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

0:00Welcome back to the podcast. Today, we're taking a deep dive into sleep, one of the most critical yet often misunderstood pillars of health, cognition, and performance. Joining me today is Dr. Michael Grandner, a renowned sleep expert and researcher whose work bridges academia and real-world applications in optimizing sleep for peak health and performance. Dr. Grandner serves as the director of the Sleep and Health Research Program at the University of Arizona, where he's also an associate professor in the departments of psychiatry, medicine, and nutritional sciences. Beyond academia, Dr. Grandner consults with professional athletes,

0:35elite performers, and high-level organizations to implement sleep strategies that directly improve athletic performance, cognitive function, and overall health. In today's episode, Michael and I cover an extensive range of critical topics, including differentiating clinical insomnia from common sleep disruptions, and the subtle yet significant signals used to identify underlining causes like hyperarousal, circadian misalignment, insufficient sleep drive. We discuss why cognitive behavioral therapy for insomnia, CBTI, is the gold standard treatment, its most potent mechanisms,

1:11and we also discuss key interventions that yield the greatest improvements in sleep quality. We discuss practical protocols for addressing common sleep disturbances like stimulus control, strategies for nighttime awakenings, and personalized sleep restriction methods. We also discuss recognizing and addressing sleep apnea, including non-obvious symptoms, data-driven red flags from wearable devices, and effective non-CPAP interventions like oral appliances, positional therapy, breathing training, and more. We discuss advanced evidence-based sleep hygiene practices, including actionable

1:44protocols involving temperature modulation, breathable techniques, and also precise timing of light exposure. We also evaluate popular sleep supplements and substances from melatonin dosing and timing of magnesium, lavender, glycine, as well as nuanced impacts of THC, CBD, alcohol, caffeine, and late night eating on sleep architecture. We also discuss actionable strategies to manage unavoidable disruptions of sleep like shift work and jet lag, the accuracy and limitations of best practices for

2:14interpreting and acting on data from consumer sleep tracking devices like the Oura Ring, Whoop, Apple Watch, Fitbit. And we talk about practical insights on how sleep consistency and strategic napping directly impact cognitive performance, athletic outcomes, injury prevention, and recovery. Whether you want to improve cognitive or athletic performance or achieve better cognitive health, by the end of this conversation, you'll have an arsenal of scientifically robust, actionable tools to transform your sleep. A quick reminder before we jump in, if you enjoy these conversations and want more practical health insights, consider signing up

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3:53foundmyfitness.com forward slash p-r-e-m-i-u-m premium. And now on to my discussion with Dr. Michael Grandner on all things sleep. I'm pretty excited to be sitting here with Dr. Michael Grandner, who is one of the, I would say, foremost experts in sleep science, behavioral medicine. And he directs the sleep and health research program at the University of Arizona. His research focuses on, I couldn't even tell you everything, it focuses on all things sleep. But, you know, even, I think you're

4:27probably some, some of your research is some of the first to really kind of throw out this idea as using sleep as a performance enhancer, both athletic performance, cognitive performance. So I'm super excited to get into that today, as well as a lot of other topics on sleep. So thank you for coming to the show, Michael. Yeah, no, thanks for having me. I, as we were talking about earlier, I kind of wanted to start this episode talking about sleep problems. You know, you've got a lot of patients that come into your, your clinic with sleep problems, insomnia being probably one of the most prevalent ones.

5:00Um, when someone comes into your clinic and says, I have insomnia, what sort of data points or clinical features do you kind of look at to distinguish whether or not this person actually has insomnia versus all the other things that could just be causing poor sleep? Right. That's a great question. The way I think about it is that there's really two kinds of insomnia. Uh, I call it sort of insomnia with a lowercase I and insomnia with a capital I think

5:31of it. It's kind of like depression too, where it's a word, it's a word that we use to mean a lot of different things, but in a clinical context, it means something specific. So a lot of people will say, I have trouble sleeping, um, and I have insomnia, but is this an insomnia disorder is how we would call it? We'd call it an insomnia disorder. And the way to tell the difference is how they're presenting. So an insomnia disorder is defined as a persistent difficulty initiating or maintaining

6:06sleep or waking up too early. So it can happen anywhere in the night. The difficulty has to be there. Um, it has to occur at least three nights per week. It has to have gone on for at least three months to be considered a chronic insomnia. It has to cause some sort of daytime functioning problem could be almost anything, but it's got to cause problems. You have to give yourself adequate opportunity to sleep. So just sleep depriving yourself isn't insomnia. Um, and when you think about

6:39what that means in terms of difficulty falling asleep, there's no hard and fast rule, but a good rule of thumb we use is about 30 minutes. So if it's taking you at least 30 minutes to fall asleep or you're, or you're awake for at least 30 minutes during the night trying to sleep and you can't, that's a good sign that maybe what you have is an insomnia disorder where a lot of people will have occasional sleep difficulties sometimes, but, but that's really the difference where it's crosses the line to where it's really interfering with your function. And how do you just determine, um,

7:14you know, what is the underlying cause of someone's insomnia? I would imagine, you know, hyper aroused nervous system being one of them, but there's probably others. Yeah, there's, so there's actually something really interesting about chronic insomnia versus acute insomnia. So acute insomnia, there are an almost unlimited number of things that can cause acute insomnia for a very good reason. I mean, evolution figured out a long time ago that when, when we're under periods of stress and our survival is questioned and it's bedtime, we kind of should just keep going until

7:49we're safe. Right. And we have all these systems in place to protect ourselves. So under any kind of period of, of hyper arousal or stress or anything, whether it's mental, physical, or both, we have systems in place that can prolong wakefulness relatively safely, especially in the short term. And so there are a million causes of short-term insomnia, but there's only really one cause of chronic

8:19insomnia. And, and that's, there's a switch that flips from short-term insomnia to chronic insomnia. And that switch is all around the concept of a conditioned arousal. That's why when someone comes into the insomnia clinic, often the thing that caused their acute insomnia is actually no longer relevant. It's sort of like a ball is rolling, right? And if the ball is rolling down a hill and with the ball was pushed, shoved, kicked, leaned on heavily, whatever caused the ball to start moving

8:56is important because you want to prevent that in the future. But if you want to stop the ball from rolling, knowing what that is and doing anything about that is largely irrelevant. The problem you're dealing with now is gravity and momentum. And that's what happens with chronic insomnia. It takes on a life of its own because of this concept of conditioned arousal. Can you, can you give an example of that? So let's say, you know, someone has work-related stress or something, right? And maybe it's a project related, or maybe there's

9:29emotional related stress from a relationship and, and it does eventually kind of get better. And yet there's still kind of having problems fall asleep. Now, why, what, what would be the conditioned stimulus? So this is what happens. Something causes you to lose sleep, right? And what ends up happening is you exert effort to get that sleep back. Now, when you lose your keys, what do you do? You go looking for it. Where do you look for it? The last place you had it. And if you're losing sleep, where are you

10:00looking for it? You're looking for it in bed. But what's happening is you have this activation going on. You have this cortical or cognitive or physiologic or any combination of these arousal systems engaged. And when those are engaged, it is just physically harder to fall asleep. So even if you are tired, even if your natural sleep-wake drive is working just fine, you have this counterweight sort of keeping your mind and body sort of activated. So what ends up happening is

10:32the act of trying to fall asleep, whether it's the beginning of the night, middle of the night, or wherever, becomes predictably stressful. The brain's a pattern recognition machine. You feed it the pattern of sleep is difficult, sleep is stressful, sleep is hard to obtain, sleep is a battle. You feed it that over and over and over again. Even when you are exhausted and tired and sleepy,

11:03just getting into that mode will then wake you up. When sleep becomes predictably stressful, think of something else in your life that's predictably stressful. So a common analogy I like to use is that you go to the dentist's office. I have a friend who's a dentist who hates that I use this analogy, but people know what I'm talking about. Whatever that metaphorical dentist's office is for you, you go, you're there, nothing has happened yet. You're already in this heightened state of arousal. You're responding to a stimulus that hasn't even occurred because you're predicting

11:36that it's going to occur. You're in the waiting room. You're already kind of a little antsy. You're delaying making the phone call to make the appointment three months in the future because you're already responding to that future stimulus that's causing you stress. Being in a place that's predictably stressful, you anticipate it. You can predict it. And by predicting that stress, it creates arousal and activation. The difference is when you're in the

12:08dentist's office, no matter how activated or stressed you are, as long as you open your mouth, they can do their job, right? But in bed, it doesn't work that way. If you get into bed and you are dead tired, you are exhausted, you are sleepy, you are ready, and you get into bed and all of a sudden your body's like, oh, here we go again, or is this going to be a problem? Or whatever that automatic process starts happening, that predictable process happens, it builds activation. activation. That activation makes it just a little bit harder to fall asleep. You eventually

12:44fall asleep, baby. But the connection between activation and sleep is not weakened, but strengthened. And so you're a little stressed, you get into bed, have trouble falling asleep, eventually fall asleep. Getting into bed is predictably tied with stress. And by adding stress to it, you strengthen the prediction and it becomes a self-perpetuating cycle. So whatever the initial cause of the stress was, it's the stress about not sleeping itself that creates the very activation that makes it harder to fall asleep, which strengthens the connection with stress, which

13:17makes it harder to fall asleep, and it becomes a cycle. That's why the best treatments for insomnia aren't about sedating you, they're about reprogramming that whole cycle. Wow. You've just explained insomnia to me in a way that no one ever has, and it's like just clicked, and I'm like, this is... That's what happens. What happens, right. And so now I completely understand this concept of stimulus control. Right. So let's talk about CBTI, cognitive behavioral therapy for insomnia. Yeah. And obviously there's lots of components to it, one of them being the stimulus control,

13:49which now is like making so much more sense to me. Yeah. But let's talk about what that is, why it does work so well for people. And also, back to this whole training, this negative association, this negative stimulus, where you're like just the act of getting into bed is making you hyper aroused, is giving you anxiety. Is that also true then, let's say you do eventually fall asleep, then you wake up, whatever you have to repeat, whatever it is, it wakes you up, you're hot. And then all of a sudden you're still in that bed. And it's like, again, that negative association, right? And so it's like every time you wake up.

14:21And that's why some people, they fall asleep just fine because... So something for people to understand is that sleep-wake is not a unidimensional line where you're sleepy on one end and awake on the other end. There's actually two separate dimensions. Think of it like there's treble and there's bass. And it's not just mono. There's treble and there's bass. You have a wakefulness signal and you have a sleep signal that are separate from each other.

14:53They're related, but they do function somewhat independently. And so sedatives boost that sleepiness signal. A lot of times with insomity, what happens because of the excess activation arousal, your sleep signal could be just fine. It's your wake signal that might be too high. And so when someone is taking, say, a sedative medication, what you're doing is you're just, you're trying to drive up that sleepiness signal so high, it's just steamrolling over whatever activation you have. And often that may work. And the reason it can work long-term sometimes is if

15:27you steamroll it over enough, you can maybe break that learning. So it's not, so it isn't just the sedation, but for a lot of people, it's not sedation that's the problem. The problem is in the activation. And when you're doing therapy for insomnia, it's often not about, so, so patients will come in thinking like, how do you make me sleepier? Actually, I've got, we've got some tools for that and we'll talk about that. But often the magic isn't about making you sleepy. It's about making you less awake and it's a different process. And that's also why it doesn't work a hundred percent

16:00of the time. Nothing does, but that that's why CBTI is so effective because it's actually targeting the problem that the person actually has. Okay. Let's talk about it. Awesome. So, so here's the deal. Oh, a few, several decades ago now. So, so stimulus control was first published in 1972. This isn't new stuff. Um, and it was this, it was under this idea. The idea of stimulus control is if you're in a place where only a very limited number of things could possibly occur there,

16:36you will predict that they will occur and you get yourself in the zone. So we talked about the dentist chair, but a great positive example is going to the gym, right? Like if you're going to the training room or wherever you don't do anything else there. So even if you're kind of tired or if you're in a bad mood or whatever, once you start that process, you can usually finish the workout at the end and then you go back to your life. But when you're there, you can get in the zone and because it's because being there creates the conditions that are predictably tied with doing

17:09what you're going to do. And so when you're in a place where there's a limited number of options, those options become predictable. On the other side of stimulus control is if you're in a place where all kinds of options exist, none of them become predictable. So a great example of this I found is, especially over the pandemic and as people are working from home more, is the dining room table started also becoming where people work. And it wasn't just a place where you eat. So it used to be you sit down at the dining room table because all you do is eat there, you'd start getting hungry. But if that's also where you work and it's also where you watch TV

17:42and it's also where you're socializing, you sit down, you're thinking about work and you want to put the TV on and you may or may not be hungry. So it dilutes the ability of the place to have a response if you start increasing the number of things that occur there. And so the way this is applied to sleep is that if in bed, if being in bed is predictably tied to sleep, you can program that association. But if being in bed isn't predictably tied to sleep, you don't know what

18:16to predict. So here's an example. If I say bed sleep, bed sleep, bed sleep, bed sleep, I say bed, you say? Sleep. Correct. If I say bed sleep, bed wake, bed think, bed wake, bed sleep, bed wake, bed sleep, bed think, bed surf, maybe. Scroll. You have no idea. Right. You have no idea what's coming next. You can't predict the pattern. Human brains love patterns. And if you can't control the

18:49sleep side of the equation yet, at least you can control the bed side of the equation. Stimulus control therapy, which is one of the core components of CBTI, was built around that. And since that time, CBTI has emerged as sort of this multi-component toolbox. Stimulus control is one of the core components. But there's all these tools that we have that are essentially, it says therapy. It's a lot less like psychotherapy. It's a lot more like physical therapy, where we're teaching your body to

19:22do a thing it physically can do. It just doesn't know how anymore, or it forgot, or you need to build it back up again. So you have all, everything is there inside of you. I mean, when a patient comes in and says, I'm having trouble sleeping, it's like saying, I'm having trouble breathing. When someone says, I'm having trouble breathing, it's not just because like they suck at breathing and it's just a skill they never mastered, right? Like you were breathing when you were born. No one had to teach you. It's a part of how your body works. The trick is, why aren't you able to do this thing you were built to be

19:57able to do? What's in the way? What's preventing your body from working the way it's supposed to? And insomnia treatment is often like that. It's like, you can probably sleep just fine. You were built with this ability. There's a chance maybe there's something else, but most of the time you have everything in you you need to sleep fine. Something is in the way. Let's get out of your own way and clear that path. So do you, I was going to ask you a question about what you think the most

20:27important mechanism behind why CBTI works. It's through the conditioned arousal. It's teaching people that, that A, they can gain more control over their ability to sleep than they thought. But also paradoxically, it also teaches people how and when to surrender some control. So like, let's say you have a stomach bug and you have no appetite for a day, right? You're eating like toast and drinking tea or whatever. I just, if you eat anything, that would be bad.

21:01You don't think, what if I starve to death? That's not a thought you have. You don't think, oh, I have this stomach bug. What if I get a niacin deficiency and have permanent damage? Because no, you don't. What you think is, I don't have an appetite for a couple of days, but in a couple of days, it'll come back and I'll be fine. And when people deal with temporary sleep loss that same way, it's a similar system. The system can correct itself if you let it. But what ends up happening is when we start stressing about it, it starts creating these problems. And a lot of times

21:35it's us, it's us getting in our own way. Right. Um, it, let's say you had, you know, someone that has to work on their stimulus control. Yeah. Um, you know, there, there's someone that likes to get into bed. They have trouble falling asleep. So they pull out their phone, they're scrolling, they're looking at, you know, social media, whatever. And maybe they're ruminating. Yeah. Like what would be your, how would you approach that? Like what would you be, what would be like your two week fix? Great. So first of all, um, in addition to stimulus control, in terms of the

22:07other tools within CBTI, a lot of them focus on this idea that you want to drive your natural sleep drive, put that sleep drive in bed. And when you're not, when bed is not really going to be used for sleep, you get up. And so if you're going to be on your phone, the first thing I would say is try and separate the phone from the bed. Have the bed be the place where sleep is occurring, not where sleep is predictably not occurring. Cause it's not occurring when you're on your phone. See if you can do that. Um, if for some reason you have to be in bed when you're on your phone,

22:43I would say the thing to do is you still want to create that separation. The best way to do that is maybe stand next to your bed because like I say, stand it's silly and very rarely do people actually do it, but people sometimes do. And I do this because if you're standing, if, if, if being in that proximity is important for, for your ability to sort of wind down or whatever, but at least a, you're not in bed, but B the standing does something very important. And especially people in the athletic space will know this, that you don't lose touch

23:18with your body's communication to you. When you're standing, there will eventually come a point where you say, but I really want to sit down now. That's your body telling you that you're ready. Or you may be standing thinking like, what am I standing here? Like an idiot for? I've been here for a half an hour. What am I doing? That's your other signal that you're not ready.

23:40Sleep is not something that you do. Sleep is something that happens to you when the situation allows for this. That's a concept I, I borrowed from a colleague of mine, Lindsay Shaw, who's also a fantastic sleep person and sports psychophysiologist. I learned this from her. I use it all the time. It captures it really well. Sometimes sleep is, is not under your, your ability to sleep isn't under your control. You're awake. Like you need to wind down. Maybe you're just not ready. And if you're just not ready, laying there in bed, scrolling is going to help go do that

24:11somewhere else. If you are getting ready, respond to those body signals. If you can't stand next to your bed, if that's a little too silly for you, sit and sit up on your bed. Don't not like just a little propped up. Your head's not on a pillow. You're not under a blanket. Sit up. Again, you're not going to lose touch of your body's signals. And, and worst case scenario, at least you get the head bob. The head bob is, is, is your friend. The head bob means it's your body telling you you're

24:42ready. There's also like, if you're watching TV or on the couch or whatever, and you're within that zone where you might be wanting to go to bed, lean forward when you're watching TV or your movie or whatever, we're scrolling. Cause you'll get the head bob. You won't get it when you're leaning back, get it leaning forward. That's your signal that you're ready. And what happens if, you know, someone wakes up in the middle of the night and then they're ruminating. Yeah. Can't fall asleep. So again, sleep is not something you do. It's something that happens when the situation allows

25:13for it. And if the situation is not allowing for sleep in that moment, get up. If you're sitting there and you're eating and you have no appetite, you don't just sit there and stare at your food till you become hungry and it becomes more appetizing and actually backfires. So often when people wake up in the middle of the night, it's because it's because something naturally occurred to produce that awakening, whether, um, most commonly would probably be some sort of physical discomfort, like pain, or maybe you sunk into your mattress a little bit and, and,

25:45and it's just a little discomforting. You need to wake up and move. Sometimes it's untreated sleep apnea, super common. You have a respiratory event that you don't know you had. If you ever wake up suddenly for no reason, and you don't know why and can't get back to sleep, you know, we'll talk a little bit later about sleep apnea, but, but that can cause these awakenings. And when you have something that causes this awakening that arose from inside you, wasn't under your control. And what ends up happening is that that physical activation escalates and just like

26:17a snow globe, you know, you shake up the snow globe. It takes a little bit of time for it to come back down. And when your snow globe got shaken up while you were asleep and you're awake, you can't make it fall back down faster. There's nothing you can do. You can poke at it, make it go slower, but you can't make it go faster. You just have to wait till everything settles back down. And it often doesn't take as long as people think, but what ends up happening is as your snow globe is settling, then your stress starts rising again, slowly rising because like, why can't I sleep? What if

26:48I can't fall asleep? What if I'm up the rest of the night? Blah, blah, blah, blah, blah, blah. And then you start stressing and freaking out about it. So now your body is ready, but your mind isn't anymore. And I got to wait for that to come down and you just prolonged it. The, because you don't have control over this part, surrender that control, recognize that you're going to get up. You can get up, take a break, wait till you're ready. Try again. Just don't prolong it any more than is necessary. So sometimes surrendering control actually shortens the awakenings. Sometimes it

27:21doesn't. Sometimes, you know what, what if you're up for the entire rest of the night and you just don't go back to sleep? That's often people's fear. But the truth is, A, that's unlikely. And B, even if it does happen, you'll be fine the next day. And guess what happens if you're halfway through your dinner and you just lose your appetite and you just don't eat the rest of it? What happens the next day? You don't die. You just are a little more hungry and you'll eat a little more the next day and the system will correct itself. Over-correcting is the problem. So to kind of just, from my understanding,

27:55for the stimulus control, like the most important part of it, like for these, for these individuals that do have this like fear of like not sleeping or like it starts to, you know, they, they just immediately get like anxiety about it. The best thing is to surrender or is that like the, the strongest part of the stimulus control? Yeah. It's the performance anxiety. The fear is what's creating the activation that's getting in your own way. So, so recognizing that it's not under your

28:29control, trying to control it is not going to help. Nobody got to sleep faster by trying harder. The enemy of sleep is effort. If you're engaging in effort, you're adding energy into the system. And athletes especially are vulnerable to this because, you know, athletes are used to gaining control over their body and learning how to control their body in ways that most people just don't know how to, because they haven't been trained to. So there's always a solvable problem there. Sometimes it's

29:04like, like injury recovery. Sometimes you can't make it go faster. Like if you injure yourself, you got to do what you got to do to recover. You can't, there's no like dance you can do or, or book you can read that will make that recovery go faster. You got to give it the time it needs. Similarly, this is a process that's outside of your control. Trying to control it will actually make it go slower. Okay. And so the, the next part of, you know, CBTI that, you know,

29:35you hear about is the sleep restriction, which sounds awful. Worst name. I mean, so, so if you actually look to the original publication and they didn't, they didn't even call it sleep restriction therapy, they called it restriction of time in bed, which is really what it is. It's, it's a simple concept of, um, again, a lot of these things are simple in concept, but difficult than execution. But the concept of sleep restriction therapy, which I hate calling it that because it doesn't, it's, it's not about the restriction. And that's the thing. Sleep restriction could be part

30:06of it, but it isn't always the idea is let's say you're spending eight hours in bed, but six hours asleep. We know you physically can sleep six hours. Okay. Let me give you six hours time in bed. See if you can fill it. Let's get you to the point where you can fill it. And then we'll slowly increase it from there. Actually, sleep restriction therapy has more increasing of sleep than decreasing, but there's that, there's a decrease at first. The way I explain it to people is this. It's actually not super complicated. Let's say you're trying to eat your vegetables and you've got a kid who's not eating their broccoli, right? And you put 20 pieces of broccoli on their plate and they're

30:39not eating, they can eat one or two. And then they're like, Oh, I hate broccoli, blah, blah, blah. Then you say, okay, I need you to learn how to eat your broccoli tonight. I'm going to give you two pieces of broccoli. Can you, I know you can eat that because that's what you've been eating every day. I know you can eat that. So you eat the two pieces of broccoli and then they say, but I'm still hungry. And then you say, great, you will get three tomorrow. Let's see if you can eat those. Then they can eat the three pieces, but I'm still hungry. It's like, okay, hold off on, don't eat anything else. But the next day you'll be hungry enough to eat four. And then you slowly,

31:12you start with what they can already do, but you don't give the other stuff that, that will, so you, you don't let them stay in bed when they're not sleeping. At least give them the opportunity they're already able to fill. At first, all the mental blocks and stuff will be there. So it might drive down their sleep a little bit in the short term for, for several days, maybe even up to a couple of weeks, but they eventually, eventually they get hungry enough where they can eat all the broccoli on their plate. Cause you're not giving them anything else. Then all of a sudden you start introducing other foods back that they actually like, but they've gotten over their broccoli deal.

31:45And that's what it is with sleep. You drive up their natural sleep pressure. You separate out, um, the time in bed. That's not wake. You make it so that being in bed, you're so you go from not being able to fall asleep to not being able to stay awake because you drive up that natural sleep pressure. And it's like, well, you have problems with your appetite fast for a little bit. That'll help a lot of problems with your appetite. You're going to be hungry again. And so this idea of not having your phone in bed is part of that. Yeah. It's part of that because you don't want to do

32:16anything in bed that is not sleep. You want, you want, you want to make it so that when you get into bed, you put your head on the pillow, you're under a blanket, your eyes are closed, you're breathing through your nose, um, that, that, that feeling is so predictably tied with becoming unconscious in a very short amount of time that even when you get good at that. So this is, this is the power of this. When you get good at that, you're using the prediction, not just to solve a problem, but to

32:49create a benefit. Imagine you're a little bit stressed. You've got a big day tomorrow, but you've so trained yourself that that place is so predictably tied with sleep that you're stressed. You've got a big day. You've got stuff you're working on. You get into bed, close your eyes, head on pillow, under blankets, start breathing. Then all of a sudden you fall asleep. You've, you can, you can train yourself to get the outcome you want. And that gives you control. So let's say you got to wake up super early one day cause you're, you're, you're going somewhere,

33:20you got to practice or something. You need to go to bed an hour or so earlier than you really are used to. If you've got yourself well-trained, you can use the environment as a condition stimulus for sleep when you want it to be. So when, so how long does it take to, to, for most people to train themselves, like through the stimulus control, sleep restriction, where, you know, the bed is really just for, I've, I've heard sleep and sex. Yeah. So sex is fine. That's usually not the problem. Right. You know, do that in bed, out of bed, wherever you want. That's fine. Usually that's not

33:51taking up so much time. I mean, and it's, and it's not interfering with your ability to sleep. Sometimes it can help your ability to sleep, but that's fine. But, um, it's probably the phones that are the biggest problem. Right. It's, it's distractions. So distraction, the activation, all of this stuff, it's, you're adding energy in instead of taking energy out. Relaxation is fine to do in bed, but if it's brief, you know, if you're spending, you know, a half an hour meditating in bed, that might be a little too long. If you're, I've known people who like, they have this whole

34:24hour long routine that they do. Like by the time that hour is done, the bed is no longer predictably tied to sleep anymore. So yeah, it's about, it's about getting this stuff out. It doesn't, I'm not saying don't be on your phone, but I mean, I actually think does the sleep field telling everyone get off their phone for an hour before going to bed is not a helpful recommendation because no one's going to follow it. We should be talking about how to do it safely in a way that's not going to get in your way. And that comes down to what you were saying earlier, either being in another room or

34:55sitting up or standing. Yeah. And, and also it's what you're doing. That's important. You might want to create sort of boundaries. So like maybe within a half an hour of when you're planning on going to bed, maybe switch to something that's not too mentally activating. Like if, if you're the kind of person where you watch the news and it gets you all worked up and angry, don't do that before going to bed. Maybe do it the hour, you know, in the, in the earlier part of the evening. Um, I mean, the great thing now is TV isn't live anymore. Back when I was a kid, you had to watch it when it was on

35:28and that was it. Now we can watch, we can, we can gain more control over what we're exposing ourselves to media wise. The rule of thumb I use, and this is what I use for myself. If an alarm went off right now and said, okay, time to turn it off. Could I, if the answer is yes, then it's probably okay to do within that timeframe. Cause I can easily disconnect from it. If the answer is no, no, no, five more minutes, I want to see how it ends or I want to, you know,

35:59whatever. That's probably not the thing to watch in that buffer time. Watch it before the buffer time, but don't do that in the buffer time. Like if you're scrolling and you can easily put it down. I don't know that. I don't know that that's that big of a deal, but if you're scrolling and like half an hour will go by and you wouldn't even notice and you lose that time. And then you say you don't have time, but you just threw away some time, you know, that you didn't need. So like, those are the sort of things you want to, you want to make sure that you curate what you're doing so that it's not too activated.

36:32Why, why are a lot of people that have, that have insomnia, why are they prescribed, you know, these sedatives like, you know, Ambien or. Well, they don't not work. I mean, like I was saying, like what they do is they drive up that sleep drive so much it overpowers whatever's in the way. And it's kind of an easy solution. The thing is, honestly, it's much easier to write a prescription. Like you can go to any primary care anywhere and they can write a prescription. But if you, if you look at every

37:03medical organization that has any recommendation around how to treat insomnia and for athletes, you know, this includes like NCAA and IOC, who, who've put out sleep related materials. Um, they all say CBTI first. And that's because every study that has ever been done shows that when you compare, when you pool the data from CBTI trials, it works shockingly well.

37:37Not only does it work reliably well, it works when you have other, like, well, what about if you're in chronic pain? Like the pain is keeping you up. How is that? You don't have conditioned arousal. You have an active thing going on. Still works in, works in fibromyalgia, works in chronic pain, works in cancers. It actually might be better in cancer survivors than people who aren't cancer survivors. Cause they don't want to take these medications. They're more motivated. It works in sleep apnea. It works before your sleep apnea is even treated. It helps with your insomnia. Uh, find me a condition works in older people, works in younger people, works in, so like it's a blunt

38:13instrument. It's retraining yourself to sleep. It doesn't, it, and it works well by helping people gain control. It doesn't necessarily add hours to your night, but neither do sleeping pills either. What it does is it removes some of those barriers about, again, about 85% of the time, not a hundred percent, but it's also some people don't know how to get access to it or they read about it online and either the, the information they get isn't, isn't great, or they have exposure to it in that, you know,

38:45maybe, you know, maybe they're doing it by the book, but they might need a little flexibility with it or something, but there's lots of adaptations. I mean, we edited a textbook on how to adapt CBTI to different populations, but you know, a lot of people just don't know it exists. And the people who do don't really understand what it is or how to find someone who knows what they're doing. Is that the key? Do you really have to find someone that knows what they're doing or can you try this yourself? Yes. And yes. I mean, there are many people that I've talked to who've, um, tried it, done it with themselves. I mean, cause it's not rocket science. Um, the, there's an art to it,

39:21but the, the basics of it are relatively simple. It's bed, equal sleep, get out of bed. If you're not sleeping, you know, compress your window of, of opera, you're giving yourself too much opportunity. You're not filling it, compress your opportunity, but then expand it again, once you can fill it, um, some basic stuff like that. Uh, and some people could just do that on their own and that's all it takes. Some people, they need somebody who knows what they're doing. The problem is there's not a whole ton of people who are trained in this, despite it's being around

39:52for a long time, despite the fact that it's really well supported, there's not a ton of people who are well-trained. There are some online versions available where they can automate some, some aspect of this. It's a very, it'll be very by the book, but for a lot of people, that's all it takes. Um, you can do this over telehealth, any state that you're in, I can promise you there's someone who can do this via telehealth in your state. So it used to be very geographically restricted. It's not anymore. Um, there's a couple of good directories online of, if you're looking for

40:25somebody, um, we have a board certification, you can see who's board certified in this and we, it exists because it's not part of normal training. So to be able to say that you're good at, you have to like prove that you know what you're doing, but, um, yeah, you can look online for people. And again, there's, there's telehealth options too. So whatever state you're in, um, you can find somebody. What, what percentage of like the U S population has insomnia? It's a great question. Um, for decades, any population level study has generally found kind of the same thing mostly.

40:59And it hasn't, it doesn't seem to have mostly changed much that about one out of three people in the U S has some sort of sleep complaint or problem or something, whether it's falling asleep, staying asleep, not feeling refreshed, that seems to be about a third of the population at least. And it seems like about one in 10 people probably would meet the criteria for an insomnia disorder. If you, if you, if you assessed them. Um, and then what ends up happening is they start trying to fix it on their own and they start going down paths that end up being unhelpful. And then they

41:34get more frustrated and then sleep becomes more stressful and they give up and they say like, I'm a, I'm a hopeless case. I get one of these a week in clinic. So I'm the worst sleeper you've ever seen. I've tried everything. I've had this problem forever. And then six to eight sessions are better. Yeah. I, one in 10 is a lot. And, you know, I definitely think we're going to talk about some of these substances people then turn to because they think it's going to help treat their sleep problem, which they don't necessarily know is even insomnia. Right. And so they're, you know, turning to things like alcohol and, um, and that doesn't really help. So, um, but let's, before we

42:08get to that, um, sleep apnea, you mentioned, and that's another one that I wanted to talk about. I've known a lot of people, it seems that have had sleep apnea. I wonder how you can tell me how common that is as well. But, um, first I kind of wanted to ask you, like, what are some of the non-obvious presentations that, you know, of sleep apnea that you see, especially in people who like, maybe don't even report feeling sleepy. Right. So, so the thing with sleep apnea is the first thing to know about sleep apnea is it is shockingly common. It is very, very, very common. Um, the

42:44most recent data I've seen estimates that about one out of four or five men over 30 probably has at least some sleep related breathing issues, especially if their BMI is over 30, it's more like 50, 50. Um, it's really high women get it less often, but it's also shockingly common in women too. It might be more like one out of every 15 or 20 women. Um, and then as, as BMI goes up, it gets

43:14more common. Um, so it's, it's shockingly common. It's so common that my threshold for screening for it is very low, especially among otherwise fit people because the normal risk factors. So like as you gain weight, it, it, you get it more because it can crowd out your airway. Muscle too. Yeah. Muscle too. It's because think of it this way. So most mammals, their airway is a straight line, you know, from snout all the way up and, and to, to, to their lungs. It's a straight line from snout to their

43:49lungs. Humans by, by moving upright, we solved a lot of problems and we've gotten a lot of benefit from being upright, but we created, it created a problem with us in that our tube now has a 90 degree angle in it. And if you're designing a pipe and you put a 90 degree angle kink in your hose, where is it, where is it going to start having problems? It's going to have problems at that. And that's what happens. So like right around that spot here, that's where we get narrowing of the

44:25airway. And so like any mass, whether it's muscle or fat or whatever, any mass, I mean, there are people who look at MRIs of like tongue fat, like, like cheeks, like anything here that whether even skinnier people with smaller airways, you know, where it's a little more compressed, it just, it's, it's a, it's a vulnerability in, in the human physiology for breathing issues. And it's actually mostly fine in that you can have four or five breathing pauses per hour in the night and be in

45:04the normal range. It's actually a sleep apnea doesn't begin at five is mild begins the low end of mild. And it's not even until you get to 15 per hour that it becomes, start becoming moderate. So many people who are in the mild range don't even have any symptoms and might not be causing any problems. And we have a lot of flexibility in the system, but as you get older and neuromuscular control changes, as we put on more pressure here in the airway by gaining weight or whatever, it just becomes more and more common. And my guess is it's actually been common through history.

45:39It's just, we've written it off as something else, especially in people that don't have those obvious signs. So what are some of those less than obvious signs? I have a patient who comes in and they say, I fall asleep just fine. Actually, if I'm anything, I'm a little tired during the day, whatever. I fall asleep just fine. But then I wake up in the middle of the night because of stress. My stress wakes me up and then I have a hard time falling back asleep. When I hear that, I think there's greater than 50, 50 chance in my mind that that was a respiratory event. Stress doesn't wake

46:15you up. What happens is if you wake up and you're thinking I'm stressed, your brain is reading signals like elevated heart rate, elevated respiratory rate, the endorphins of the muscles getting tense. It's reading these physical signs. And then because we live in the society we live in, stress is readily available. We can fill that space really fast. But what was happening was, it wasn't the stress that woke you up. It was that your breathing was starting to get a little bit constrained.

46:49So then what happens is your airway tries to open itself up and it was trying and it wasn't, it wasn't successful. So it tried harder, still wasn't successful, tries a little harder, still not successful. Worst case you wake yourself up and you, and you can, you could wake up with a gasp because you can breathe when you're awake, just fine. It's a different neuromuscular control system. So as soon as you wake up, you sort of get that, that sudden awakening. Cause you just got that little sort of a shot of adrenaline to wake you up. And like, if I just shot you up with

47:21a little bit of adrenaline during the night, you'd wake up and you would not be able to fall back asleep. Your mind would start racing and you'd have all these physical signs, but it wasn't the stress that woke you up. The stress got superimposed on it later. So when I have a patient who comes in and describes that sensation of, I wake up in the middle of the night, either because of stress or for no reason, I don't know why something wakes me up. I have no idea, but I cannot get right back to sleep immediately. Like within a few minutes, I mean, something just happened. Some flare up just happened somewhere. Um, that's, that's what I look at in athletes. Often what I'll look at is I feel

47:58like my sleep is really shallow and I don't know why, because what's happening is you might be having lots of these low level respiratory. That's the thing when you get the more severe sleep apnea, like 30 events per hour or more with, with these other presentations, but you get a lot of the mild to moderate cases in people who, you know, don't have a lot of extra weight, aren't older and have neuromuscular control issues. Like, which just happens with age. They're younger, they're healthier, but they just might have a narrow airway. And, and so like, I'll never forget, like there was this,

48:32there was, uh, um, uh, an Olympic level athlete I was working with. She was, she was in the trials and she's like, she's not meeting the times. I think I should, she was still faster than everybody else. But she's like, my intuition is telling me something is in my way from reaching what I could be doing. I don't know what it is. And like, how are you sleeping? It's like, I feel like my sleep is kind of shallow. I fall asleep just fine, but I feel like I'm up a few times during the night and I don't really know if that's a problem or not. So I'm like, well, let's see what's going on.

49:03Turns out she had, she had mild sleep apnea, got that treated better. And she's like, oh, that was it. And, and in the real world, it would have been missed. It would have been someone just slogging through their day. They would have just been like, oh, you know, life is hard. I'm tired. Not sleeping is good. And then probably in 30 years, she would have gotten diagnosed by the time it was more obvious if she weren't an athlete. So what should a person do? Like how many, is this an every night thing where people are getting woken up? Like if they're having apnea,

49:34is this like an every night thing? Um, like what sort of, sort of symptom clusters, biomarkers can people look at, um, short of like going and getting the thing on your finger and measuring the oxygen and you know, the whole. Yeah. I mean, so, so here's the thing. It's normal for people to wake up in the middle of the night. Sometimes actually the typical adult will wake up 10 times a night or more during the night. They just don't remember. It's very short. I mean, again, evolution figured this out a long time ago. You wake up, no bear back to sleep. Like that's

50:04normal. But if you're remembering more of those awake, if you're remembering three, four awakenings, if you have an awakening, especially waking up like with a gasp, like if you wake up like that, or you wake up with a snort, if you wake up with something like that, um, if you, if, or if you feel like you just can't get enough sleep, like you try and sleep a little bit more, but it doesn't help. It's like, it's just, it's just empty calories. You know, like it's not about the

50:35amount anymore. There's like something that's keeping it artificially shallow. There's lots of things that could be, it's just sleep apnea. So common. Why not take tests? Why don't you just get tested? Just go get a referral, get tested. You can do them at home. Now it's easy enough. Um, in turn it's, it's, there's no real good biomarker for it yet. I know people are working on it. There's no real good biomarker except that, that sleep is shallow. It's fragmented and you don't know why. I mean, it could be something else could be inflammation. It could be pain. It could be

51:08environmental. There's lots of things. It's like, if you're not breathing, is there a problem with your lungs? Is there a problem with your airways or problem with the pollution in the air? So like, is it, is there something that's preventing your body from being able to sleep or, and, and, and if it is sleep apnea, it's so common. This is why my threshold for screening is just ultra low. Because, um, if it was that, and I do all the tips with you and I work out this and I do all this and you're still feeling like, oh, but my sleep just isn't good. And I knew when day one, that this was a

51:42possible reason why, then I'd feel like an idiot for not even checking. Cause I, we did all this work and we, maybe we didn't even need to. Do those, um, at home kind of, could have, I remember doing one once like years ago when I was in graduate school and I was, I think I was waking up because of stress, but, um, the test came out negative, but I wore this like ox pulse thing. I think I don't know what it was in my finger. So there's, there's a bunch of devices. They've gotten better and smaller over the years. Um, there's still people who do need to come into the lab. Those are usually reserved for when there's like another sleep disorder you're also looking for like

52:17narcolepsy or, or, or limb movements or something. Or if you're medically complicated, like you need supplemental oxygen, or if you might have heart failure or something where you need to kind of be monitored in the hospital while you're doing it for safety. Other than that, or, or the test you did at home was negative, but you still have a lot of symptoms and maybe it missed it. Cause the, the home tests aren't as sensitive. Like you'll, you won't get false pauses, but you might get false negatives. That's the only time you'd really need to come into the lab. Most of the time, usually they just give you the thing to take home. And these days you can wear it as a strap.

52:50They have ones that just go on your wrist and they measure, they measure, um, your oxygen levels during the night. And what you can see is how is your respiration tied with your O2? Cause respiration drops during the night too. And so does O2 a little bit, but if, if your respiration is dropping and then your O2 starts dipping and then it, then it opens back up again and gets recovered, like you look at these patterns of what's happening during the night and you can see in one night if someone's clearly has sleep apnea or not. Okay. It's easy enough. If you're working with someone who has

53:24obstructive sleep apnea, like how do you go about differentiating if it's like caused by allergies or positional or, you know, something, something like nasal congestion. I don't know. Like, yeah. Yeah. Especially when it's more on the mild to moderate side where, um, so the great thing is the, the, the ones that are on the strap, they usually have a gyroscope in it and they can measure your breathing separately on your side and on your back. There's a lot of people where it's just that it's on their back. That's the issue. And, um, for those people, there's actually really simple

53:58fixes. You can set, they sell these devices where the truly just a strap you wear in the old days, they used to sew a tennis ball on the back of a t-shirt and that's all it is. So like, whenever you rolled on it, you just roll off it. And they have like fancy versions of that now where that's essentially what it is, where it's, there's one, there's a couple of them where it's a strap, it's like a belt, but like the back of the belt has a little bump on it. And so like, whenever you roll on it, you just roll off. It just stays off your back. That's it. Um, you can't force yourself to stay off your back when you're asleep. You're like, well, I'm just going to fall asleep on my side.

54:28Well, you can't control it when you're unconscious. So like you can see if it's positional easily in the diagnosis. And if it is, then just try and treat it positionally. And then what I would do is retest using the positional device and see if it all goes away. Cause it might, might not. Um, if it's allergies, um, this is why the, the, the sleep docs, you know, we get a lot, they get a lot of training and, and I've gotten some of this too, when I rotated in sleep medicine, like you see what to look for. So like you look at nostrils, you look at their nose, you have them breathe in, you

54:59look inside the airway in the mouth and, and like, you can see where their soft palate is. You could see their tongue. You could, you can see some of these things. Um, and you know, sometimes, you know, there's a lot of sleep medicine that's using, you know, Flonase and, and some of this stuff to sort of clear up the nose. But remember the obstructions almost all the time are back here in that 90 degree angle in your airway. It's not up here. It's like people think snoring is a nose based thing. It really isn't. Sometimes you get like sort of floppy nostrils or whatever, but almost entirely

55:33it's the, the issues back here. It's the back of your tongue. That's also why on your back, it's worse often because gravity starts pulling stuff back or like when you open your mouth and your tongue falls back and can block the airway. So, so that's, so like you can do that in the physical exam when you go to the sleep topic and took a, take a look at your mouth and take a look at your nose and, and they'll be able to see, but I'll, but I'll tell you it is a vast, vast minority of the time where that's actually the cause. People want it to be, cause it's an easier fixed, but, um, that's usually not it. It, it, what happens if someone has untreated sleep

56:09apnea? So, I mean, what, what happens to their sleep architecture? I mean, first of all, maybe we should briefly mention like the sleep stages, but like, does it affect their sleep architecture? So here's the different sleep stages stage. So when you fall asleep, you enter stage one, stage one is super ultra light sleep. If you have sort of like nod off and someone bangs the table and you're like, well, what was that? That's stage one. When they say you were asleep and you say, no, I wasn't that's stage one. It's very light. Um, this is also where you get hypnic jerks and you, if you have one of those, you were in stage one sleep. Um, totally

56:44normal, medically harmless. Everyone gets them. Um, so that's stage one. It's a light transitionary stage. Then you drop into stage two. Now stage two, when you first drop into it, you're in it pretty quickly, but for most of the night, that's actually what you spend the most time in. Stage two is sometimes called light sleep. I don't like that name for it. I like just calling it normal sleep. It's regular sleep. It's vanilla sleep. It is more than 50% of the night. Most of the work that your brain does in sleep is done in stage two. Um, but then you drop into stage three,

57:18which is also, you know, in our world, we call it slow wave sleep because the brain waves are bigger and slower. Um, a lot of people also call it deep sleep. It's not called deep because it's the good one or the most restful one. Even it's called deep because your arousal threshold is the highest and it is hardest to wake you up from that sleep stage because the the thinking parts of your brain are largely like detached and offline. You're not, you're not thinking during that time. Your muscles are very relaxed. This is for athletes. This is super

57:52important because this is when growth hormone is secreted in N three sleep at stage three or non-rem stage three sleep. Um, but it's also highly protected. Even sleep deprived people are mostly getting all of the stage three sleep their body wants. Like it's, it's actually, again, evolution figured this out a long time ago. You, it's the hardest to wake up from and it front load, it front loads it into the night. So usually within the first few hours you're done with it anyway. So it's not a, so sleep deprivation doesn't actually eat into slow wave sleep or deep sleep very much. And people,

58:27so they don't need to worry about it so much. So anyway, you get into that and then you come out of that into an episode of REM, um, REM sleep. A lot of people have heard of now, um, is weird. REM sleep is just fundamentally weird. So like, this is where dreams and nightmares happen. Peak blood flow in the brain is actually REM sleep. Like your brain is extremely active. It's actually more like waking than many, any other sleep stage. Um, but the waves are very different from waking brain waves,

58:59but it is, it is more, more like that than, than, um, than other stages of sleep. You're also, your arousal threshold is different in that it's easier to wake up out of REM sleep, but there's also a couple of other weird things that happen that you're paralyzed. You're so, so if, if indeed in the deep sleep, your muscles were very relaxed, that's nothing compared to how much relaxed your muscles are in REM sleep, not because they're recovering, but because you're actively paralyzed. Uh, your alpha motor neurons are hyper-polarized. You cannot move. Uh, even if you wanted to,

59:33that's because otherwise you'd be acting out your dreams because you think they're real at the time. It's just part of your brain has its foot on the brake while it's jamming on the accelerator at the same time. And that's why it's not going anywhere. That's why sometimes you see twitches where it sort of breaks through a little bit, but that's it. Um, it's fascinating. And then also, that's also why you get sleep paralysis sometimes where you wake up at a REM sleep, but you're still a little bit paralyzed, but you're also conscious and that that switch forgot to get flipped really briefly. So anyway, so you get that in REM sleep. You also get the eye movements, which might be looking at

1:00:03things, but might not be it's the data are very mixed where when you, if you go looking to match eye movements and REM sleep to dream content, you can sometimes find it, but then sometimes you can't. It's, it's, it's fascinating. Um, but what seems to be happening in between deep sleep and REM sleep, there's a really, really interesting dichotomy where they're both important for, for different reasons, where one of the things, the main thing that seems to be happening in the deep sleep is synaptic pruning and synaptic homeostasis. So what, and, and in REM sleep, there's a lot of

1:00:39synaptic strengthening and connection building. And those two things work in concert with each other. Think of it this way. When you're experiencing the day, you're taking in lots of experiences and information. Some of those experiences and information are important. You will learn from are related to important things. Maybe they're not super important, but they're worth keeping. And a lot of those are not that important. Like that piece of equipment over there. I don't need to remember it tomorrow. It's not, I will remember it for the next few minutes, but it's not that important to my life. It will get filtered out. So what ends up happening

1:01:10in slow wave sleep and in the deep sleep, the, the, the experiences from the day and all those new things floating around, they sort of get sorted and the things that are important are kept and everything else gets let, it gets let to fade. Interestingly, this is a similar thing happens where the spaces between your brain cells actually increases and like sort of like a, like actually like a, like a filter, the, it increases and actually waste products can start clearing out

1:01:44of your brain. Is it because you're thinking parts of your brain are working a little bit less and it gives it the chance to do that? Who knows? But it seems to happen specifically during that time, just very protected at the beginning of the night. So when you're after a few hours into the night, that cleaning out process is done and then the cycles toward the end of the night. So drop down to deep up into REM and then you cycle through, but the cycles change. The second cycle, you'll have a little bit less deep and a little more stage two and a little more REM by your third cycle. You might have no deep left and it's all just stage two and REM, maybe a little stage one interspersed in there.

1:02:19If you wake up and the REM episodes get longer, the dreams get more interesting. That's why the dreams in the first half of the night, you, you, you probably won't remember them anyway, but if you did, they're usually a little more boring where the dreams at the end of the night are the cool ones, the ones with the stories and the characters and then, and, and the blend, the blurring of reality and all the, and emotion in the later parts of the night, like nightmares, nightmares to a sleep scientist. A nightmare is a dream that wakes you up. That's the definition of sort of a nightmare in our world, a dream that is so where the emotion is so powerful, it overcomes that, that process.

1:02:52Sorry, if this is sleep stages, you go through these during the night and in REM sleep, it takes those important experiences that you, that you segregated in deep sleep where you got rid of all the junk, kept the good stuff and REM sleep, what the dreams are doing is you're witnessing the brain rewire itself using what was left. So basically the dreams are among other things, essentially what's happening is, okay, here's what's left. How do I, what do I do with this? How is it, how does it connect to other things? How do I sort it? How do I file it? How do I process it? And the other stuff

1:03:26that's floating around that I was thinking about during the day, where's that? Where do I do with that? How do I process that? So dreams are, you're witnessing your brain rewiring itself, speaking to itself in its native language of ideas and metaphors and concepts and feelings and how they relate to each other without rules. Um, and so that's why all of the stages are important. And in stage two, that's not happening, but in stage two, it's happening. It's, it's a lot of, a lot of the

1:03:57recovery and repair stuff is also happening. Cause in REM, your brain's active doing this stuff. And in deep sleep, your brain's also active doing this other stuff. And in stage two is when it's, everything else gets to happen. Um, in a, in a more particular, so like all the stages are important. You cycle through them and it's about every 90 minutes. Anyone can Google that, but it's not exact. It's, they're different across the night. Um, and that's also why it's easier to wake up out of stage two and REM than deep sleep. But so if you woke up and you remember a dream, it's cause you woke up at a REM. That's all, that's all that means. So anyway, how does sleep apnea affect this?

1:04:33Can I, before you get to that, it's so fascinating. Um, particularly the part where you're talking about, you know, all the new information that you're learning every day, you know, you're during that transition between deep and, and REM, you kind of, your brain is like sorting it out and getting rid of the things that you don't really, aren't really that important to remember. And then during REM sleep, you're like using what's left and somehow attaching it to like other memories and stuff and concepts. And sometimes they don't even seem to make sense. Like you'll like, they may not make logical sense or, and maybe they're wrong. I mean, you're sorting through, you're, you're,

1:05:06you're playing stuff out. And that's also why, like when you're awake, a person is a person, a house is a house, a car is a car. But when you're in a dream, the rules of the universe don't apply. The concept of a car can also be the concept of a person. And that person can be somebody else too. And then it was me. And then it was my sister. And then we were in this house that I grew up in, but actually, no, it wasn't. It was really a mall. Like things can happen. It's because you're not bound by the rules of the universe. You're just bound by how your mind is organizing

1:05:42that information. Well, based on what you just said, I have now a new hypothesis for why we dream, but I want to ask you, why do we, why do you think we dream? I think we dream because evolution figured out a long time ago that you can learn a lot by reading all the words on the page, but you can, you can also learn some really important things by reading between the lines on the page, by reading things that aren't on the page and reading the concepts

1:06:13behind them. But when you're engaging in the day, so the way the brain works, which is fascinating is the brain works by shortcuts. It's extremely efficient. It's extremely efficient because it makes a gazillion guesses and shortcuts without actually doing any real work, except when it absolutely has to. So for example, it's like when you take a picture, your brain doesn't store every pixel. Your brain stores this line here, this line here, this sort of pattern of colors and a set of

1:06:45instructions and fills in the gap. Your brain stores the blueprints, not the house. And the blueprints are rolled up this, the house takes up, the building can take up a whole city block. That's why the brain is super efficient. It stores, it figures out what is the minimum amount of information it actually needs. And then what are all the assumptions it needs to make to fill in all the details. And the good thing is the universe works that like when things go farther away, they get smaller. And like, there's all kinds of rules of the way that like you are you and you

1:07:18will be you five minutes from now. And I don't have to assume, make any assumptions that that can change. There's rules to the universe. And when you're engaging with the world that way, it could be really efficient, but maybe there's, maybe there's connections that aren't explicit that might help you navigate your life. So like, let's say we're having this conversation now. Maybe you remind me of somebody who's a friend of mine from like years and years ago. And, but you're not that

1:07:52person. My conscious mind knows you're not that person. There's no question about that, but it may change how I speak or what my body language is going to look like, or how much I choose to ramble when I tell these stories like these sorts of things. Dreaming is about, I think it's about taking the actual written words on the page of life and sorting through those connections and sorting through those unspoken and, and, and details that don't actually exist, but do and inform our life. So dreams are the

1:08:30difference, I think, between memory and experience where it's, it's a difference between what you did and who you are. Like the dreams are what sort of make you that person who reacts to things based on your own history that, that forms those connections. But I don't know, that, that's my, that's my ramble of what I think. Well, thank you. Okay. So back to the sleep apnea, because you know, people having these awakenings where there are multiple wakings in the night, obviously this is happening during different stages. What, how does sleep apnea, untreated sleep apnea affect sleep, the sleep

1:09:03architecture. That is one of, sleep apnea is one of the few things that can artificially, reliably, dramatically reduce your slow wave, deep sleep because it prevents, because you can't detach because your bodies keep trying to get your attention. The other thing it does is it dramatically increases, it can dramatically increase stage one. Um, and it can also, because your sleep is more shallow and you have more of these arousals and awaken, even if you don't wake up all the way,

1:09:34your brain is still sort of moving around. The other thing it can do, it can dramatically reduce your REM sleep. Because remember what I said about muscles and REM sleep, even your respiratory muscles get weaker. That's why snoring is worse in REM and, or worse at the end of the night, because you have more REM at the end of the night. So if you're, if you're already in a floppy tube, trying to breathe out of this floppy tube, that's already having an issue. And then you make the muscles go extra limp, snoring is going to get worse. So you're going to have more awakenings out of REM. You're

1:10:05going to have less deep sleep and your sleep's just going to be more shallow overall. So that's why people with sleep apnea, they wake up and they feel like it's sort of like, I just ate a whole meal and I'm still hungry. Right. Yeah. I wonder if anyone's, or maybe you can tell me if anyone's ever looked at, you know, because you mentioned deep sleep is really important for this, you know, cleaning out the toxic waste, these are aggregate protein aggregates, amyloid beta 42 being one. Yep. Yep. I wonder if anyone's ever looked at like people with Alzheimer's disease to see if any of

1:10:39them have sleep apnea, like the untreated sleep apnea. Oh yeah. Untreated sleep apnea is a known risk factor for neurodegeneration, especially when it's more severe. So this is the thing, mild to moderate sleep apnea is a, is a gray area. Severe sleep apnea seems very, that's 30 events or more an hour seems very reliably tied to bad outcomes. Mild seems like it's really only tied to bad outcomes when you also have daytime symptoms. Like you're, you're mostly treating like the fatigue and the memory

1:11:09issues, whatever you can still get, um, cell death and you can get neuronal problems. Cause you're think of it this way. Every time you have one of these respiratory events and you're having it, you know, maybe dozens of times per hour in the night, your oxygen drops and it's not the hypoxia. That's the problem. This is what a lot of people get wrong about sleep apnea. It's not really the hypoxia. It's the intermittent hypoxia. So you're not hypoxic because what'll happen is you drop a few

1:11:40points. Most people, unless you have some other lungs, most people with sleep apnea, their O2 doesn't drop a lot for sustained amounts of time, unless you have like emphysema or something, it'll drop a few percentage points. Then your body wakes up and then it recovers. Then it drops again. Then your body wakes up and it recovers and it drops. So it's like, it's constantly putting out all these little fires all over the place. The fires are never burning any houses down. They're just sprouting up all over the place. But what ends up happening is all of these cells are releasing reactive oxygen

1:12:14species every time this happens. So you're releasing these reactive oxygen species. This oxidative stress is happening and then it's quelled and then it's stressed and then it's quelled and then it's stress and then it's quelled and it's stress. Then it's all night, four days or months or years or decades. Usually imagine the stress, like your cells are trying to do their job and they're constantly dealing with all this nonsense. Instead, imagine trying to do your job and you're constantly having to do all this other stuff. So you're not getting the recovery function that

1:12:48you were built for. And so your trajectory goes slightly off. So that's why sleep, not just sleep deprivation, but also sleep, untreated sleep apnea can lead to liver problems, kidney problems, brain problems, heart issues, you know, immune system problems, because all of the, every cell that relies on oxygen starts getting stressed and some of them are more sensitive than others. Right. And you're also disrupting your sleep architecture and not getting enough sleep.

1:13:19Right. So, so, so people with untreated sleep apnea then probably do have problems with working memory. Yeah. Yep. I mean, emotional regulation, motion regulation, executive function, attention. So this is the thing when you, when your sleep is poor, whether it's sleep deprivation or sleep apnea or fragmentation or whatever, the first brain function to go is vigilant attention. Your ability to maintain focus, especially when whatever you're focusing on, isn't super excited. That is usually the first

1:13:51brain function. That's the first warning sign that something's up and the re and that can start creating memory issues. But a lot of the memory issues are memory issues because sleep is really important in memory. Remember you're taking all this stuff I was talking about is all memory connected functions. It's about sorting through information, processing information, consolidating information, integrating information. And if you're not able to do those things, you're operating inefficiently. You're not performing those functions, but memory, but memory is also a function of

1:14:27attention where if you're not able to focus and attend, even if your memory machinery was working perfectly, you have nothing to process because it never got in there. This is the thing with people taking sedating medications. Sometimes it impairs memory. Sometimes it impairs attention, which also impairs memory.

1:14:45You mean, so it does that not while you're on it, but like that's it. It can. Yeah. Wow. So, I mean, that's why a lot of these medications and stuff, and really anything, anything that is impairing your ability to focus will have ripple effects to memory and decision-making as well, because the information you took in informs those other processes. I mean, just like most simply, you can't recall a memory that never got stored because your working memory

1:15:19couldn't process it because you didn't attend to it in the first place. Is this why men have a lot more attentional issues? Maybe. Maybe. I mean, there's a lot of untreated sleep apnea out there, and then there's a lot of other sleep problems too. And they all, I mean, sleep does a lot. We live in this society that sees sleep as an unproductive use of time, especially people who are training, especially people who are like trying to maximize their day. And sleep is not an unproductive use

1:15:51of time. Sleep is an extremely productive use of time. I mean, if you're working out and you're trying to get stronger, when you're working out, you're stressing the system so that it rebuilds back stronger, right? When do you think that other part happens? Not while you're working out. It's when you're recovering. It's the recovery. Sleep should be your number one recovery protocol for any kind of performance-driven person, whether it's physical performance, mental performance. I mean, when you sleep-deprived people, we trade sleep for work

1:16:24all the time, but you actually get less done. And we've actually measured this. You actually accomplish more on less time if you're well-rested and your brain is clear. Right. Okay. Well, let's talk about treating sleep apnea. I know we can talk about CPAP and what that is, and it certainly works. Yeah. It's a blunt instrument. It works. Long-term adherence, maybe not so great. What do you find to be some of the best evidence-based non-CPAP interventions?

1:16:55Yeah. So the thing about CPAP is it's a blunt instrument because it's, think of it, it's just a split that keeps open your airway. It creates a pillow of air that, so if your airway wants to collapse, it can't. And CPAP, it's continuous positive airway pressure. Continuous because it's blowing continuously. Positive airway pressure as opposed to negative pressure, which is sucking positive airway pressure is blowing. So it's just continuously blowing air in your airway to create a pillow of air to keep it open. That's all it is. It's a blunt instrument. If your airway wants to

1:17:26close, you, you, you blow enough air in there, it won't be able to close. But for some people, it's too uncomfortable or whatever. So there's other approaches. The one I tend to use the most, especially with athletes who are often presenting with more mild to moderate sleep apnea anyway, are what are called mandibular advancement devices. What these are, it's essentially a retainer you wear at night, mandibular, like your mandible advancement. So essentially it's a retainer that pushes your jaw forward. And in a nutshell, that's all it is. There's obviously a science behind it,

1:17:59but what it does is it creates a little muscle tone here, even when you don't want, well, even when you're trying to rest. So usually that's not a good thing, but it creates just not enough muscle tone to keep you awake, but enough muscle tone to keep this part of your airway open a little more than it normally would be. And for a lot of people with especially more mild sleep-related breathing issues does the trick. That's, that's all it takes to knock out at least enough of those events so that you don't end up noticing it anymore. And you don't have to plug it

1:18:29in. You don't have to switch out your hose every couple months. Like it's a little easier. You do have to get it adjusted. And as your jaw remodels, you might have to do some adjustments. You do it with a, there's a whole field called sleep dentistry. It's sleep medicine dentistry, not sedation dentistry, but sleep dentistry, where it's about people diagnosing and treating sleep apnea with these dental devices. That's a very common one. Um, there's an, there's, there's also, um, musculo myofacial therapy. So like you can use the musculoskeletal system and essentially

1:19:02exercise these muscles so that they just carry more muscle tone that can work. I mean, there's, there's very famous work done with like people who play the didgeridoo where they have to do the cyclical breathing. It ends up strengthening certain muscles that even when you're asleep, they're a little stronger and they can maintain a little more tone. So sometimes that can help, especially for more mild apnea cases. Um, there's a device, um, called, uh, excite OSA, uh, where, where it's, you put it on your tongue when you're awake and it's sort of electrically stimulates your tongue muscle. So then you go to bed, it keeps a little, it's like a tens unit kind of

1:19:36where it like, where it stimulates your tongue muscles so that when you go to bed, there's a little more muscle tone in there that seems to work. Okay. Um, there's a new device. People have maybe seen commercials called inspire, which just means breathe in, but, um, it's, it's sort of like a pacemaker that they install. So it's an implantable electrical device that they do surgery, but it's a sort of a pacemaker for your tongue muscle. And so what it does is when it detects that your tongue is falling back, it zaps it to open it up. And that also for people for whom it's a candidate for

1:20:06it, that can also, it's, you don't have to, again, there's no equipment to replace, but you do need surgery for it. And, and there's complications there sometimes, but it seems to work. Okay. Um, there's more options now than ever. And the technology is always getting better. Even with CPAP, there's more than 200 different kinds of masks out there. So for people who don't like their device and don't like their mask cause it's uncomfortable or whatever, it's rare that I find a mask problem that can't be fixed. If, if what you need is one of those. What about, um, mouth taping? Mouth taping.

1:20:43So, all right. Mouth taping. So mouth taping for decades in the sleep medicine field, we've been using chin straps, just like an elastic band at night for people who are snoring. That don't, that where it's just mild snoring and they don't have sleep apnea, um, or their sleep apnea is mild or their sleep apnea is due to them opening their mouth at night and their tongue falling back and they can breathe through their nose. Okay. Chin straps have been great. They're,

1:21:15they're, they've been, again, used for decades. Mouth taping, I think is just sort of the same thing where you're essentially just keeping your mouth closed. You're just keeping your mouth closed in a way that you can breathe through. Like it's, it's special tape where air flows through fine. If the problem is that you're opening your mouth, I have no problem with it. And it probably, it may help those people. But if the problem is that you actually have sleep apnea and if you don't open your mouth and you can't breathe, like, and you're opening your mouth to gasp for air, then that's probably not what you want. It's probably the opposite of what you want. If,

1:21:49if you need to open your mouth to breathe or else you're going to have your, your oxygen is going to plummet. Don't do that. But if for like more mild snoring cases or for people who are, it's mild enough, or if it helps you keep, like maybe you're using a nasal device or like, or like strips or, or, um, rhinomed makes these, these nasal splints where you can keep your nose open. Like if you're using one of those and you just need to keep your mouth closed, I have no real problem with it. I just don't think it's going to like cure cancer and save the world, but I feel like it's, it gets overblown

1:22:21by people. So yeah, it's gotten overblown and it sounds more like maybe for snoring than anything. And it's, it's, if you need, if keeping your mouth closed during the night solves your problem, go ahead. But if that's, but if you're hoping that keeping your mouth closed during the night will solve your problem and it doesn't, there are other options for you. Are there any, for people that are experimenting with some of these, perhaps the retainer or the myofunctional training? Um, we're going to get into sleep wearables, you know, soon, but like,

1:22:53how do they really know it's working to this? What's yeah, it's tough. The best way to know, and this is not a perfect way. Um, second best way to know is, are you, how do you feel during the day? How's your energy level? How's your ability to focus? Are you falling asleep whenever you stop moving? A lot of people sleep after you. They can't, they don't stop moving because then they'll, they'll fall asleep. They can't watch TV. They can't watch a movie. They can't go to a dark movie theater without nodding off. Like they have a hard time with that or meetings. They hate meetings

1:23:25because they have trouble keeping awake. If all of a sudden that's just not a problem for you, it's like your appetite isn't ramped up because you're starving all the time. You're actually getting good nutrition. So you're not starving. That's a good signal, but it's not a great signal. It's not, it's not a perfect signal because there's a lot of people where their sleep apnea seems to be treated just fine, but they still have some of those daytime symptoms and no one really exactly knows why. Um, but it seems just means we need to learn more about what this condition

1:23:56really is and what it's doing in the brain when what's permanent and what's not permanent. We don't know yet. And I say that second best, cause the best is just get retested. And a lot of people with sleep apnea, if it's been a couple of years, get to do it to do the test again, do it while you're using your treatment to see. And, and for a lot of those devices, insurance requires you to do that anyway, to make sure it's working fine. See if he needs to get adjusted because sometimes they need to get adjusted and they're not working great because your mouth changes or something. So that's one

1:24:27way. I mean, really, really, there's no other way besides either looking. I mean, you can, you might in the future might even be easier to look at the wearable data, check your oxygen levels during the night, check your heart rate during the night, see if you have these spikes that you used to have or see it. And most, most importantly, see how you feel the next day. All right. Um, I kind of wanted to shift gears. We're going to get into the supplements cause that's something everyone wants to know about. But before that, I kind of wanted to ask you a little bit about, you know, we've, a lot of people have heard about sleep hygiene and the most important things for sleep hygiene.

1:25:00I mean, rapid fire. I do good sleep hygiene. I do all the sleep hygiene or I, or my sleep hygiene is bad. Like people talk about this all the time, but yeah, but there's a difference between sleep hygiene and behavioral sleep medicine. They're different things. Right. Exactly. I mean, obviously people need to have sleep, good sleep hygiene too. Like that's important, but like, like everything you were talking about with CBTI, like that's just one. Yeah. The sleep hygiene is just something that already needs to be done. Yeah. Hygiene is hygiene. Hygiene isn't medicine. So like washing your hands

1:25:34is hygiene. Everyone should wash their hands more than once. You know, you should be, and if you're sick, wash your hands more, but washing your hands won't cure an infection. Right. But for people that perhaps don't have insomnia, have apnea, sleep hygiene. But everyone should still be washing their hands. Everyone should still be brushing your teeth. Even if you can't brush your way out of braces, it doesn't mean you shouldn't be brushing your teeth. So, so sleep hygiene is all about setting yourself up for success or dealing with some of these more minor problems. Right. So I was wondering

1:26:06if you had any tips on some more advanced type of sleep hygiene. Like we know, we all know dark, cold, quiet. Rocket science, right? Yeah. Rocket science. But like, are there any other sort of more advanced sleep hygiene techniques? Like, oh, maybe your resting heart rate or respiratory rate or something like that. Like people could. Some unconventional, the stuff, you know, if you Googled, if you Google sleep hygiene, what's some stuff that might not come up on those initial lists that would still be useful? One of the, one of the things that you'll see often on sleep hygiene

1:26:40lists is keep a regular schedule. Because predictability, the brain loves predictability. So if you keep a regular schedule, time itself becomes a cue. So like, if you want to eat lunch at noon every day, start eating at noon every day and your body will learn to get hungry at that time. But what if you can't keep a regular schedule? Well, an alternative approach I would take is find other ways of building predictability into your sleep. For example, so like, so one of the

1:27:12groups I do a lot of work with is Major League Baseball. And in Major League Baseball, when they're in season, they're constantly moving around and playing in different time zones and sleeping in different hotels. How do you keep regularity when you're constantly moving around? And so like, for people whose lives are like that, what do you do? Well, I usually say, okay, stop trying to keep a regular schedule, but, but find other ways to build predictability. And so maybe have a nighttime routine that is highly predictable, where you do the same things in the same order, even if you do them

1:27:45in different places, in a different hotel room or whatever. Especially if you can bring things with you, like bring the pillowcase with you, uh, as a, as a condition stimulus, um, use the same toothbrush that whether it's at home or on the road, if you travel a lot, use, do the same things in the same order. So even if they're at a different time in a different place, find alternate ways to build predictability. If time itself is not the predictable one. Um, another one is avoiding bright light at night.

1:28:17So what if you can't, um, so blue blocking glasses are great for this because, and by blue blocking glasses, they have to be orange or red. Most of the time, some of the other ones will work. Some of the yellow ones or brown ones will work, but if you put the glasses on and you look at something blue and you know that it's blue, it's not going to do its job from a circadian perspective. So some of them block blue for eye strain, but that's different, different thing. So if you put on say orange tinted glasses and

1:28:48you can't see the color blue, then the environmental light is not going to interfere with your sleep in the same way, because it's not going to send a daytime signal. Another one that even fewer people know about is bright light in the morning can help set your sleep up at night in three ways that are, that are actually a little unconventional. Number one, by having that morning be a regular timing and a strong

1:29:19daytime signal, I'm talking about daylight. I'm talking about like outdoor light, not just turn on the light in my bedroom light. That's a couple hundred lux step outside. It's thousands of lux of light. So getting that strong daytime signal in the morning at a predictable time starts a clock. And that clock, just like when you finish a meal, you'll start getting hungry a certain number of hours later. If you don't really have a really strong meal, you're sort of hungry all over the clock. You don't have that rhythm. But if you have a strong morning signal with some bright light at a predictable time, about 16 to 17 hours later, your body

1:29:55will expect to be ready for sleep. And if you can make that a little more regular, it makes, it's like if you want to be, if you want to throw, if you want someone to catch a ball downfield and you throw it the same amount of about the same distance every time, but you keep moving, the person downfield doesn't know where to stand. But if you stay still, they can predict where the ball is going to land. So like by setting that time, it creates, it sets you up for success by starting that timer. The second thing that it does

1:30:25is that it creates a circadian amplitude. So your circadian rhythm, this 24 hour cycle, it's like when you're on the couch in the dark all day, you don't have a strong daytime rhythm. So you don't have a strong nighttime rhythm. But if you get a strong daytime signal by being active and, and getting especially outside light, especially in the morning to start that curve going by the time nighttime comes, you'll have an even stronger nighttime signal. And then the third thing that it does that even fewer people know about is, you know, everyone knows that light at night is bad and that

1:31:00light in the morning is good, but light across the day matters where the more outdoor light, the more bright light, but it's mostly means outdoor light, the more light you get during the day, it inoculates you against light at night. Because if you've got a really strong light daytime signal, you can get all kinds of light from screens or whatever at night. And it actually won't matter for most people. You can actually, you can, so you, again, it's lesser known, but because the system

1:31:32knows where it is, it's not looking for information anymore and, and conflicting information will get thrown out as opposed to like, I don't know, it's, it's light now, but I didn't get a ton of light during the day. Maybe it's daytime. I don't know, but you can inoculate yourself against nighttime light by getting plenty of daytime light. That's fascinating. I've noticed that of course, when I'm traveling and I'm, I'm outside all the time. And then it's like being in my hotel, I don't usually have my dimming lot, my dimmers and everything that I usually have, but it doesn't matter because I am dead tired, you know, after being.

1:32:02This is humans lived for most of our existence in equatorial bright days, dark nights, relatively little seasonal variability all around, all around like the Mediterranean area and, and that part of the world, you know, we solved all kinds of problems by creating these walls and buildings and artificial lights and everything. We solved a lot of problems. We've created some new ones too, and we're still running the same code. Right. Um, a couple of questions, um, follow-up questions for that.

1:32:34Do you think the time of, of, um, morning light matters a lot? Like you wake up in the morning and like, is it like first thing you go outside and how long should you have to go outside for 30 minutes? Yeah. Morning light is key earlier. The better. Um, I mean, honestly, earlier, the better and how much I would say 15 minutes is probably fine. Um, 30 minutes is probably better. Like a morning walk

1:33:07or a morning run is actually probably perfect. Um, and cause what's happening, it's not only that day time. The other thing it's doing, and we'll talk about this when we talk about supplements, but melatonin. So melatonin naturally, your, your natural melatonin will drop in the morning down to like almost from its peak to almost nothing light suppresses melatonin naturally. That's what it does. And so the early, if your melatonin is still kind of high and it's dropping by getting

1:33:41that light, you accelerate its ability to drop. It's like coffee. Yeah, kind of. And, and actually