sleep deprivation. So I mentioned this. Yeah, you know, you know, it was in the book.

When you could still try and beat the World Record of Sleep Deporation and it got up to about, I think the last true effort was about 24 days. But I think it was debatable that one. But based on the weight of the scientific data, the relationship with between sleep loss and mental health, sleep loss and cancer, sleep loss cardiovascular disease, sleep loss and metabolic syndrome, Guinness started to feel very, very uncomfortable. And then when suicide came on the table, it pulled it. So in other words, think about this, you know, there was a gentleman Felix Baumgardner, I think his name was, who sponsored by Red Bull, went up in a capsule in a hot air balloon to the outer surface of our planet. This was about four years ago. Four years ago. He opened the door and then he jumped out and he fell back down to earth

at over a thousand kilometers an hour using his body alone. He broke the sound barrier and he successfully came down. And now Guinness says for that, just fine. However, for that, just fine. However, to sleep deprived yourself, no, much more unsafe. We're not going to let it happen. You are allowed to put it in context. You're allowed up to 12 jumps off Niagara Falls. Basically, but that's okay. But no, no, you're not going to bet such a great point. So let's shift gears just a little bit and go back to the polysum. Let's explain to people because we're going to eventually have to talk about tracking these things. And I want to bring up some of the sort of commercially available ways that people do that, which I think by definition are still not accurate enough for people to,

you know, compare them to their polysum. But if I came into your lab tonight and I was willing to go to sleep there and you would hook me up to an EEG, what are the different patterns of brain waves and how would you morph ologically describe them and then bucket them by these stages? You've already sort of touched on a little bit as deep, ram, deep, ram, deep, non-ram, etc. Yeah, so upon falling asleep, human beings, and in fact all mammals, will experience two different stages of sleep, one of them is called non-rapid eye movement sleep.

The other is rapid eye movement sleep. Non-ramp sleep has been further subdivided into four separate stages, which are unimaginatively called stages one through four. I know, yeah. I think that's all that for sleep deprived people who are, you know, experimenting could come up at that time. So increasing in their depth of sleep, so stages three and four of non-Rem sleep are the really deep restorative stages of sleep. Stages one and two are the lighter stages of sleep. So stages three and four of non-rem sleep are the really deep, restorative stages of sleep, stages one and two are the lighter stages of sleep. And then on the

other hand, we have rapid eye movement sleep or REM sleep, which is named not after the popular Michael Steip pen, but because of these bizarre horizontal, shuttling eye movements that occur during the stage of sleep, these rapid eye movements. So, you have these two different types of sleep, and they will essentially, as you fall asleep here in at the sleep center at Berkeley, they will go into essentially a battle for brain domination throughout the night. And that cerebral war between non-REM and REM is going to be one and the last every 90 minutes and then replayed every 90 minutes to create what we call a standard cycling architecture of sleep or what we call a hypnogram of sleep. And so what you will see is that upon falling asleep you'll go into the light stages of non-rhym

stages. Before we do that, let's say before I fall asleep, when I'm just laying in the bed, how would you describe my brain waves under the wakeful condition? So at that point, what we typically see is that when you close your eyes, the back of the brain goes into what's called an alphorhythm. So when you're awake, your brain shows this remarkably

frenetic, high frequency electrical activity. In other words, your brain is going in terms of its brain waves. It's going up and down many, many times a second. And the amplitude is very small, which kind of is paradoxically you think, if I'm awake, then my brain is active. And so the size of those brain waves should be big. It's not, it's actually very small.

And here's the reason. Different parts of your brainwaves should be big. It's not. It's actually very small and here's the reason. Different parts of your brain are doing different things at different times. So those brainwaves sort of are all cancelling each other out. So the analogy would be, if I were to dangle a microphone above a sport stadium, what I'm picking up is the signal from the crowd of 100,000 individual neurons that sit underneath it. That's how an EEG electrode is. Now, before the game starts, that's wakefulness. And at that point, the 100,000 people in the stadium,

and the trans-thousand brain cells, they're all speaking to each other at different moments in time. So there's a lot of cancellation. So there's a lot of cancellation, they're all speaking to each other at different moments in time. So there's a lot of cancellation. So there's a lot of cancellation, they're not all coordinated. But it's very fast and frenetic. So I just get this signal that is very desynchronized and it's not synchronous.

So they're not summing their power together. So the size of that brain wave is not very big. But it's going up and down. But that's why the frequency is so high. The frequency very big, but it's all the frequencies. It's all the frequencies, so high. The frequency is high, meaning that you're sort of going up and down maybe 50, 60 times per second. Now, as you start to fall asleep,

or actually even before you start to fall asleep, as you're lying in bed awake, the back of the brain is the first part of the brain that really starts to settle down. It goes into what we call alphorhythm when you close your eyes. And I assume that's just because the occipital cortex is in the back and you've closed your eyes. Brilliant. So the back of the brain, visual brain, if you close your eyes, that part of the brain essentially stops processing the outside world. And it goes into its sort of default state when it's awake of slowed frequency.

sort of default state when it's awake of slowed frequency, it drops down from maybe 50 times per second down to about, let's say 10 cycles per second, but still relatively low amplitude, but still relatively low amplitude. Then once you start to actually transition, when you make that bridge from the world of wakefulness to sleep, as you sort of cross through that window from one of those worlds to the next. Something bizarre happens, and if anyone out there is lucky enough to be listening to this and they have a bed partner,

you can actually see this, just look at their eyelids as they're falling asleep. And what you'll see is that their eyeballs start to roll in their sockets and they're called slow rolling eye movements. Now we don't know why the eyes roll in the sockets like that but it's the first sign that you're making the transition from the world of wakefulness into sleep. We use it as almost an indicator of the transition into sleep. Now by the way if your partner wakes up sometimes people will wake up from that state, and they see you just looking over them in bed, staring

at their eyelids. If you're in early in a relationship, it's usually the end of the relationship. It's just a point of note, please don't blame me. Usually, wait till you're married and then start to do that one. The divorce usually is hard to come by. So then you start to go down into the light stages of non-ramps sleep stages one and two. Then after about 20 or so minutes you'll go down deep into stages three and four of non-ramps. And in one and two have we transitioned out of that alpha wave? I mean where do we start to see the already- Already. Theta's and theta already happening in stage one. In stage two, you actually go into Theta activity, which is now down from 50 cycles per second, maybe down to just sort of six or seven cycles per second.

And the amplitude's getting a bit bigger, isn't it? It is getting a bit bigger. Yeah. And then every now and again, during stage two, the way that I know that you're in this lighter stage of non-rem sleep stage two is that you'll get these synchronous bursts of electrical activity that we call sleep spindles. That's the K spindle. And that's sort of where you get this, actually you get a nice big slow wave, like almost like a single slow wave, and then you get this burst of a sleep spindle. And we actually did this great project here

at the sleep center where we did the sonification of sleep and we extracted brain waves from human beings. And then we sort of smooth them a little bit with some sort of audio software and then you can play them back. And it's beautiful because when you hear these sleep spindles, they are the short, synchronous bursts of electrical activity that lasts for about a second and a half, and they go up to about 10 or 15 cycles per second. So it's almost like that beautiful rolling R in sort of in the Hindi language, you know, sort of like a cat pairing. So you get these big slow waves and then you get this ripple of a spindle. And when you hear it on the speakers, it's just sensationally you get this and it's every time I hear it. I mean, this is spine tingling stuff when you realize this is going on right now, fitologically in someone's brain. And then from there, you start to go down to the really deep stages of non-rump sleep stages,

three and four. And at that point, the brain goes into this incredible synchronous mantra chant of these slow waves. So the brain wave slow down. of these slow waves. So the brain waves slow down. You go down to maybe just one or two cycles per second. Very, very slow brain wave activity. But the size of those waves crashing on the beach of the cortex, as it were, they are huge. And the reason is this, go back to the sports stadium analogy. Let's say that we're here at Berkeley and we're playing Stanford Oltrivals. Yeah, which hopefully you're going to kick their butt. Fingers crossed. Just make sure there's no band anywhere to be found. It always does as a terrible to say, but at that point, they're chanting in University. They're all chanting in University. So it's louder, but they're now

making the same sound together. And you can actually hear what's being said. Exactly. So now in that single microphone And you can actually hear what's being said. Exactly. So now in that single microphone, you can hear Stanford sucks. Stanford sucks. So all of a sudden, all of the reasons that we are only now starting to understand, the brain coordinates hundreds of thousands of neurons

unlike it does at any moment elsewhere in the 24-hour period. Hundreds of thousands of brain cells all decide to join hands as it were physiologically, metaphorically, and they all fire together, and then they all go silent. They all fire together, and then they all go silent. And what I find amazing about that, by the way, is how slow that frequency is. You're basically, you could be, this could be only happening once a second, right?

That's right. And that's why it got a terrible rap for 20 or 30 years because it actually looked not dissimilar to some aspects of coma. That's how slow those brainwaves were. So sleep scientists were, you know, understandably fooled into thinking that deep sleep was a time when the brain essentially was just doing nothing. Now we realize the exact opposite is true, because it's during that deep sleep that you get essentially information transfer within the brain. It's a file transfer mechanism.

And the way to think about this is, let's say it's like long wave radio. If you're in the city, you tune into FM, which is short wave radio, you can pick up a bunch of signals. Then the further you drive out into the desert, let's say here in California, you just lose those channels because the range from the tower is so short that you just lose that range. But if you go on to the long wave radio stations, you can still pick up stations for hundreds of miles. Why? Because the carrier frequency of those radio waves is much slower. And so the distance over which you can transfer information is much further. Deep sleep is a brain state of long distance information transfer.

Is there more philogenically a difference that you can see between stages three and four, which are obviously both delta waves, but how do you distinguish those two? Technically no. The way it's defined is that what proportion of a 30 second period of time, and that's the way that we score sleep. I'll have you sleep for eight hours, then I'll chop up that eight hours into 30 second bits of information, and for each 30 seconds you'll get a sleep score, and then we add them all up. And what differentiates stage three of deep non-ramps sleep from the very deepest stage, which is stage four non-rims sleep, is simply what proportion

of that 30 seconds is consumed by that deep slow brainwave activity. If it's sort of less than 50%, then it's stage 3. If it's more than 50%, stage 4. So morphologically know, although if you really look at it, morphologically, on average, yes, the waves are typically larger in amplitude and slower in frequency in stage four than they are in stage three. And do people always progress monotonically through these or do sometimes people go one, two, four, three, REM, for example. No, you have to go through three to get to four. You have to go to three to get to four. You have to go from two to get to three to get to four with the exception of probably,

let's see, two examples. One is pathological. If you suffer from narcolepsy, one of the things that typically happens is that you go from being awake straight into REM sleep. So to sort of finish the 90 minute cycle and this will make sense, you go sort of stage one, stage two, stage two, three, three, four, then after about 70 minutes,

you'll rise back up into stage two and then finally you'll pop up into REM sleep and then you'll have a short REM sleep period and then you'll go back down again, down into non-REM sleep up into REM, down into non-REM sleep up into REM and you do that as I said every 19 minutes. However, what changes is the ratio of non-REM to REM within that 90 minute period as you move across the night, such that in the first half of the night, the majority of your 90 minute sleep cycles are comprised of lots of deep non-rem sleep and very little REM sleep. But as you push through to the second half of the night, now the sea-saw balance changes

and the majority of those sleep cycles are comprised much more of rapid eye movement sleep and almost no deep sleep. And that's why it's always dangerous when people say, you know, I'm one of those who survives on, you know, six, six and a half hours of sleep at night. I wake up, you know, five, five, thirty to get a jumpstart on the day. And you can ask, well, let's say you're getting six hours of sleep, how much sleep are you losing? And they will say, well, according to your definition of eight hours of sleep, well, I'm 25% off because I'm getting, I lose two hours at the end of an eight hour night of sleep. So I'm sleeping 75%. I'm losing 25%. Yes and no. Because yes, you're...

You're just proportionate. Exactly. So yes, you're losing 25% of total sleep, but you could be losing up to 70% of all of your REM sleep because it's the REM sleep rich phase that you are short-changing to get a jump start on the day. So you've got to be very careful when you try to think of your sleep dynamics. But to come back to your point, sorry,

yes, you always have to go through that linear progression. Noclepsy is a standout case there. You'll usually go from wakefulness sometimes immediately into REM sleep, very frightening, most people don't experience, you know, logical, rational waking consciousness and then go immediately into irrational hallucinogenic consciousness, which is what REM sleep is. It's very disturbing when you speak to these patients. The other is if you are horrifically REM sleep deprived or chronically sleep deprived, occasionally you can make the transition straight into REM sleep. We see this in people who are abusing alcohol, heavily,

you are alcoholics. Alcohol will come onto this block your REM sleep. You can build up such a hunger for REM sleep that the brain says, well, tonight, I'm going to forego the non-REM sleep. I'm just going to go and feast on REM sleep straight away. This hysteresis in the system, maladaptively. So that's a bad sign when you get hysteresis like that, that type of pressure.

Matt, last time we sat down, you talked briefly about the sleep chronotypes. And I found this interesting for basically two reasons. One is just observing probably a migration in my own daughter's chronotype, which is as she's getting older, she's sleeping in longer in the mornings and going to bed later and later. And I know that as she gets closer and closer to being a teenager, that's probably going to increase. But also just more cognizant, I think, of other people. You alluded to it briefly earlier, which is like there are just people who are going to go to bed later and wake up later. And it doesn't mean that there's anything wrong with

that or there's anything wrong with the reverse, which is people who go to bed early and wake up really early. So kind of wondering if there's a way to actually know what chronotype you are beyond just observation because is it possible that the observation is not your optimal state? In other words, if you have somebody who's sleeping a certain way because their job is imposing it, but it's not the way that they're, you know, ideally meant to do it.

Let me give a better example. A student in college could easily drift into a later chronotype because everybody in their dorm room is even though they may actually be more suited to be earlier. So how can one figure this out? So there are genetic tests that will give you a stronger sense of your coronatype. So coronatype simply means, yeah, are you a morning person, are you an evening person, or are you somewhere in between? And somewhere between 25 to 30% of the population are morning types, 25 to 30% are evening types, and then the rest of us are somewhere in between.

25 to 30% are evening types and then the rest of us are somewhere in between. Sleep sciences then gone a little bit further. We split it into five categories sometimes, which is extreme morning types, morning types, middle, evening types, and extreme evening types. We know that it is under strong genetic control for two reasons. First, there is a significant degree of heritability. So if you are a morning type, it's more than likely that one or both of your parents were morning types. Secondly, we now know that there are a collection of genes that will determine to a degree your chronotype. And this is why companies like 23 and me will tell you what type you are, or they will give you a probabilistic estimation of what type you are.

Last count, I think, from data from 23 and me and this data from the UK Biobank, there's about nine different genes that we know of right now that will contribute to your Kronotype. Most of them are what we call clock genes. This refers to the fact that these genes control the rhythm of your circadian cycle. Now, those genes don't control necessarily the size of your circadian rhythm. In other words, how it's kind of strongly active and awake you are during the day and how deeply sort of down you go at night These genes do something different these genes control when that Sinosoidal wave of your circadian cycle arrives on the clock face what I mean by that is

if you have a certain type of gene complement a certain type of gene complement that makes you a morning type, your activation peak, your peak alertness is going to arrive earlier in the day and your awesome downstroke of your circadian rhythm will arrive earlier in the evening. Whereas if you have a different combination of these gene composites, then you could be an evening type. In other words, your circadian rhythm looks very similar in its sinusoidal pattern, but when the peak and the trough of that circadian rhythm arrive on the 24-hour clock face is very different to a morning type. So we know that there is a complement of genes that you are given at birth that will determine on average once you're an adult, are you a morning type or are you an evening type?

What you alluded to, however, for your daughter was something different, which is that no matter what chronotype you are, that innate chronotype rhythm that you have gifted by your genes will change as you develop from a young child to an adolescent teen to an adult to an older adult. In other words, you go from being much more of a morning type when you're a kid even though you want to stay awake longer, you're found on the couch and you're carried to bed and you're fast asleep, to then being a teen where you're cronotype fast forwards in time. And this is a problem for early school start times where you're putting kids to bed at 9pm and saying you've got to go to bed because you have to wake up at 5 o'clock in the morning to catch a 530 bus for a 715 start time.

Well, there's no point in saying that. It's not their fault that they're now in bed and it's 10-30 an hour and a half later, and they can't fall asleep as a 15-year-old, because their chronotype has moved forward in time. They want to go to bed later and wake up later. Nothing they can do about it. It's biology. And then once they become an adult, it starts to shittle back a little bit. Once they become sort of, you know, moderate age 30 or 40. And then as we start to get older, we regress. That's why

in Florida, there's something called the early bird special where people are going out for dinner at, you know, 4 p.m. or 5 p.m. Because their chronotype has regressed back and they're embed by 8pm. So there are genetic tests to come back to your question. However, you don't need to do a genetic test to get close to understanding what you are. There is a pencil and paper method that sleep scientists have developed. And you can Google it. It's called the M E Q test. And maybe I'll send you the link and we can put it in the show notes. Yeah, we'll put it in the show notes.

And it's a very simple link that you just click and it's a test. It probably takes about five or six minutes to fill out. And it's called the MEQ test, the morning evening, this questionnaire test. And you go through your answer list of questions and at the end, you add up your score and it will tell you what flavor of

Chrono type you are and what's nice is that then they've pattern matched this test and validated it against these gene, these genetic tests. And there's a pretty good correlation, it's not too far off. So this is the poor man's version of the 23 in me test if you want it. And we'll do a link in the show notes and you can take it. And that's a cheap away pencil and paper method or an online method. So the bigger question is Matt, what do we do with this information? Right? I mean, you've, I think we did talk about this previously at one point that you have a couple who have different chronotypes. That can be really difficult. They're going to bed and waking up at different times. You've already alluded to the problem of children who are,

I think, being subjected to potentially too much early school when in reality they probably would do better with later school. Is this the kind of thing that should factor into decisions people make about when they pick classes in college? I mean, it seems like there seems to be, there seems to be one of those things where there might be a bunch of people that go through life kind of miserable when they don't have control over their schedule as opposed to knowing this.

And so, would knowing this by itself provide a benefit to folks? I think it would, I think it would explain a lot about why you struggle so much where other people seem to be just these energizer bunnies and they've even got time to go to the gym for an hour before they sit down at their office desk at 7 a.m. in the morning. And you're still on your fourth cup of coffee desperately trying to wake up and you're struggling to make it in by 715, having woken up 20 minutes before. And I think the second thing that it helps with is realizing that you're not culpable, it's sort of non-miraculpa. It's not your fault. It's, you can understand that

this is genetic because a lot of night hours have gone throughout life being chastised and thinking, well, if only I could get my act together and get to bed earlier and stop being what people tell me I am, which is slothful or lazy, you know, I could hold down a better job or... and again, I think society needs to be much more understanding of it and also then modifying itself in response to accommodated. And neither of those things I see in full serving scoop sizes in society right now. And I that should change. And I think COVID is interesting because if there's some positive upside to it, it may have given us the chance for people to understand how much better they can sleep when they're closer in harmony with their own

chronotype rather than trying to work against it because when you fight biology you normally lose and the way you know you've lost is often through disease and sickness. And I think there is a version of that going on here. I also think it can sometimes explain incorrect insomnia. Often I'll hear someone tell me if I'm sort of out in the public. They'll say, well, I suffer from insomnia, I get into bed and I can't fall asleep and I'm wide awake for the first hour and a half and I need to take some sleeping pills. And then I'll say, you know, first thing I'm not a doctor, but let me just ask you a question. And then I'll say, you know, first thing I'm not a doctor, but let me just ask you a question.

If you are on a desert island with no responsibilities, nobody foot to wake up for, nothing to do, and you could just sleep whenever you want to get up whenever you want. What time would you normally go to bed? And they would say, well, I would actually like to go to bed at midnight and wake up around eight o'clock in the morning in truth.

But I have to get up from my job. I have to wake up at 6. I'm getting in bed at 10. But I still have this terrible insomnia. And I say, well, you know, I don't know this, but it's possible that what you could have is not insomnia, but a mismatch between your chronotype and your working life schedule. And you may want to explore some of this. And there's a test, an MEQ test, and I tell them about this and then go and speak to your doctor. So that's the second implication that I think comes from the question that you asked about how it impacts society. Once you know it, what do we do about it and what should we be doing about it? Those are some of the ramifications, I think. I forgot to say in the episodes before and I'd love to say it now is about sleep opportunity versus duration.

We've constantly been speaking about in our discussions how much sleep does a person need, what's the optimal amount, and we're speaking about somewhere between seven to nine hours. When I say that, I'm talking about seven to nine hours of sleep. Not time in bed where you might lose 10 to 15% of it. Right. And this is the reason that when I think people who say, well, surely you can get by on six and a half hours of sleep or seven hours of sleep, you've got to be very careful because that's a dangerous statement.

This comes to something that we call sleep efficiency. Now, if you are in your 40s, you will probably have, if you're healthy, you'll probably have a sleep efficiency of what we call 90% in other words, of the time that you're in bed, 90% of that time is a sleep and 10% of the time is awake. So let's take an eight hour sleep period. And you think, well, I'm in bed for eight hours, so I'm good. I'm getting my eight hours of sleep. That's not true. Eight hours of sleep is what? That's 480 minutes if my math is correct. If you get a 10% loss of efficiency,

it's like a heating system. You lose 10% of the... You're down to 712. You're down to 712. So in other words, for you as a 40-year-old With a healthy sleep efficiency of 90% for you to get eight hours of sleep, you need to be in bed for eight hours and 48 minutes even a bit longer actually. Yeah, or even a bit longer. So you've got to be very careful That's why I constantly speak about a sleep opportunity of eight to nine hours in bed to get your seven to eight hours of total sleep if that makes sense. Yeah. And this is where I think devices like the aurora ring are very helpful because that's where they're very good. They're very good at telling you you're in bed this long, but you're actually only asleep this long. And that's the number we want the patients to fix eight on. We don't even look at time and bed when we give our patients feedback.

We're talking about total sleep time and efficiency. So if there's a problem with total sleep time and efficiency is low, you have to improve the quality. If total sleep time is low and efficiency is high, you need more time and bed. And it's getting people to understand that distinction that's very important. And the caveat that comes for people

within Somnia though, that I'm here saying you need to increase your time in bed, your sleep opportunity, as I call it, to make sure that you get the right total amount of sleep. And you have to accept there's inefficiency in the system, and you need to extend your time in bed to overcome that slight inefficiency. So again, sort of 8,050 minutes to get your 8 hours total sleep.

The only time I would say that you should not be thinking about longer time in bed is if you're someone who is struggling with insomnia and you're lying in bed awake a lot of the time. reprogramming. We actually do the opposite, which is we actually shorten your sleep opportunity. We crunch that down. It's one of the tools that we have in the CBT. You want to drive the efficiency up by taking a denominator out. People have lost their confidence in going into the bedroom and sleeping constantly, soundly throughout the night. So what we end up doing is actually constraining them, maybe down to just six hours of sleep opportunity. We put them on a diet of sleep opportunity rather than an extension.

And very quickly what happens, so it's ironic, you come to me and you say, I'm not sleeping well and I say, great, I'm going to have you sleep less. And you see ridiculous, it's not what you do is by compressing that window down, you're sleeping less. And you're building up more of that sleep pressure, because as a consequence of the reduction of sleep opportunity time, you're going to be awake during the day longer, the longer that you're awake, the more of that sleep pressure you build up. So, firstly, you're coming into the following night with even more sort of sleepiness on your shoulders.

with even more sort of sleepiness on your shoulders. And then secondly, I'm teaching the brain, unlike it's been giving, it's been given luxury time to just be awake as long as it wants to at night and maybe sleep some. And that's that phenotype of insomnia awake time at night. By constraining that time, I start to force your brain to realize, I'm sorry, you no longer have the luxury of having all of this time to sort of be awake and be asleep. And very quickly, the brain starts to realize and learn that in fact, it only has this tiny opportunity at the dinner table called sleep that is six hours.

And now you start to brute force efficiency, the brain starts to realize, my goodness, I've only got six hours. I need to get my sleep into that six hours. So efficiency markedly increases when you constrain total amount of time in bed. So it's this ironic way that we help treat insomnia. We constrain total sleep time. You brute force efficiency and a brute force response from the brain. And all of a sudden something magical happens. Now that you've set this to age for what sleep is and why it's so important, the next set of clips will really look at ways in which we can improve sleep. These clips will look at the pros and cons of napping, proper sleep hygiene,

and an ideal wind down routine. Optimal temperature for sleep and how Matt changed his thinking on blue light. The question now comes down to one of napping, which we did touch on in our previous episode, but I want to revisit it. Lots of times patients come to me and say, Peter, you have no idea what a 20 minute nap does for me between two and four o'clock in the afternoon. And my historical response to that has been, you know, gosh, you really shouldn't need a nap. I mean, if you're sleeping gosh, you really shouldn't need a nap. I mean, if you're sleeping correctly, isn't that actually a negative thing because it's

depleting some of that adenosine-based pressure and wouldn't you be better off letting the pressure cook or cook and driving you into a deeper sleep when you first take your sleep? So what are your thoughts on that type of a nap? That sort of short, 20-minute, you know, late afternoon, pre-dinner nap? Naps really are a double-edge sword, and we've done lots of studies where we use naps to study the functions of sleep, and we see benefits from naps.

Even naps are short as 17 minutes can produce learning and memory benefits. So there does seem to be some some enhancement that you get and you can see that from cardiovascular benefits as well. The downside of NAPS is that it can take away just what you describe which is sleep pressure and so the typical recommendation that we have is the following, if you are struggling with sleep at night, avoid naps during the day. Because what you want to do if you are already having problems either falling asleep, which is what we call sleep onset insomnia, or you can fall asleep, but you can't stay asleep, which is what we call sleep maintenance insomnia.

You want to build up as much sleep pressure, as much sleepiness as you possibly can during the day. If you are struggling with your sleep at night, do not nap during the day and the pressure cooker analogy is beautiful, keep building up all of that healthy sleepiness pressure because when you nap, it's like having the valve on the cooker open up and you just release some of that healthy sleepiness and now when it comes time to go to bed you're not going to feel the sleepy anymore. However, on the flip side, if you are not struggling with your sleep and you can nap regularly during the day, the advice is, naps can be just fine, because in fact,

if you take a step back from an evolutionary perspective and you study hunter gatherer tribes, whose way of life hasn't changed for thousands of years, they don't necessarily sleep the way that we do in modernity. In fact, particularly during the summer months, they will typically have an afternoon nap right in the time zone that you just described. And this is very much the Mediterranean's, yes,

to like behavior. And in fact, if I stick an electrode on both of our heads throughout the day, and I monitor our physiological brain wave activity, it'll stick much better to my head, by the way, than you. Yeah. Well, yeah, right now, especially because I've got this terrible COVID, which I look like

I should be out of book Rogers and anybody who remembers that television show. But anyway, what we will see is that somewhere between about two to four pm, both you and I will have this kind of drop in our physiological alertness, in our physiological level of brain activity. In other words, as a species, we're almost pre-programmed to have this enforced dip in our alertness. And so many people see this, in the afternoon meetings around the boardroom table

or wherever you could have get these ugly head nods that start to happen. It's not people listening to good music. It's just that people have this sort of, they're falling asleep, they're falling prey to this, what seems to be a genetically hardwired, pre-programmed drop in our alertness. As if maybe we should be what's called by physically sleeping as a species at times during the year, rather than mono-phasically sleeping, which is how we do in most first-world nations,

in other words, one single bout of sleep at night versus two bouts of sleep, which is how those hunt together a tribe sleep, especially during the summer. And so Matt, would they sleep long enough in that two to four window that they would get a full 90 minutes say and get through a full cycle? And then if so, did that mean when they did their nighttime sleep, presumably they would get a full 90 minutes say and get through a full cycle. And then if so, did that mean when they did their nighttime sleep, presumably they would stay up later and get maybe six hours in the evening instead of, you know, because people always talk about how well hunter gatherer studies have always suggested that, you know, seven and a half to nine is the species required amount of sleep on average. But you're saying it was potentially broken into two chunks.

Was that afternoon daytime chunk or day light chunk call it about 90 minutes? No, it wasn't. It was actually typically shorter than that on that basis, but you're right. They typically are not sleeping. What we currently recommend for monophysics sleep, which is the average adult should get somewhere between seven to nine hours. That's the recommended range that we all provide. But what they would typically do is they would maybe sleep

just six, six and a half hours at night, and then they would make the rest up and they would get into that exact same sort of territory by way of the nap. So they would take it in these two chunks. Now I should note this is very different to something else that's been described in the literature, which is first sleep and second sleep. That activity does seem to have occurred during our historical past. It seemed to have emerged in the sort of de-kenzy and era. That was different though. That was different, though.

That was where people would sleep for the first four hours, then they would wake up in the middle of the night. They would, you know, write, they would drink, they would play music, they would make love, and then they would go back for another four hours of sleep. Did that happen? Yes, it seems to have, based on historical writings, but is that the way our physiology and our circadian rhythms are designed? No, it doesn't seem to be. There's usually ones that he that cited that suggests. Maybe we should do that,

but overall, the physiology that we know of for human beings doesn't seem to suggest that that was more sociologically driven, rather than biologically driven. Biologically, we may be by phasic but very differently according to this hunter gatherer sort of tri-pipothesis. By the way the other thing that's interesting in those hunter gatherers and it comes on to what I think we'd describe before which is this concept of midnight. Most of us don't think of what the term means but in those

individuals it means what the word states, which is it's the middle of the night for them midnight, because they usually go to bed maybe two hours after sundown, and they're asleep, you know, by let's say 9 p.m. in the evening, or 830, and then they're awake, you know, just a little bit before dawn. In fact, what's interesting and maybe we'll get onto this in later discussions, all we want to, but what seems to wake them up is not necessarily daylight. It's the change in temperature because there's a rise in temperature that seems to happen before daylight starts to break. And it seems to be, it's the temperature change that they are much more buckled to

in terms of regulation of their sleep way grhythm. And so the way in which the structure of their sleep byphasic is different to ours in modernity and the timing of their sleep is different to some of our timing. You know, for many people midnight is the time that you think, well, I should just check Facebook one last time or you know, send my last tags. That's what midnight means, but normally for a couple of thousand years or hundreds of thousands of years,

it probably meant that was the middle of your solar cycle and it was the middle of your sleep cycle. I'm glad I'm closer to our ancestors. If I could go to bed at 8 o'clock every night and wake up at four, that is a perfect night of sleep for me. Matt, and on previous episodes, obviously, we went into some pretty good depth on tricks, tips, etc. Inside our practice, we have a whole sleep hygiene protocol and we sort of run patients through it relatively early, especially if they're having any sleep issues. But do you mind just sort of going through where you

are now and how you think about this? And again, I'll caveat this by saying, you're not a sleep physician, so it is not your practice to be out there treating anyone individual with respect to their sleep. That's right. But also you're infinitely more qualified than virtually anybody to help people start to think through what the parameters are that factor into sleep. And that's the way we kind of explain it, which is look here, these five or six levers of sleep. And here's how you could move each of them in your control. But I kind of want to hear how you think of it. Yeah, so I think in our past episodes, we've gone through the fine five main sort of sleep

hygiene tips. And I'll just quickly go through them here because we've dealt with them before, which is regularity going to bed at the same time, waking up at the same time, getting lots of darkness at night because we are a doctor-pride society. And I actually think I've done a bad job of describing to the public the importance of the opposite, which is making sure you get daylight during the first half of the day. I think that's just as important. Then temperature, we've spoken about that a little bit,

you need to get cool to get to sleep, I think that's just as important. Then temperature, we've spoken about that a little bit. You need to get cool to get to sleep and it's the reason that you will always find it easier to fall asleep in a room that's too cold and too hot. You shouldn't stay in bed awake. That trains your brain to be triggered by your bed and force you awake because you have a learned association. So if you've been awake for 20 minutes, then get up, go and do something else and only come back to bed when your sleepy is the general rule.

And then finally, you know, trying to avoid alcohol and caffeine in the afternoon and for alcohol in the evenings, as we've said. So those are the sort of typical tips. But I think if I were to add a few others, the other one that's absolutely critical that I probably haven't espoused enough is a wind down routine, because many people in society expect sleep to be like a light switch that we should just jump into bed and we should just turn off the light and the brain should do something similar and go straight into sleep. Sleep as a physiological process if you study it. It's just not like that. Sleep is much more like trying to land a plane. It takes time to gradually descend down onto that hard foundation

of this thing that we call a stable night of sleep. So give yourself some wind down opportunity time, build it into your routine. For some people it's 15 minutes, others it's 30 minutes, light stretches, meditation, putting all of your phones and your gadgets away, staying clear of any inbound in the last 30 minutes, whatever it takes, set it up and then maintain it. Because if you have kids, you'll know all about this, you know, you have a routine for the kids and you've got to try and then maintain it because if you have kids you'll know all about this. You have a routine for the kids and you've got to try and stick to it. If you break the routine bad things usually happen with sleep. We're the same as adults.

There's no difference. So I think that's the first thing I would say. The second probably tweak is if you are struggling with sleep, remove all clock faces from your bedroom. It's not going to help you to know that it's now 2.35 am in the morning and you've still not been able to fall asleep. It's only going to trigger more anxiety. There's been a nice study here from UC Berkeley, not from my centre, but from another sleep

research, Alison Harvey, who looked at this in people who were poor sleepers with insomnia, removing clock faces can certainly help. The next thing I would say is that try to keep, of course, all of your technology outside of the bedroom. And if you can, don't make it the first thing that you check in the morning, because for most of us, the first thing that we do when we wake up is that we swipe right and this flood of anxiety just washes onto us like a tsunami. And that's problematic not just because it's a bad way to start your day, but because you train your brain in this Pavlovian way that every morning, as you're taking yourself into bed at night, every morning, what's coming to you when you wake up is this jag of what we call anticipatory anxiety. And it lightens

your sleep throughout the night because of that expectation. So try to avoid that if you absolutely have to, and again, try not to be pure technical, take your phone into the bedroom. One of the other problems is that it causes what we call sleep procrastination, which is that you're sitting there in bed, you've got your device and you think, well, I'll just check Amazon and order that thing. I'll just check Facebook and I'll send that last email and you look up and now it's 40 minutes later. The rule of thumb that a friend, a colleague of mine, Michael Gradner said, I love this. If you're going to have your phone in your bedroom,

the rule is that you can only use it if you're standing up. And after standing up for about 5 or 10 minutes of phone use, you just think, I just want to sit down, I just want to get into bed. And at that point, the rule is you've got to put your phone away. So those would be sort of three additional things that I would advise.

That can really help. I like that a lot. I would actually add just from a personal standpoint, I've maybe maybe three months ago instituted a little policy for myself that I've really enjoyed, which is not looking at my phone for an hour when I wake up. Yes. Luckily, I don't sleep with my phone in my room, so that's not an issue. but it used to certainly be the first thing I'd go and grab when I got up. And if I get up, but you know, five, I won't look at it till usually after 6am. And that's interesting. I didn't realize that the effect that that could have on my brain as I'm coming into consciousness, knowing that I'm not going to be flooded with information, especially the type of information I don't like,

which is generally all the information on my phone. Yeah, I'll just take two additional pins in that. The first is, I think everyone has had this experience in the extremities where you know you've got to wake up the next day for an interview, or you've got to wake up for a flight that you have to catch. You know for a fact that firstly, your sleep is going to be shallow, it's not going to be particularly deep. And secondly, you almost wake up two minutes before the alarm because you're that

on edge. Well, imagine a diluted version of that, but every single day, that's what bringing your phone into the bedroom and opening it up first thing is all about. The second thing I would say is you're right and set manageable goals. I really enjoy the work of a guy called BJ Farg who's a researcher at Stanford who looks at behavioral change. And it's all about incremental. So if you're trying to get someone to floss their teeth for the first time for dental hygiene, don't say, okay, here's how you floss. You need to floss before you go to bed. You say,

all you're allowed to do for the first week is flush your front to teeth and you cannot do anymore. That's it. And then we say, then's the next, then add two more teeth for the next week, and then two more. The same with sleep. If you are accustomed to doing this with your phone, which is so understandable for all of the pressures that we understand from society and social media, start by saying, I'm going to give myself five minutes. I'm going to firstly not check my phone. I'm just going to wake up, brush my teeth, and make whatever drink that I have in the morning. And when I sit down, that's when I am gifted the opportunity to look at my phone, and

then try to push it to 10 minutes and then try to see if you can get changed, have your shower, wash yourself up, whatever you do in the morning and only then open up your phone and keep pushing it longer and longer, make it a manageable goal. Otherwise, don't set yourself up for failure,

do it for success. Yeah, I think the same advice is great for something like meditation where, you know, for many people saying, hey, why don't you commit to 20 minutes of meditation a day? I mean, that's, that's almost impossible out of the gate, but if it's, hey, meditate every day and if you do a three minute meditation, that, you know, you're better off doing three minutes a day than 20 minutes once a week, I think it's the same sort of idea which I, which I agree.

I think it becomes a lot easier. The last thing I would say is that none of these tips that we've spoken about, which are typically sleep hygiene tips, are going to work if you actually have a sleep disorder. So the analogy here, again, from a colleague, if I'm an athletic sports coach and I'm giving you all of these tips for improving your performance,

but you've got a broken ankle. None of them are going to make any difference to your performance until we actually get you to a doctor and fix the broken ankle. It's the same with a sleep disorder. If you have, you know, insomnia or if you have sleep apnea, none of these things that I've been talking about are going to help you. If you suspect that you have either one of those, definitely go and see your doctor see if you can get some kind of sleep intervention. [♪ INTRO MUSIC PLAYING [♪ OK, let's shift on to temperature. We have a ton of questions on this,

including one of my patients who has specifically asked me to ask you a bunch of questions on this. So I'm looking at all these questions of which there are so many, and I want to start at the top rather than, so I'm going to kind of mix up the order a little bit on these. And this question in particular, I think is a great foray into the discussion. So the question is, did our ancestors get better quality sleep

during certain times of the year and or in certain climates? So for example, death value in the summer, and I don't know how many of our ancestors were spending that much time there, hopefully not too many, but presumably there are hot places, cold places, etc. So I think what this question is obviously getting at is there's a general belief that we sleep better when we're colder. There must have been a number of times when our ancestors were either in places that were not cold or in places where at least during a season it was warm. What can we infer

or impute about sleep quality and temperature from that? So the best data that we have right now, again, comes back to some of these hunt together, tribes, some of them live at different latitudes, and the best data that we have are folks who are very close to the equator. At that point, you think, well, how is this going to answer the question? Well, temperature variation where there are at is still quite significant from summer to winter. It turns out it's just more about, sort of, yes, rainy season and dry season, but the temperature does fluctuate by some degrees too. And you can look at other communities that are a little bit further out. But here's what we find in the summer, typically yes, they actually sleep less when it's hotter, which is going against what needs to happen to your core body temperature

to get good sleep and needs to drop and needs to get cold. During the hotter seasons, they typically sleep less at night. And then they seem to try and do some recovery by doing a short afternoon siesta. But when they switch over to the winter season where it's cooler, it's a little bit darker but not that much, but it's really the temperature when they get cooler, then they sleep longer at night and the frequency with which they have daytime naps actually decreases. So I think that's the best evidence that we have right now from just sort of going back to basics, homo sapiens, what was going on in terms of temperature, the seasons give us the experiment, and the data favors coldness for longer sleep. When you now bring that question to a laboratory where presumably you can take and someone has done this I'm sure where they've taken subjects and basically develop the optimization curve of all things equal but temperature.

There must be an optimization. There's probably temperatures at which you reduce latency. So it's easier to get to bed, but maybe temperature is where it's harder to stay asleep. For example, using myself as an example, I actually like to be really cold when I get in bed. And if I am, it might take me a little longer to fall asleep a minute or two, but it almost guarantees I'll sleep in a more uninterrupted fashion throughout the evening. There are times when I get into bed,

and this is again not true at home because I can control the temperature in my home. I have more difficulty controlling it here, for example, like when Bakersfield, it's hot as Hades, the last two nights, and again, it could be the excitement of racing, but I also feel like I've been waking up a little warm, and I don't have my chili pat. I don't have that little cooling pat on my blanket. I had no issues with latency, but I'm waking up early. So if you run through all the permutations and combinations of this, can one say there is an optimal room temperature or air temperature or skin temperature or something that we should be driving towards? So right now, the data that we have is somewhere around about 65 to 67 degrees is optimal for the sleep of most

people. Now there's going to be variability there for sure, and we know this, we can see this in the data too. But it's actually even a little bit more complex than that. And there've been studies that people have done where they almost strap in what looks like a wetsuit, but it's got all of these veins that run throughout them, and we can percolate this water. I think we've spoken a little bit about this before, where you can exquisitely control the temperature, hot or cold at any part of the body. And I'll summarize the findings as the following in terms of temperature. It's a three-part story.

For your extremities, you need to warm up to cool down to fall asleep. Then you need to get cold to stay asleep. And then you need to warm cold to stay asleep, and then you need to warm up to wake up. And so the reason that you may be finding latency easier here, but quality of sleep thereafter worse is because it's counterintuitive, how do I drop your core body temperature?

I'm going to tell you I'm going to warm you up, but the reason is because if you take a hot bath or a shower, all of the blood is charmed to the surface of your skin and it radiates the heat out of the core of your body. So in fact, your core body temperature plummets. The reason that hot bath is great, not because you're toasty and bed, it's because your core body temperature is plummeting once you get out. So this is why sometimes having a cold room but socks on or a cold room with a hot water bottle at the end of your bed, just to warm the feet because it's the feet and the hands that need to get a little bit warm to bring the blood because they are the best radiators of heat out of your body. So when we warm the pores of rats, for example, they fall asleep faster because you're charming the heat out of your body. So when we warm the pores of rats, for example, they fall asleep faster

because you're charming the heat out of the core of the body. So the answer to the question really is a little bit more complex. Keep the room cool, warm yourself a little bit inside of bed to radiate that heat out and get you to sleep quicker. That will make the latency. You fall asleep faster in other words, then the ambient temperature will keep your body cold throughout that middle section and later section of sleep. And then if you have a sort of a smart thermostat, you can rise that temperature. I would say actually quite late in the game in the perhaps in the last 20 minutes or the last 15 minutes, and that will try to rocket your temperature out and bring you.

You will wake up easier and feel less groggy if that temperature is higher. Now it's hard because the ambient may not necessarily change much of what's going on under the covers, but it's the reason that most people, when they wake up, they would like hot drink even sometimes in the summer because the hot drink, for the most parts of people, they're just using caffeine and that's what they think keeps them awake. But some of that benefit of the caffeine is actually not caffeine. It's just the hot drink itself that is helping bring back up the core body temperature that makes you feel more awake. So can we quantify the following? Someone comes to you and they say, Matt, I'm doing all of these

things off my check list. But currently I sleep at a room temperature of 75 degrees. How much better would you predict? I would sleep if my room temperature went from 75 to 65. So I think the hard part of this equation and some people may face this too. If they look at that data from sleep trackers, you're going to be sleeping better. We know this is using population statistics for an individual, so this is always dangerous. And I never want to sort of fall into that fallacy, but let's go with it. On average, people are

more likely to sleep considerably better at 65 than 75. Do you say that in terms of duration or stage quality or what metric? So that's where the devil is in the details, because some people will see it in terms of quantity, particularly the quantity of deep sleep. So when we do these studies, that's where you see some of the greatest benefits for the cooling down throughout the night. That's where the thermal gradient can be beneficial. But what's not told is that the largest effect size is not really in quantity, which is minutes,

which is what your sleep tracker, your wristwatch, or your ring will tell you. And you have to be very careful to judge the efficacy of that experimental change on the basis of quantity in minutes. Because if anything, when you look at the data, where you really see the effect is less so in minutes, which is quantity, instead it's in quality, which is measured by the electrical brain wave signature. Now your wristwatch or your ring is not going to be giving you that detail. So if you assume that the drop in temperature has given you a nominal percentage benefit in terms of your deep sleep time and therefore

you don't think it's worthwhile. I think you may want to just second check that logic because there we're seeing it's qualitative, that's more beneficial and you as an individual, it's very difficult for you to sense that qualitative change because you're non-conscious, of course, and there's no good trackers out there right now that you can work typically on your periphery that will tell you that metric. So with that said, it's not necessarily that hard of a question, because I'm constantly trying to run these calculations about all of my scientific sleep beliefs

and think about these three buckets. I think the thing that I've probably changed my mind on most or had a reversal on is the effects of blue light on our sleep. And in fact, in the book I spoke about a study at the time that had been done out of Harvard, which I still think is valid, where they'd used an iPad, where you read on an iPad for an hour versus you read a book under dim light. And they showed that that iPad had this detrimental effect on sleep. It had delayed the release of melatonin. It had caused a reduction in REM sleep. And even when they stopped reading the iPad, it had a blast radius to it where the sleep quality was still bad for a couple of days afterwards. And it

was a compelling study in publishing a good journal. But over the years, I think there's been some research that's pushed back on that and there's been some great work from a university in Australia called Flinders University and Michael Greduzars has done some just great work on this at Flinders. He has changed my mind. I'm less bullish now about the idea that these devices that we use are sleep disruptive because of the blue light. I still think that has an effect. But what I think he's shown in some elegant work is that it's less about the light, it's more about the fact that these devices are just so activating.

That these devices are designed to trigger alertness and what we call physiological arousal in the brain. And in other words, what happens when we use these devices, the reason that they're so disruptive to our sleep is less about their blue light. It's more the fact that we are masking our sleepiness with this overriding artificial activation from the devices. In other words, let's say that all of a sudden it's 10pm and you think, and wide awake, I'm on my computer, I'm working, I've got my phone next to me, I'm checking it, it's pinging, it's dinging. All of a sudden, all of the lights go out, there's a massive electromagnetic pulse that

curses across your environment. It knocks out all of the devices. You've got no phone, no iPad, no electricity. I suspect that within about 15 or 20 minutes, you'd start to feel sleepy. And it's not because of the blue light effects. It's the fact that you are, and you were all along, sleepy, but these devices, because they're so activating, was creating a competing force that hit the mute button on the sleepiness. And it activated you. So I've actually downregulated my belief in the effects of blue light.

And I've introduced this new mental framework regarding the effects of the invasion of technology into our evening lives and our bedrooms. And I'm much more now enamored with this idea that they are mentally stimulating rather than blue light emitting. I forgive my ignorance for this question, but has the experiment not been done where you've taken groups of subjects and you've subjected one group to just a blue light. So an actual blue light that's hitting, I forget how many nanometers that is, but the actual... Right, in the short to that wavelength, yeah.

Yeah. And then you have another group that is just being blasted with red light, and then you have another group that is just being blasted with a regular LED and white light. So you're getting the same intensity of light, but you're moving the wavelength, and therefore you're nullifying the stimulatory effect of what's being red or looked at. I mean, to me, that experiment would eloquently demonstrate whether or not blue light per se is the problem. Has that not been done? It has. So people have played around with the wavelength of the light, and what we believed is that it's the cooler blues, the shorter wavelength flight that are most detrimental and

the reason that screens were blamed is because they are LED based, which is enriched in the lower visible light spectrum, the shorter wavelength, in other words, the cool blues. And that's why the blame came because it was stamping the brakes on melatonin, especially powerfully. And those studies were done. They were done by Chuck Seisler and Steve Lockley from Harvard years ago. why the blame came because it was stamping the brakes on Melatonin, especially powerfully, and those studies were done. They were done by Chuck Seisler and Steve Lockley from Harvard years ago and that led to this sort of belief. And I still think there's good validity in that. And by the way, there was a couple of studies that came out in animals that were

now suggesting at least, I think it was in rats on mice. I could be wrong, or if it was in fruit flies, I apologize, where they actually found the opposite, where they found that the warmer color lights had stronger blocking effects on melatonin. It began this sort of controversy, had we got it wrong about blue light. And then this work from Flinders University from Michael was coming online regarding this cognitive component, and it really sort of made me shift my belief system. So yes, those studies have been done and they principally looked at melatonin. I think they studied less,

a full night of sleep with polysomnography and really asked the downstream consequences. They were just simply saying, how does it affect your melatonin? Which is maybe one step short of saying, how does it then affect as a consequence of that change in melatonin, your subsequent sleep,

without necessarily doing a much more sophisticated study, which I think are now being done, where you do the Coke Pepsi challenge of same amount of light stimulation. So light is standardized. Right, light becomes the variable that's the only independent variable. That's right.

And then you start measuring independent variable at polysum and melatonin for what it's worth and do everything. And then you do a second round of studies where light actually becomes the constant stimulus where you maintain the same light exposure, but in one condition, you're doing something cognitively activating, like building a Facebook account or checking that versus you're simply just there in front of the blue light. But there's no cognitive stimulation to really do the two by two disambiguation of that. I think those studies are coming. But that's one of the things where I've definitely changed my mind, I think, and I felt compelled to now speak more about that and less about the blue light.

The last set of clips will shift our focus to look at the effect that caffeine can have on our sleep and the dangers of sleeping pills. If you find yourself enjoying these clips and want more content, we have seven episodes with Matt, including three AMAs. These are great pieces of content to go back to and listen to if you want to scratch this itch a little bit more. The other place where I think I've changed my mind and maybe even some of my behavior is around my mind and maybe even some of my behavior is around coffee and caffeine. The evidence has continued to mount and it's unignorable and now again these are mostly associational epidemiological studies which both you and I know are problematic for lots of different reasons but they're so consistent that if you look at coffee drinkers, they reliably

de-risk a whole constellation of diseases that you want to avoid. And yes, there is a dose dependency to it where once you get past kind of like three or four cups, then things go in bad directions or the opposite direction at least. But for the most part, there seems to be the set of very clear associations between low-term moderate caffeine consumption and de-risking health disease conditions. How on earth does this square with walkers espousing of caffeine's impact on sleep? And the fact that a lack of sleep seems to be associated with many of those same conditions, the go between here is that caffeine, of course, can disrupt your sleep. So, I've kind of modified my beliefs a little bit.

I think caffeine consumption is actually not only just fine, but maybe to be encouraged if there is more causal evidence. I think you and Tim Ferris would speak about this idea that the dose makes the poison. And that is true with caffeine, but I also think there's a second variable here, the dose and the timing make the poison when it comes to caffeine. If you're drinking it later in the day, then I don't think we would see those same health benefits. We would see health detriment, and we don't have the would see those same health benefits. We would see health detriment,

and we don't have the data to help to find that. But then I've added a layer of complexity to that after listening to a good friend of mine and a writer here in Berkeley, Michael Pollan, who wrote a book on Audible that you can hear called Caffeine. And it goes into great depth, and we spoke about this. He interviewed me for

the book. He believes that the health benefits which are very hard to deny of caffeine are not really due to a cup of coffee. It's actually the fact that the coffee being itself carries with it, lots of antioxidants. And in fact, the reason that you get these health benefits is because the antioxidants take a joy ride on the good bus of this thing called caffeine, and his belief is that for Americans, for many Americans who don't get a balanced diet. Coffee in the morning may be one of the only primary sources of antioxidant consumption, and that's why you see the health associations. And in fact, I looked at a fantastic review from 2017. And what they found was that, in fact, decaffeinated coffee, which carries the same antioxidant load, but without the caffeine, has many health benefit associations with it,

which then started to make it all a bit more nuanced, that perhaps it's more about the antioxidant benefit, rather than necessarily the caffeine benefit. But there is certainly an association with coffee that I think makes me more likely to tell people it's fine to be drinking a couple of cups of coffee in the morning. Please do that. In fact, if anything, there seems to be some health benefits. I think it's probably because of the antioxidant benefits, but I've changed my mind, too. I think I've become more relaxed. And in fact, I've now started to drink decaffeinated coffee in the mornings. And is the reason you're not drinking caffeinated coffee because it just activates you too much or because you still fear it will, and because you fear it will impact your sleep negatively?

Yeah, it's because I still fear that it impacts my sleep negatively. There was a study by a good colleague of mine at the University of Suri in England called Dirk Jan Dyke published many years ago, and they were actually dosing people with caffeine at seven o'clock in the morning, and they could still pick up in the signal of subsequent deep electrical sleep that following night, a reduction in the quality of that deep sleep. So, I think it again, it depends on who you are. There are genetic differences in how quickly people metabolize caffeine. And I think I'm someone who may be on the moderate end of the sensitivity spectrum. So, I typically stay away from it.

But other people, I think probably don't have that same sensitivity in morning coffee consumption. Caffeine is fine. Well, thank you, Aaron Hatch, for the supplement industry. We owe you a debt of gratitude, and I hope you can hear this archasm in my voice. I think most people now are wise to it, and we certainly spoke about it at length in the original episodes about the real downside of things like ambient lynesta, these drugs.

In fact, very recently, I just saw something in the news that tried to tally up the number of deaths that could actually be attributed to these things. So I mean, I feel very comfortable telling patients that I would rather you stick your genitals in a grinder than you take Ambien or Linesta. There's always the point in taping a podcast with Pistrate here where it just comes to one of these wonderful christened those, the things that I think about, but I have no bravery to say, and he just comes out and says them, and this is part of the reason I adore him as a person. I really hate drugs.

I really hate them. By full disclosure, I still prescribe them on occasion to patients who really insist on having them as a safety net. I would not let any patient have those. And I can monitor by prescription. There's no patient. I'm going to let take those drugs every night.

And maybe if they needed a couple of nights a month as they're traveling and such, we work really hard to get them off it. But let's talk about sort of the softer things that people often rely on consistently for sleep aids. What about things like Benadrill or Advil PM? I get a lot of questions about that here. I don't think we would argue that those are good for sleep. I think that maybe we could frame the question as how bad are they for sleep?

Yeah. So firstly to come back to ambient and sort of its collection, Lineshtar, all of those classic, what we call the sedative hypnotics. In fact, you're right. I think it was nine days ago from the point that we're speaking right now, the FDA updated its mortality risk warnings regarding those sleeping pills because of this increased risk of death, both acutely for a number of reasons, but also this data just chronically in terms of chronic, the risk of far greater, right? Cancer, we also see in part, I think it's probably because of a weakening of the immune system. And I think we spoke about this before. The irony is that

your sleep is incredibly powerful in boosting the whole collection of weaponry in your immune system. Yet when you sleep and sleep long with those sleeping pills, you would imagine your immune system gets even better. The opposite seems to be true. It gets worse and the reason we know this is because there's a higher rate of infection in those patients who are taking sleeping pills, scales with the degree of use and dosage. So I would say trying to use those as a very last resort. Now, there are some patients for whom alternatives don't seem to work. And for a short period of time, that seems to be recommended right now by the medical community. But I should also note that in 2016, the American College of Physicians

made a landmark recommendation that they said, based on the health risks and the concerns together with the nominal benefit of those sleeping pills above and beyond placebo. Sleeping pills must no longer be the first line recommendation for insomnia. It has to be something else called cognitive behavioral therapy for insomnia or CBTI, which we can come back to in a second. Which I've had three patients go through formal CBTI with great success. It's a non-phomacological, it's a psychological method you work with a therapist and they try to understand where your sleep problems are at

and create a bespoke solution for you, the individual. So there's lots of tools in the CBTI box that we can use to try and help people sleep better. And because everyone who has sleep problems is usually a little different from one person to the next. You have to create a more Savile Row tailored suit for that person in terms of that sleep prescription quote unquote. But it's just as efficacious as sleeping pills in a short term. But what's just as efficacious a sleeping pills in a short term. But what's better is that when you start working with your therapist, those benefits can last. Now I think the last report was maybe somewhere between up to five years that you can maintain

that benefit. Unlike sleeping pills, where when you stop them, you not only go back to the bad sleep that you had, it's usually even worse. It's called sleep rebound in some near. How do you recommend people find good CBTI therapists? Because like all things therapy-wise, the practitioner matters. Now, I've been very fortunate because we work with this amazing sleep doc named Vic Chene in Chicago and wherever my patients are, if it's San Francisco, New York, he knows the best therapists and he just makes that introduction plugs us directly. And but if you're listening to this and you're thinking, I live in St. Louis and boy, what I really benefit from this, how can a person listening figure out there's a just trial and error.

You just have to go through people until you find someone who's really clicking with you. So one of the things that we can do maybe in post in the show notes, there is a website that comes out of the American Academy of Sleep Medicine and there is one page, it's not that easy to find, but I know the link so I'll send it out and you go to that link and you insert your zip code into this website. So this is of course just for people in America. And it will return the closest certified centers by the American Academy of Sleep Medicine for sleep disorders, including CBTI. And you can give it a radius and you can give it a distance, tell me where is close. And they will give you the sleep centers to contact them and you can go

from there. And what should you look for in terms of, because we know that all doctors are not created equal, all mechanics are not created equal, all lawyers are not created equal, how does a person evaluate their own individual or is it simply through the results? I mean, right now it's going to be in part trial and error. And I would say have a conversation with two or three potential CPTI therapists and just try them on

for size and see how they work. If you can get any referrals right now, sometimes you can even go into places like Yelp or other places where you can get some reviews to some people. If they're motivated to write, it's usually because they had a bad experience. So keep that bias in mind. But I would say if you can get a referral from a friend or a colleague, that's a fantastic way to go to. And then speak to these people and ask them about their success rates and ask them also, where have you found problems with your patients, which patients have you typically had the hardest difficulty with in terms of the profile of sleep problems and if they sound like you,

then maybe you want to look elsewhere as well. But CBTI over sleeping pills for sure, in terms of things like Tylenol PM or... Benadrol is typically used. There is a little bit of evidence that Benadrol-induced sleep also has some of the risks associated with it that sleeping pills have. It's less potent in terms of that bad consequence and outcome to sleep, but the bad consequence and outcome remains statistically significant in those reports. So I would shy away

from things like Benadrill as well. Tyronol PM, I just don't think there's good enough data yet to suggest that it's either good or bad. And what about low doses or intermittent use of benzodiazepines, either short-acting ones like Adivan or longer-acting ones, Xanax or longer-acting ones like Valium? I talk about this in my jet lag protocol when I'm doing heroic bursts of jet lag, you know, 12-hour time zone difference. And I have to put myself to sleep. We talked about the entire routine around exercise and caffeine and going to sleep immediately

getting on the plane. And I use phosphatital serine. And I use the Kirk Parsley stuff. And I'll also use valium to just make sure I am out. And what are your thoughts on the short term use of Benzo's, again, paired with these other agents around JetLeg? I don't think anyone's really advocating they'd be used in any ongoing manner, either. Certainly not. Yeah. In frequent use, I suppose it depends on how infrequent in one of the

studies by a guy called Dan Kripke, who was actually a meritist here in San Diego. He just looked at not only whether use of sleeping pills was detrimental to mortality. He looked at the frequency of how often you were taking those. And what he was finding is that even anywhere between three to 18 pills per year carried a statistically significant increase in mortality risk. And did he put benzos in the same category as the out of end lunestas? He did, yeah. So he sort of has broken some of that stuff down and broken it out too. I would say in truth, see how far you can really get with all of the other kaleidoscope of

possibility, of sleep enhancing possibilities that we've discussed. And if those fail, then I think you can think about last resources, but those drugs typically just are not producing natural sleep. So I would think of those medications like that box on the wall that says, break glass in terms of emergency. If you're in that situation and you're really struggling, then it's possible that that's the time to break glass. But those shattered chads can sometimes still be. Because they'll cut you. What about GHB or Xyrem is a precursor? This is a drug that is incredibly potent in patients with narcolepsy. Xyrem is available by prescription. Of course, unless you have narcolepsy, you're going to pay an unbelievable amount. It's one of the funniest sort of economic incentives imaginable. But several listeners have asked, and several of my patients actually have asked about does Xyram actually produce appropriate

sleep staging? What's the data on that? So the data, if you look at it, almost looks like Xyram is a great drug or GHB is a great drug for increasing the amount of deep sleep that you have, mostly because it puts your brain into a more sort of sedated slow rhythm, which a sleep technician, if they didn't know that you were on Xyram, would look at it and say, that looks not dissimilar to deep slow wave sleep. So I'm going to score it as I'm sort of scoring these eight hour sleep. So I'm going to score it as I am sort of scoring these eight hour sleep records.

I'm going to score it as deep sleep. So overall in terms of total amount of sleep, GHB or Xyram does seem to actually increase the amount of slow wave sleep time that is scored by a technician. And I'm being very technical in my language because I want to be precise in this regard. However, if you look at the electrical signature of that sleep, which is now independent, so when a sleep technician scores a trace, they have a set of criteria that they use to define which stage of sleep each 30 second epoch of time, each 30 second window of time. There is throughout

that eight-hour period and they scroll through it 30 second page by 30 seconds and they score each of those. They add them all up. That's what gives your sleep profile and sleep score. So using the criteria that we've had now for about 60 or 70 years, they will score more of your sleep as being quote-unquote slow wave sleep when you are on GHB because it seems to produce what looks like slow brainwave activity and by that criteria they have to score it as such. But if you umbuckle yourself from this kind of standard sleep scoring criteria and a human and you just let an algorithm process the electrical signature of that sleep. It now does not look like naturalistic sleep. And in fact, if there's anything that we've seen that Xyrum seems to be detrimental to, it's actually these things called sleep spindles.

Now sleep spindles are these short synchronous bursts of electrical activity that happened during non-rem sleep. They last for about a minute or a minute and a half. And we know from the work that we've done and other people have done, they are critical for things like learning, memory, and brain plasticity. And what we found is that when you take GHB or Zyram, the amount of sleep spindle activity is decreased often. This shows up sort of at the end of, as your transitioning from theta to delta,

does this typically occur? It actually, what happens is usually sleep sleep spindles at the end of a deep slow wave. So you've got all of these slow waves that happen during deep non-rhym sleep. And typically what happens is that, sort of once you've hit the peak of that slow wave, you will often have a little bit of a spindle burst.

In fact, those two things, couple, it's called phase amplitude coupling. So at the peak of the deep slow wave on its awesome rise up, that's the burst. That's when you get the burst additionally of the sleep spindle. So if I could convert it to a sound which we've done, you would get these slow waves, which would sort of sound like and then often riding on top of those slow waves, you'll have a sleep spindle. So you'll sort of have like And that is the sleep spindle. It's this burst of faster frequency activity. And the coupling of those two seems to be critical in terms of things like long-term memory transfer,

shifting memories from short-term to long-term. So you protect them and make them safe. Those spindles also seem to have a role in terms of triggering the strengthening of connections between brain cells, something that we call brain plasticity, or long-term potentiation within the brain. And when you are blocking those sleep spindles, the idea would be that you're preventing typical memory and brain plasticity events that occur. So once again, you can see that. So it's kind of a lesser of two evils. It's you take a patient who's got narcolepsy, if the alternative is they're constantly falling asleep at the point where

they can't function normally. Well, maybe we have to give up something. But again, what I'm hearing you say is, if you're an individual who's sleep is not fully optimized, assuming you can afford Xyrem, which pretty much no human being can afford it, that's just not the solution either. We don't have deep sleep in a pill. That's right. Your analogy I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember I remember in the favor of taking the medication. Thank you for listening to this week's episode of The Drive. If you're interested in diving deeper into any topics we discuss, we've created a membership program that allows us to bring you more in-depth, exclusive content without relying on paid ads. It's our goal to ensure members get back much more

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