Dr Rangan ChatterjeeSleep Doctor: If You Wake Up Between 1–3 AM, Your Body Is Trying To Warn You | Dr Michael Breus
EVERY SPOKEN WORD
115 min read · 22,683 words- 0:00 – 1:45
Why “8 hours” and weekend sleep-ins can sabotage your sleep schedule
- RCDr. Rangan Chatterjee
Let's just start off by going through some of the common mistakes you see people make, perhaps inadvertently, that is getting in the way of them having a good night's sleep.
- MBDr. Michael Breus
Oh, it, it's a great question. There's a few. I think the biggest one is people get locked and loaded with the idea that they have to get eight hours of sleep, and what ends up happening is, for example, if they stay up late, then they just add more sleep to the end of their sleep period. So as an example, if they normally go to bed at, let's say, 10 o'clock and get up at 6:00, they get eight hours. But let's say it's Friday night or it's Saturday night, they stay up till midnight, what do they end up doing? They end up sleeping in by a couple of hours in order to try to capture that extra supposed missed sleep, and I would argue that's probably one of the worst ideas that you can possibly have. Let me explain why. When you wake up in the morning, sunlight hits your eye, uh, and, uh, you have a special cell in your eye called a melanopsin cell, and this s- cell sends a signal to the back of your brain to turn off the melatonin faucet in your head. But it sets a timer for approximately 14 hours later. It's called the melatonin phase response curve, right? So what I just said was the time that you wake up directly determines when melatonin, which is your internal, you know, sleep hormone, turns on, right? So if you have a variable wake-up time 'cause you're trying to capture that eight hours of sleep, you end up with variable melatonin time in the evening time, and that becomes highly problematic. There is a lower level limit. I don't want people to get less than about five and a half to six hours of sleep. However, if for whatever reason one night you get six hours, it's not gonna be the end of the world.
- 1:45 – 3:57
Top sleep traps: circadian mismatch, weekend catch-up, and social jet lag
- RCDr. Rangan Chatterjee
In, I think, your latest book, Sleep Drink Breathe, you have these top five sleep traps.
- MBDr. Michael Breus
Yes.
- RCDr. Rangan Chatterjee
And I wonder if we could go through those, because I kind of feel that people are often doing things without realizing that it's-
- MBDr. Michael Breus
Oh, yeah
- RCDr. Rangan Chatterjee
... negatively affecting their sleep. So the five you put in the book are living out of sync with circadian rhythms.
- MBDr. Michael Breus
That's the one we just talked about.
- RCDr. Rangan Chatterjee
Playing catch-up, freaking out. I mean, we can go through more-
- MBDr. Michael Breus
[laughs]
- RCDr. Rangan Chatterjee
... but maybe let's go to those two next. What's-
- MBDr. Michael Breus
Yeah
- RCDr. Rangan Chatterjee
... what's playing catch-up and what's freaking out?
- MBDr. Michael Breus
So playing catch-up is where you only get five and a half hours during the week, and then you say to yourself, "Okay, I'm just gonna catch up on my sleep over the weekend and add a couple or three hours, and hopefully cumulatively across the week I will get the amount of sleep that I need." And the, the truth of the matter is we have an argument about this in sleep medicine every couple of years. Some people say you can catch up. Some people say you cannot catch up. It... Quite honestly, if I was the consumer, I would be incredibly frustrated, because every couple of years it seems to change one way or another. Here's what I'll tell you you can do. You can catch up some, but what you don't wanna do is sleep in for a long period of time. So as an example, if you wanted to catch up for, let's say, 30 to 45 minutes of extra sleep in, I don't think I have a huge problem with it. It's when somebody who normally gets up at 6:00 gets up at 9:00. They've completely thrown off their internal circadian rhythm, and you do that more than one night in a row and you get what's called social jet lag, where your entire circadian system shifts, and now Mondays are horrible. So as an example, stay up late on Friday, sleep in on Saturday, stay up late on Saturday, sleep in on Sunday. Monday sucks, because guess what your body wants to do? Stay up late on Sunday [laughs] and sleep in, and that makes it even more difficult. So the weekend catch-up, I think you can catch up for some, but I wouldn't say you can catch up for all. So my official recommendation is, yes, you can sleep in for between 30 and 45 minutes, but no longer than that, for sure.
- RCDr. Rangan Chatterjee
Okay. So circadian rhythms, very important, we're gonna talk more about them throughout this conversation.
- MBDr. Michael Breus
Yeah.
- RCDr. Rangan Chatterjee
We've just dealt with number two, which is, you know, be careful with how much you try and catch up at a weekend. Okay.
- MBDr. Michael Breus
Correct.
- 3:57 – 5:58
The ‘freaking out’ trap: how anxiety, heart rate, and temperature block sleep
- RCDr. Rangan Chatterjee
But now the third one I think is really interesting, and perhaps, I don't know if you'd agree, but perhaps might be one of the biggest ones of all, which is freaking out. What do you mean when you say freaking out is a sleep trap?
- MBDr. Michael Breus
So a lot of people get really upset about their sleep, right? And so as an example, they wake up in the middle of the night, uh, which by the way happens regularly for them, and they get very, very upset about it. They're like, "This is unbelievable. I keep having problems." And what happens is that escalates heart rate, which makes it harder to fall asleep, right? So there's three main ways that we can get people to fall asleep, through lowering heart rate, lowering temperature, lowering anxiety. Those are the three, right? And so when we look at those three in particular, lowering heart rate, lowering temperature, and lowering anxiety, freaking out affects all three. [laughs] So when people start to get really upset about their sleep, guess what happens? Their anxiety increases. When your anxiety increases, so does your core body temperature and so does your heart rate. Now you're moving further and further away from the actual sleep. I have a saying that I tell people all the time that I think is appropriate here. I tell people all the time, sleep is a lot like love. The less you look for it, the more it shows up, right? So when you're out there in the world trying to find your perfect relationship, right, you can never do it. But the second you stop looking so hard, that person wanders right into your universe. The same holds true with sleep. The more you think about it, the more you worry about it, the more you freak out about it, the less likely you are gonna be able to get your body to sleep. Now, don't, don't get me wrong. There are environmental issues, like you need to have a good setup in your bedroom, and also there are circadian rhythm issues. You need to know what timing is. But at the end of the day, I would argue 75% of sleep is between your ears, right? It's your mental state. It's your how do you create a mental state in order to allow your body to then fall into an unconscious state.
- 5:58 – 8:47
Modern life vs. traditional sleep: why we ‘forgot’ how to sleep
- RCDr. Rangan Chatterjee
Yeah. One thing I was hoping to talk to you about, Michael-
- MBDr. Michael Breus
Uh-huh
- RCDr. Rangan Chatterjee
... is this, it's something I've thought about in nutrition for- A number of years now, which I think we can apply to sleep, which is this idea that we never used to need nutrition experts, right?
- MBDr. Michael Breus
Right. [laughs]
- RCDr. Rangan Chatterjee
You, you, you would learn nutrition from your family and culture, you know-
- MBDr. Michael Breus
Exactly
- RCDr. Rangan Chatterjee
... your grandparents-
- MBDr. Michael Breus
Your grandmother would make great food.
- RCDr. Rangan Chatterjee
Yeah.
- MBDr. Michael Breus
You would have family dinners, the whole thing.
- RCDr. Rangan Chatterjee
E- exactly, and I sort of feel it might be similar with sleep. Like, like-
- MBDr. Michael Breus
[laughs]
- RCDr. Rangan Chatterjee
... I'm sure in more traditional societies w- who haven't-
- MBDr. Michael Breus
Mm-hmm
- RCDr. Rangan Chatterjee
... been as affected by modernity, like-
- MBDr. Michael Breus
Right
- RCDr. Rangan Chatterjee
... did they have all of these sleep problems? Did they need-
- MBDr. Michael Breus
No
- RCDr. Rangan Chatterjee
... all of these hacks? So what-
- MBDr. Michael Breus
No
- RCDr. Rangan Chatterjee
... what, what does it say about us as a society-
- MBDr. Michael Breus
[laughs]
- RCDr. Rangan Chatterjee
... where we actually need people like you and me to actually help them do-
- MBDr. Michael Breus
Yeah
- RCDr. Rangan Chatterjee
... something that's very basic?
- MBDr. Michael Breus
It, well, it, it's such a great question, right, is like, you know, do, do we really need a sleep expert, right? Or a sleep doctor, and the truth of the matter is maybe for some pathology, like for sleep apnoea or narcolepsy, that makes intuitive sense for me. But for the general public, no. Like, let's be fair. 90% of the time I'm reminding people about something that their mother told them, [laughs] or their grandmother told them, right? Like, "Go to bed without the television on," or-
- RCDr. Rangan Chatterjee
[laughs]
- MBDr. Michael Breus
... "Go to bed at the same time," or, "Wake up at the same time, you know, here's some warm milk." Like, all of those things, right, are real, and they all really work if we just... Let me, let me say it a different way. We all used to know how to sleep until we grew up, and then life seemed to get in the way.
- RCDr. Rangan Chatterjee
Yeah.
- MBDr. Michael Breus
Right? And so I think that's what ends up happening. I, and when we look at these cultures that have, uh, not a level of, of, of modern, uh, technology like what we do, they sleep better. Like, I've got news for you, like if you look back at the data, like, well, I'll take the ultimate piece of technology. That kind of idiot Thomas Edison, he invented that thing called the light bulb. He screwed it up for everybody, okay?
- 8:47 – 12:01
Don’t wait it out: sleep apnea fears, testing avoidance, and treatment options
- RCDr. Rangan Chatterjee
... do later on. But let's just go to that fifth sleep trap that you write about-
- MBDr. Michael Breus
[laughs]
- RCDr. Rangan Chatterjee
... in Sleep Drink Breathe, you know, hoping the problem will go away on its own.
- MBDr. Michael Breus
I know.
- RCDr. Rangan Chatterjee
Are you specifically talking about sleep disorders there, or are you talking about more lifestyle related sleep issues, or a bit of both?
- MBDr. Michael Breus
I think, I think both, if I'm being super honest with you. I think both. Uh, like an example of a sleep problem that goes away on its own, 'cause there are some that do, for, as an example is, uh, if your child doesn't wanna stay in bed at night, right? Like, m- most children don't at college age wander into their parents' bedroom and say, "Mom, I can't sleep," right? Like, it eventually it goes away, right? But something like sleep apnoea, eh, that probably doesn't just go away on its own type of thing. So a lot of people avoid the idea of even sleep testing, Rangan. This is also another thing I think is kind of an interesting topic to bring up, which is a lot of people come to me and they're like, they have obvious symptomatology of a sleep disorder, so the first question I have is, "Well, why haven't you, why haven't you gotten sleep tested yet?" And they say, "Oh, I don't wanna get sleep tested." I say, "Well, why?" And they say, "Well, I'm gonna end up on a CPAP machine," right? And so just for your audience members to understand, most people are fearful that if they have a sleep test they're gonna end up with a diagnosis of something called sleep apnoea, right? Now, sleep apnoea, for folks who don't know it, is a situation where you stop breathing in your sleep. This is very serious, uh, we want all of our patients to breathe. Um, but most people will say, "Oh, I don't wanna do that sleep test because I'm gonna end up with the treatment for sleep apnoea," which is a mask, uh, that you wear on your face that helps you breathe at night. Now, I wanna be clear about a couple of different things. I wanna kinda double tap on a few things here. Number one, not everybody who has sleep apnoea sleeps with a mask on their face. There are a whole host of protocols that we use nowadays to treat sleep apnoea that are extremely effective and do not involve sleeping with something covering your face. But the most effective treatment that's out there happens to be a CPAP machine. So I think there's a lot of people out there who just are fearful of the answer, um, and even more so fearful of the protocol that could follow, which would be the treatment, which by the way, would make them feel like a million bucks, right? So it's like it's so funny because people are like, "Oh, I don't want it. I'm claustrophobic. I can't handle it" and then at the end of it all, once we get them on treatment, whether it's a CPAP machine or not, it turns out that they, they do really, really well. That's something that doesn't just go away, right? Now, I will tell you that s- a lot of people turn to me with sleep apnoea and they say, "Well, what, what if I just lose weight, Michael?" And you know what? Weight loss can definitely help, but as a general guideline, you can still lose weight and have rip-roaring sleep apnoea, right? So let me give you another example of myself, right? So I personally, Dr. Michael Breus, I have sleep apnoea. I stop breathing in my sleep 26 times an hour, which is quite a bit [laughs] if you look at it, right? And guess what? I sleep with a CPAP machine. I wore it last night. You can probably see the marks on my face still they're from this morning, right? And so at the end of the day, you don't wanna be fearful, thinking that something is just gonna magically disappear, because nothing in a health related situation usually magically disappears.
- 12:01 – 15:08
Sleep apnea explained: symptoms, mechanics, and how treatments ‘open the pipe’
- RCDr. Rangan Chatterjee
Yeah. That word sleep apnoea, could you explain what exactly sleep apnoea is?
- MBDr. Michael Breus
Sure.
- RCDr. Rangan Chatterjee
But also, what are the- Signs that people may be experiencing, you know, that might indicate they've got sleep apnoea
- MBDr. Michael Breus
Absolutely. So here's, there's a tricky one, uh, which everybody says, and I wanna say it first, but I wanna put a caveat on it, which is snoring. Okay? So not everybody that snores has sleep apnoea. However, I'm, if I'm honest with you, most people that have sleep apnoea do snore. So it's kind of like it's a two-way street, but the traffic is different on one side [chuckles] of the street than on the other side of the street. Um, but, uh, he- snoring is one. Waking up in the morning with a headache, that's another symptom. Uh, waking up and being tired during the day, or waking up hitting the snooze button four or five times because you just can't get your butt out of bed. Uh, mood disruption, so up and down moods, uh, where there's some irregularity there. Um, also difficulty focus, difficulty with attention. Um, there's quite a few symptoms that are, that are out there. Um, also, let's be fair, most people kind of wake up and say, "Oh my God, I got a terrible night's sleep last night." That's something that sleep apnoea people report all the time. Now, what is sleep apnoea in effect? When you breathe in through your nose, you form a vacuum which pulls all of the tissue slightly back just a little bit. If you are a large person, if you have big tonsils, if you have a deviated septum, all of these different scenarios, when you pull that tissue backwards, you can push it to the back of the throat and actually close the throat. Most sleep apnoea is the back of your tongue touching the back of your throat. So what we have to do is open up the pipe, right? Now, there's a lot of different ways to do that. One is with a mask on your face, pushes air up your nose, and when it hits that area, it just ever so slightly opens it up, keeps you breathing all night long. But that's not the only way to do things. There's also something called an oral appliance. This is like a mouth guard, like, you know, like you see the football players wear, but it's an upper and a lower, and the lower is slightly forward, and when you move the jaw slightly forward, you open up the posterior airway space. Again, opening up the pipe is another way of doing it. Most surgical interventions do something once again to open up the pipe. So that's really what we're talking about here, is anything that we can do to mechanically open this area up to allow people to breathe better and, and that usually works actually quite well.
- RCDr. Rangan Chatterjee
Yeah. I, I really appreciate how open you are sharing your own story with sleep apnoea.
- MBDr. Michael Breus
[laughs]
- RCDr. Rangan Chatterjee
No, because, you know, it's really interesting. You're saying a lot of people are scared.
- MBDr. Michael Breus
Yeah.
- RCDr. Rangan Chatterjee
They don't wanna get tested 'cause they don't wanna have a CPAP machine. But I think there's also, with health sometimes, like an embarrassment, a shame, a guilt, right? And what's-
- MBDr. Michael Breus
Oh, yeah
- RCDr. Rangan Chatterjee
... and, and you are, you know, you are the sleep doctor, right?
- MBDr. Michael Breus
[laughs] I know.
- RCDr. Rangan Chatterjee
Yeah, y-
- MBDr. Michael Breus
It's kind of ironic. [laughs]
- RCDr. Rangan Chatterjee
It, but it is, but it's also, I think, quite empowering. It's quite reassuring to go-
- MBDr. Michael Breus
Yeah
- RCDr. Rangan Chatterjee
... "Oh, even though he is an expert in sleep, he also has this sleep condition that requires-"
- MBDr. Michael Breus
Yeah
- RCDr. Rangan Chatterjee
... "treatment."
- MBDr. Michael Breus
Yeah.
- 15:08 – 21:18
Breus’ personal apnea story: denial, home testing, and why CPAP worked for him
- RCDr. Rangan Chatterjee
Uh, and I think another point there, which I think is interesting, is a lot of people associate sleep apnoea with people who are overweight or obese.
- MBDr. Michael Breus
Yes. Yeah.
- RCDr. Rangan Chatterjee
And you, of course, are neither.
- MBDr. Michael Breus
No, not at all. So, uh, let me tell you the story 'cause it's kind of an interesting story-
- RCDr. Rangan Chatterjee
Yeah
- MBDr. Michael Breus
... right? So I call, uh, my doctor. So I have a concierge doctor, a wom- the woman who takes care of me. Her name is Dr. Kerry Bordenko. And, um, uh, I call Kerry up and I say, "Kerry, God, my workouts aren't as good as they used to be. I feel like I'm slowing down. I don't feel like I'm as... I, I've got as much, you know, kind of piss and vinegar in me, like I usually."
- RCDr. Rangan Chatterjee
[laughs]
- MBDr. Michael Breus
"I'm a pretty energetic guy." And, uh, she said, "Well, let's run some blood work. Let's make- maybe something's going on." So we run some blood work. Maybe she thinks maybe I'm anemic or something's going on. We get the blood work back, and my testosterone was at 400. Now, for folks listening, low T is 300 or less, so I wasn't in the low testosterone area, but I'd, I'd... it's not like I had high testosterone. So she said, "Let's try some testosterone. You're 58 years old." Or actually, I was 57 at the time. Like, "Let's try it. Let's see. May- that's probably it." So I'm like-
- RCDr. Rangan Chatterjee
Hmm
- MBDr. Michael Breus
... "Okay, fine." I'm not a big needles guy, so I did the oral, uh, testosterone. Uh, they were little, uh, gummies, right? So I did that for about four or five months, noticed no difference. She said, "Look, the oral doesn't work as well as the injectable. Stop being such a wimp. Just do the injectable."
- RCDr. Rangan Chatterjee
[laughs]
- MBDr. Michael Breus
So I'm like, "Okay, fine, I'll stop [laughs] being such a wimp and do the injectable." So I start doing the injectable, go for three months. Only thing that happens, I lose more hair, okay?
- RCDr. Rangan Chatterjee
[laughs]
- MBDr. Michael Breus
This is not the response I'm looking for, [laughs] okay? Like, I'm looking for libido increase, I'm looking for energy increase. I'm like, all these things. None of it happens. And so I call, I call her back up and I'm like, "Look, it's nothing's going on in the right direction." And she said, "Hey, sleep doctor, when was the last time you had a sleep study?" And I was like, "You know what? It's been a minute." Right? So I haven't had a sleep laboratory in about six or eight years, and usually when you have a sleep laboratory, you test out equipment. I'm used to testing out... I hadn't tested any equipment out in, like, eight or 10 years. So I call up, uh, my buddy who, uh, actually is over at Sleep Doctor, which is where we actually run sleep tests for people. Uh, his name's Holland, and I said, "Holland, send me a test." So he sends me a test. I wear it overnight. Boom. I get this number back of stopping breathing in my sleep 26 times an hour. So you know what I did then? I didn't believe the test.
- RCDr. Rangan Chatterjee
[laughs]
- MBDr. Michael Breus
I didn't. I swear to God. I was like, "Something's wrong with this test. Come on, I need another test." So I called Holland back up and I'm like, "Holland, clearly there's something wrong with this test. Send me another test." He's like, "Dr. Breus, there's nothing wrong with the test." I'm like, "No, seriously, dude, send me another test." So he sends me another test. Dead on same number. [laughs]
- RCDr. Rangan Chatterjee
Wow.
- MBDr. Michael Breus
So look, I, even me, even me as the sleep doctor, I denied my first test result. Like, I, I was, I was convinced, like, I'm not that guy. Like, I'm not a, I'm not a bigger person. I don't have, you know, these terrible snoring. My wife doesn't hear me waking up stopping breathing. None of this stuff, but sure enough, I've got moderate to severe sleep apnoea, right? And it came across as low energy. Right? And so that becomes important for people because you need to start looking down those paths and seeing what's going on. Do I look like an apnea patient? No, of course I don't look like an apnea patient, but to be fair, what does an apnea patient look like anymore? Like, I, I feel like anybody could be a sleep apnea patient, and we need to be thoughtful and, and, you know, nowadays sleep tests are so cheap. They're less than $200 to have them sent to your home, and you can have it done in the privacy of your own home these days. So it's, it really is quite remarkable. But yeah, that was kind [laughs] of my story is, uh, I, I was not expecting... Like when I got those test results back, I was kind of upset. [laughs]
- RCDr. Rangan Chatterjee
Do you have any theories as to why you have sleep apnea?
- MBDr. Michael Breus
I do. So, um, so I went and I, I had another physician look in my throat, uh, and so [clears throat] there's a couple different things that we think might be going on. So there, it looks like I may have some excess tissue towards the back of my throat, and that's where we think is the pinches going on.
- RCDr. Rangan Chatterjee
Right.
- MBDr. Michael Breus
Now, one question people ask me all the time is, "Well, why did you... Why are you on CPAP machine?" So let's talk about that for [laughs] a second 'cause it's kind of a funny story. So, um, so I've been putting people on CPAP machines for 26 years, right? And so I've been, and I've been talking about it and telling, and I even slept with one for a little while just to kind of get used to it, but it wasn't on and I didn't have apnea at the time, so I didn't really know what the experience was like.
- RCDr. Rangan Chatterjee
Mm.
- MBDr. Michael Breus
Right? Now, I have a very different, uh, understanding and appreciation for being not just the doctor, but also being the patient. So here's the funny story is about, uh, a year ago, not, well, maybe less than a year ago, we got a new puppy. And, um, so in our house, as people have heard me say before, there's a big screen TV that's on all night long, 'cause that's what my wife watches all night long, and both of our French bulldogs sleep in our bed, okay? And so the puppy wanders up, and he likes to fall asleep in between my pillow and my wife's pillow. That's his favorite spot, okay? And he likes to put his head on my wife's pillow, okay?
- RCDr. Rangan Chatterjee
[laughs]
- MBDr. Michael Breus
So what does that mean? That means that I get the rear end of the dog, a bulldog who farts all night long in my face, okay? So when somebody said, "Hey, Michael, you wanna put a mask on your face that's got filtered cool air that's coming in?" I jumped at the chance. Are you kidding me? I was like, "Let's go." I adapted to it super fast. But I had a [laughs] kind of a unique situation going on for me. But I think almost anybody can adapt, I think. And, and by the way, it might not be the optimal treatment modality for you. It was what I wanted to try first. I've enjoyed it. I've, I've done well with it. You can see I've got good energy. As you mentioned before we got on the podcast, I'm more of a night owl, and it, here it's, uh, we're filming this morning at 7:00 in the morning, and I've got great energy. Why? 'Cause I wore my CPAP last night, you know?
- RCDr. Rangan Chatterjee
At some point we need to talk about the sleep doctor sleeping in a bed with bulldogs and having a big plasma-
- MBDr. Michael Breus
Yeah
- RCDr. Rangan Chatterjee
... screen on i- in, in our room. Let, let's just park that for a minute, right?
- MBDr. Michael Breus
[laughs]
- 21:18 – 30:51
Waking between 1–3 AM: normal biology, not failure—and what to do next
- RCDr. Rangan Chatterjee
In, in terms of what people come in to see you with, I've heard you say that one of the commonest things people come in to see you with is they say, "Look, I can get to sleep fine-
- MBDr. Michael Breus
Yeah
- RCDr. Rangan Chatterjee
... but I wake up between 1:00 and 3:00 AM."
- MBDr. Michael Breus
Yeah. [laughs]
- RCDr. Rangan Chatterjee
Tell us about that. You know, just how common is this? What are the causes of this? And then what-
- MBDr. Michael Breus
Sure
- RCDr. Rangan Chatterjee
... can you actually do about it?
- MBDr. Michael Breus
Absolutely. So this is, Rangan, the number one question I get asked, and I think I understand the reason why. But let's talk about what is actually going on biologically and why do people wake up somewhere between 1:00 and 3:00 in the morning. So sleep follows your core body temperature cycle, right? So as your core body temperature rises, rises, rises towards the end of the evening, it will hit a peak right around 10:00, 10:30. Depending upon your chronotype, it can be a little earlier or a little later. But let's just, for the math, let's say right around 10:00, right, is where you hit your peak. When you hit your peak, then the t- core body temperature begins to drop. That drop is actually a signal to your brain to release melatonin. Your core body temperature continues to drop, drop, drop, drop, drop. At some point, if your core body temperature doesn't heat your body up, you go hypothermic and you die, okay? Guess what time that is? Somewhere between 1:00 and 3:00 in the morning. [laughs] So literally every person on earth, on earth wakes up between 1:00 and 3:00 in the morning. But here's what happens. Most people burp, fart, roll over, and go back to sleep, right? However, there's a group of people, believe it or not, between 10 and 20% of the population that has difficulty at that moment falling back to sleep. So let's talk about that particular situation. Now that everybody understands you didn't do anything wrong, I wanna be clear. Nobody out there did anything wrong to wake up in the middle of the night. This is your biology. What we need is a good strategy to get you back to sleep, allow the natural sleep process to take over. So step number one, and this is gonna sound a little strange, don't go pee. Yep, you heard it here. Don't go pee. Now you [laughs] everybody's saying, "Wait a second, Michael. [laughs] What if I have to go to the bathroom?" So here's the deal, is remember the three things that help us fall asleep, lowered heart rate, lowered temperature, lowered anxiety, right? What do you think happens to your heart rate when you go from a lying position to a seated position to a standing position, you walk across the room to go to the bathroom, right?
- RCDr. Rangan Chatterjee
Yeah.
- MBDr. Michael Breus
Your heart rate goes up, right? Uh, inevitably. By the way, so does your temperature, right? So now you've got your body is going in the wrong direction. Here's the reason I say don't go pee. Most people actually don't have to. Most people, what they say is, "I'm up. I might as well go pee," right? This is a terrible idea. I wanna be super clear. If you gotta go pee, please go pee. I, I had somebody ask me this question. It was funny. They were like, "Well, should I put on those adult diapers in-" No. No. Please, go to the bathroom, okay? But if you don't actually have to go to the bathroom, there's really no reason to do so. So go ahead and stay in bed. So that's hint number one. Number two- Don't look at the clock. Now, this is hard for most people.
- RCDr. Rangan Chatterjee
Mm-hmm.
- MBDr. Michael Breus
So what they do is they grab their cellphone and they go to the, the, the restroom, right? Or they hit the loo. And what happens is second you pick up your cellphone, you see the time, and then you immediately do the mental math, and now you've got anxiety, right?
- RCDr. Rangan Chatterjee
Mm.
- MBDr. Michael Breus
"Oh, crap, it's 3:30 in the morning. Once again, I'm awake. Sleep, sleep, sleep." And you try to force yourself... Rangan, in the, in the history of time, nobody has ever forced themselves to sleep without, like, anesthesia, right?
- RCDr. Rangan Chatterjee
Yeah.
- MBDr. Michael Breus
So, like, when you start to think about it, people are moving in the wrong direction when they look at the clock because they immediately get that level of anxiety. So number one, don't go pee unless you really need to. Number two, please don't look at the clock. Don't look at your phone. Okay, didn't look at the clock, I'm lying in bed. Michael, what do I do? So we need to get your heart rate to go down, your temperature to go down, and we need to stop something called monkey mind. Now, I don't have a formal definition for monkey mind, but I have a feeling most people [laughs] know what it is, right? It's this weird list of things that pops into your head in the middle of the night that you start thinking about. Maybe it's one of your kids, maybe it's your partner, maybe it's business, maybe it's what you were watching on TV. Maybe it's the grocery list. I don't know. But for some reason, you just start thinking, thinking, thinking. We want to avoid that. My favorite technique for avoiding this is called 4-7-8 breathing. Now, I know you've talked about, uh, breathing techniques before on the show, and by the way, love the show. Love all the, the practicality that we get from your show, and this is one of those situations where I'm gonna teach everybody how to do this 4-7-8 breathing. I think you might have mentioned it to people before, but I wanna do a quick double tap on it so people can understand it.
- RCDr. Rangan Chatterjee
Sure.
- MBDr. Michael Breus
It's exactly what it sounds like. You slowly breathe in through the nose for a count of four. You then hold for a count of seven, then you gently push out through your mouth for a count of eight. All right? 4-7-8 breathing. Now, I'm gonna be honest with you, and Rangan, you know me, so you know this is true, [laughs] I have a little bit of anxiety sometimes. And so when I first started this technique, I couldn't hold my breath for seven seconds, and I certainly couldn't push for eight. So I modified the technique. So everybody out there needs to understand, number one, you can modify this technique. So this is one of those it worked in research and now we're using it in the field type of scenarios.
- RCDr. Rangan Chatterjee
Mm-hmm.
- MBDr. Michael Breus
So instead of doing 4-7-8 breathing, start out with 4-5-6 breathing. So in for four, hold for five, out for six. Do this for two weeks, then move to 4-6-7, then move to 4-7-8. So then you don't have any anxiety about your breathing. So that's one thing that's really important is to change the count so that you're the most comfortable with the count. 'Cause what we don't wanna do is cause anxiety, we wanna lower anxiety.
- RCDr. Rangan Chatterjee
Mm-hmm.
- MBDr. Michael Breus
That's number one. Number two, I lose count. So it turns out you need 20, 2-0, cycles of this 4-7-8 breathing and then your heart rate dumps to around 60. By the way, that's the magic number for sleep. In order to enter into a state of unconsciousness, people need a heart rate of about 60 or below, and this technique does that. However, you need 20 cycles to get there. So how do you remember 20 cycles? 'Cause I lose count halfway through, then I get pissed off. Now I've got anxiety. [laughs] Now the technique isn't working very well for me. So what I do is I take my hands and I gently make two light fists and I put them down by my side. And when I do one 4-7-8, I stick out a finger. And then the second one, I stick out a finger. And before I know it, I've gotten to 10 fingers, and then when I wrap them back, I've made it to 20. Most of the time I've fallen back asleep at this point. And by the way, you've noticed me saying me. I use this technique myself. Do I have problems sleeping in the middle of the night? Occasionally, sure. Like, to be fair, dude, like, if something's going on with my daughter or something's going on with my son, I don't sleep well, right? That's, that's a pretty normal occurrence, right?
- RCDr. Rangan Chatterjee
Mm.
- MBDr. Michael Breus
So 4-7-8 can be super, super-duper helpful there. Um, the other thing I tell people to do is to picture the number in their mind. Now, this turns out to be the single most important aspect to the breathing technique, is picture a number four, then a number three, then a number two, then a number one, then picture the seven going down, then picture the eight coming back. When you picture the number, you're using your hands. You have distracted yourself so much from any of this monkey mind thinking, and if you follow your own guideline, you're lowering your heart rate. Before you know it, you're out cold. It's pretty impressive if you wanna know the truth of the matter. So 4-7-8 breathing with the modifications of using the hands to keep track, right? Maybe changing the number schema just so that it works well for you, and picturing the number in your head works incredibly, incredibly well. But let's say for half a second you've tried it all, you got through 20 cycles, and it still didn't work. Michael, what should I do?
- RCDr. Rangan Chatterjee
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- 30:51 – 36:47
If you still can’t sleep: NSDR/yoga nidra and reframing the ‘second thought’
- MBDr. Michael Breus
Well, there's now data on something called non-sleep deep rest. Um, we used to call it yoga nidra. Okay? And what is that? That's lying in a corpse pose on the, on your bed, quiet, relaxed, cool, dark room. Believe it or not, it's rejuvenative. Like, it's not as good as sleep, but if you do that for an hour, it's worth about 20 minutes of sleep. So even if you're lying there not sleeping, I'm here to tell you you're doing something good for your body. That helps lower that anxiety, right?
- RCDr. Rangan Chatterjee
Mm.
- MBDr. Michael Breus
And then finally, stay positive. Now, I know this sounds a little ridiculous, you know, stay positive. What is, what is that supposed to mean? Here's the thing. When was the last time you woke up at 3:00 in the morning for a good reason?
- RCDr. Rangan Chatterjee
[laughs]
- MBDr. Michael Breus
Right? Never, right? Nobody runs into your room at 3:00 in the morning and yells, "Happy birthday. You just got a raise."
- RCDr. Rangan Chatterjee
[laughs]
- MBDr. Michael Breus
You know, some good piece of news, right? When you, when your body wakes up at 3:00 in the morning, there's a problem, right? There's an emergency, there's something going wrong. There's a noise, there's a shout, whatever. And so your body immediately is negative in the middle of the night. And so as a cognitive behavioral therapist, one of the things that I know is it's very difficult to stop your first thought, but you can stop your second thought, right? So if the first thought is, "Crap, I'm up. It's 3:30 in the morning," here's what your second thought can be, is you can turn to yourself and tell yourself, "Okay, I've been here before. It's not like my head is gonna explode. I, I may have a good night. I may not have such a good night. But I know after listening to that awesome podcast that if I try my 4-7-8 breathing, or if I can just relax here and let the natural sleep process take over, I'm gonna be fine," right?
- RCDr. Rangan Chatterjee
Yeah.
- MBDr. Michael Breus
That lowers your anxiety, lowers your heart rate, lowers your temperature, allows the natural sleep process to come back in.
- RCDr. Rangan Chatterjee
Yeah. So many helpful nuggets in what you just said-
- MBDr. Michael Breus
[laughs]
- RCDr. Rangan Chatterjee
... Michael, which I kind of feel apply at other times of the day as well. Like-
- MBDr. Michael Breus
Sure
- RCDr. Rangan Chatterjee
... sure they help you if you're up in the middle of the night.
- MBDr. Michael Breus
Right, right, right.
- RCDr. Rangan Chatterjee
But they're gonna help us in other aspects of our life as well. And, and one thought I had when you were just talking about, you know, acceptance and having that positive mindset-
- MBDr. Michael Breus
Yes
- RCDr. Rangan Chatterjee
... is it possible to say in a, in a compassionate way, not, not in a judgemental way, that generally people who struggle with their sleep are a little bit stressy?
- MBDr. Michael Breus
Yeah. Oh, I think that's easy. I, I mean, I think you're being kind. I would argue-
- RCDr. Rangan Chatterjee
I'm trying to be kind [laughs]
- MBDr. Michael Breus
[laughs] I think you're kind. I think they're a hot mess. Are you kidding me? But you're, you're hitting on something that I think is important. Positive mindset works, okay? If you always have a negative mindset, there's a very high likelihood you're not a great sleeper.
- RCDr. Rangan Chatterjee
Yeah.
- MBDr. Michael Breus
Now, what's interesting about that is we know that when you become sleep-deprived-
- RCDr. Rangan Chatterjee
Yeah [laughs]
- MBDr. Michael Breus
... you have a far greater likelihood of being depressed and being more negative. So this is a, this is a cycle. This is a washing machine that you can get caught up in, is you don't sleep well, you have a negative affect, then you, that negative affects makes you not sleep well, and then you just, it just kind of compounds on itself.
- RCDr. Rangan Chatterjee
Yeah, and I think that's a really important point, isn't it? It may be that you started off, or maybe five, 10 years ago-
- MBDr. Michael Breus
Right
- RCDr. Rangan Chatterjee
... you were upbeat. Um-
- MBDr. Michael Breus
Yeah [laughs]
- RCDr. Rangan Chatterjee
... you, you had a positive mindset. But then you started to have what you call sleep-disrupting habits.
- 36:47 – 44:17
The ‘power-down hour’: building a bedtime runway (and why fast sleep can signal deprivation)
- RCDr. Rangan Chatterjee
A, a busy mind. And of course, that can be one of the reasons why people don't fall asleep in the first place. You know, if I reflect on my own sleep, I would say the biggest thing that I've noticed over the last few years-
- MBDr. Michael Breus
Mm
- RCDr. Rangan Chatterjee
... for me, is what do I do in that one hour before bed?
- MBDr. Michael Breus
Yeah.
- RCDr. Rangan Chatterjee
If my one hour before bed is nothing to do with work or-
- MBDr. Michael Breus
Mm
- RCDr. Rangan Chatterjee
... emotionally agitating, uh, topics, if it is relaxation-
- MBDr. Michael Breus
Mm
- RCDr. Rangan Chatterjee
... I'm generally sleeping really well.
- MBDr. Michael Breus
Oh, yeah. How you are before bed is how you will fall asleep. So if you're frantic and crazy and b- then you will have difficulty falling asleep. What I tell people all the time is you need runway to land the plane, okay? Like, that's how I like people to think about it, right? Is you've got to have some time to yourself. Like, sleep is not an on/off switch, right? It's more like slowly pulling your foot off the gas and slowly putting your foot on the brake. There's a process that should occur there. By the way, if you fall asleep really, really quickly, that's not a good sign. Um, f- a funny story, I was on stage with Oprah Winfrey, of all people, many, many, many years ago, and, um, she said to me, "Stedman falls asleep in a minute 37 seconds." And I said, "Oh, that's not good." She said, "Really?" I said, "That means he's sleep deprived," right? Because again, if you fall asleep super, super fast, don't get me wrong, there are some people out there that are fast sleepers, but generally speaking, if you fall asleep really quickly, it's probably a sign that you're sleep deprived and that you may need to get a little bit more sleep. But when we look at the time period right before bed, I've broken it down into what I call the power down hour, right? So let's say you're going to bed at 10:00. Starting at around 9:00, I break that last hour up into three 20-minute segments. So 20 minutes for just stuff you gotta do, right? So maybe it's last-minute emails, maybe it's, um, you know, getting kids', uh, backpacks together, getting lunches together, finding sports equipment [laughs] , you know, uh, lots of stuff that you'd have normally going on in your house. I like to lay my clothes out for the next morning, things like that. So stuff that will reduce your stress the next day. Then 20 minutes for hygiene, right? So brush your teeth, wash your face, maybe take an evening bath or shower. And then 20 minutes for some form of meditation, relaxation, prayer, whatever gets you there. Read a book, watch a show. I don't honestly care what you do in that last 20 minutes, but it doesn't, it doesn't have a big level of engagement to it, right? So a lot of people say, "Well, wait a second, you said people can watch a show. What about scrolling on their phone?" Well, I'll tell you, the level of engagement that you have with your electronic device directly affects how well you're able to fall asleep or stay asleep. So basically, if you're trying to get your high score on Candy Crush, you know, you ain't trying to go to bed, right? And so what we want is we want people doing something that's relaxing, that's not important in their life, that's not intrusive in their life, so that way they can kind of trail off. That's why I personally always recommend reading a book, because what's nice about reading a book is you can just turn it over and be done with it, you know? And, and close your eyes and, and turn off the light and fall asleep, and it's, it's a very easy, simple process. But people should have some type of a routine before bed. What we don't want people doing is falling asleep on the couch, watching TV in their normal day clothes, right? Then they stagger, you know, they pull their clothes off as they're getting to their bedroom. Maybe they brush their teeth, maybe they don't, and then they just fall into bed. That's not really the, the process that we really want people to be doing, and that happens a lot more often than you think.
- RCDr. Rangan Chatterjee
The way I used to explain it to patients, Michael, was I would say, "Look, do, do you have kids?" And if they said yes, I would say, "Okay, so when your kids were younger, I'm guessing what you did was dim the lights-
- MBDr. Michael Breus
Right
- RCDr. Rangan Chatterjee
... lower the tone of your voice-
- MBDr. Michael Breus
Right
- RCDr. Rangan Chatterjee
... read them a story," right? Create this ambiance to say, hey-
- MBDr. Michael Breus
Yeah
- RCDr. Rangan Chatterjee
... you start preparing, as you say, runway to land the plane.
- MBDr. Michael Breus
Yep.
- RCDr. Rangan Chatterjee
We, we know that kids need a routine for bed.
- MBDr. Michael Breus
Yeah.
- RCDr. Rangan Chatterjee
Somehow as adults we think, oh, no, we're immune, right?
- MBDr. Michael Breus
[laughs]
- RCDr. Rangan Chatterjee
We're now grown up. We don't need a, a routine for bed [laughs] . And then you look at the statistics on how many people struggle with this, so you go, well, maybe there's something to that.
- MBDr. Michael Breus
[laughs]
- RCDr. Rangan Chatterjee
And I guess what I shared with you before about that one hour before bed for me-
- MBDr. Michael Breus
Yeah
- RCDr. Rangan Chatterjee
... you can think about that as a routine. That is-
- MBDr. Michael Breus
Absolutely
- RCDr. Rangan Chatterjee
... that is my... Well, it's my evening routine, and I guess going back to that theme before, that we get good at what we practice-
- MBDr. Michael Breus
100%
- 44:17 – 52:17
First-night effect and travel sleep: familiarity, hotel hacks, and the ‘sleep kit’
- RCDr. Rangan Chatterjee
What is the first-night effect?
- MBDr. Michael Breus
So the first-night effect is pretty interesting. So this is something that we see in sleep laboratories all the time, but a lot of people experience it. It's when you are in a new environment and your brain is not used to it, right? So I have, I experience this a lot when I travel. So for folks out there who do any travel, so, you know, summertime is coming up. A lot of people are about ready to get into the travel of it all and, or, or maybe they're already out there traveling and having a good time with it. When you don't have the same noises, when you don't have the same light, when you don't have the same environment, your brain, as you said, is an adaptive organ, right? It's an associative organ. So it's saying, "Where's my associated sleep environment?" Right? Because you're in a hotel or you're, uh, you have a different situation going on. So that's oftentimes what happens. First-night effect originally came from when we brought people into the sleep laboratory, and they would have a really crappy night the first night, so sometimes we'd have to have them in for two nights.
- RCDr. Rangan Chatterjee
Yeah. If and when I go to London for work-
- MBDr. Michael Breus
Right
- RCDr. Rangan Chatterjee
... I always stay in the same hotel. It's literally about familiarity. And I tell you, literally, it was four weeks ago, but the very first time ever I didn't stay in that hotel.
- MBDr. Michael Breus
Mm-hmm.
- RCDr. Rangan Chatterjee
Long story, I did not sleep well at all. Now-
- MBDr. Michael Breus
Yeah
- RCDr. Rangan Chatterjee
... there could be a number of reasons for that, of course. This is not like a randomized controlled trial. This is a-
- MBDr. Michael Breus
[laughs]
- RCDr. Rangan Chatterjee
... one-off experiment. But there will be someone listening to this, Michael, who does travel regularly to the same location for work.
- MBDr. Michael Breus
Yep.
- RCDr. Rangan Chatterjee
And if you're able to, and it works for you cost-wise and all that kind of stuff-
- MBDr. Michael Breus
Mm-hmm
- RCDr. Rangan Chatterjee
... I th- I definitely think it's a hack that people don't think about enough.
- MBDr. Michael Breus
I, I would even go one step further because I do the same thing. So I travel roughly every six weeks to Seattle, Washington. Um, and, uh, I s- not only do I stay in the same hotel, I stay in the same room.
- RCDr. Rangan Chatterjee
Yeah.
- MBDr. Michael Breus
And that familiarity lowers my stress level, right? So as an example, since I know the hotel I'm staying at and the room that I'm gonna be in, if my flight is delayed, I don't, it doesn't stress me out, right?
- RCDr. Rangan Chatterjee
Mm-hmm.
- MBDr. Michael Breus
Because I'm not trying to figure out where am I going. I know exactly where I'm going, right? I go into the hotel. The person who's the night person knows me because I come in every six weeks. They're like, "Hey, Michael." I'm like, "Hey, how's it going?" You know, they're like, "Oh, we got you room 245." I'm like, "Perfect. That's what I want." Like, and it just lowers my stress level. Remember, stress is one of those things that has to lower for sleep, right? S- another word for stress is anxiety. What are the three things that affect our sleep, right? Heart rate, temperature, and anxiety, right? So what you're tapping into is a way for us to add an additional layer that lowers our anxiety with that familiarity.
- RCDr. Rangan Chatterjee
Well, what's your take for people who, let's say, don't have that luxury, or they travel for work-
- MBDr. Michael Breus
Uh-huh
- RCDr. Rangan Chatterjee
... but they're constantly going to different-
- MBDr. Michael Breus
Sure
- RCDr. Rangan Chatterjee
... hotels and different locations. Could they-
- MBDr. Michael Breus
That's easy
- RCDr. Rangan Chatterjee
... perhaps bring stuff from home, like scents and things that they use at home or-
- MBDr. Michael Breus
You got it.
- RCDr. Rangan Chatterjee
Yeah.
- MBDr. Michael Breus
Absolutely. So if I travel for more than three days, I actually bring my own pillow. Um, so first thing that people should understand when you travel, like most of the hotels, um, they overstuff their pillows because then they have to buy them less frequently, right? And so what ends up happening is you've got the perfect pillow at home, and it works well because you're a side sleeper, you're a back sleeper, and your neck is just, just kind of right, but most of the time, when you go to a hotel, the pillows are overstuffed, so the loft in the pillow is very high, which pushes your head forward if you're a back sleeper, and that can make it difficult to breathe. So I bring a pillow if I'm staying for longer than three days. Um, number two, I bring an eye mask, right? I actually, believe it or not, I know this sounds a little crazy, but I am a sleep doctor, so I'm allowed to be a little crazy.
- 52:17 – 58:57
Food, alcohol, hydration, and glucose: lowering nighttime heart rate and preventing 3 AM wake-ups
- RCDr. Rangan Chatterjee
Speaking of, um, people who do things a little bit differently to others, Bryan Johnson came to mind early on in this conversation.
- MBDr. Michael Breus
Oh, yeah. Absolutely.
- RCDr. Rangan Chatterjee
Right? So you mentioned be-
- MBDr. Michael Breus
He lives right by me.
- RCDr. Rangan Chatterjee
Yeah. Well, you mentioned before these three things that need to come down-
- MBDr. Michael Breus
Yes
- RCDr. Rangan Chatterjee
... to fall asleep, okay? Uh, heart rate needs to come down, temperature needs to come down, anxiety needs to come down.
- MBDr. Michael Breus
You bet.
- RCDr. Rangan Chatterjee
Now, Bryan, for people who don't know, is a, a wealthy individual who is spending a lot of money each year trying to age as well as possible.
- MBDr. Michael Breus
Mm-hmm.
- RCDr. Rangan Chatterjee
Now, one of the things Bryan has said publicly for many years now is that his resting heart rate before bed is one of the strongest predictors of how well he's-
- MBDr. Michael Breus
Yep
- RCDr. Rangan Chatterjee
... going to sleep. So the lower-
- MBDr. Michael Breus
Right
- RCDr. Rangan Chatterjee
... his resting heart rate, the better his sleep quality is. Now, he says that the way he does it is he stops eating his final meal at 11:00 AM. Not PM, 11:00 AM. But-
- MBDr. Michael Breus
He's crazy
- RCDr. Rangan Chatterjee
... right? But, [laughs] okay. But to be fair to Bryan-
- MBDr. Michael Breus
[laughs]
- RCDr. Rangan Chatterjee
... I think he would acknowledge that not everyone has to do that.
- MBDr. Michael Breus
Yeah. And I learned a lot from Bryan Johnson, which is just, uh, which is kind of interesting for somebody like me, 'cause he's, he has no medical background whatsoever, right? He's running this experiment on himself. It seems like he's kind of gone off the deep end, if I'm being super honest with you. Um, but he is the biggest sleep advocate I've ever seen.
- RCDr. Rangan Chatterjee
[laughs]
- MBDr. Michael Breus
Everywhere he goes, he's like, "Sleep, sleep, sleep." And I'm like, "Let's go, brother." [laughs]
- RCDr. Rangan Chatterjee
[laughs]
- MBDr. Michael Breus
So I, I'm, I'm a fan of his, but I agree with you. Stopping food at 11 o'clock in the morning would be difficult, but it, it's, it, it shows an interesting-
- RCDr. Rangan Chatterjee
Yeah
- MBDr. Michael Breus
... point, right? Which is the met- the metabolic process is probably increasing his heart rate, which is probably affecting his ability to fall asleep. It's also increasing his core body temperature because your body heats up when it's digesting food. So I think what he's saying makes a lot of sense, I'm just not sure practically how we do that. So that's why I have people stop food, water, and alcohol three to four hours before bed.
- RCDr. Rangan Chatterjee
So let's just talk about that then. How do you get the body calm before bed? How do you get that heart rate down?
- MBDr. Michael Breus
Yes.
- RCDr. Rangan Chatterjee
So you mentioned that food. How important is it to stop eating in the hours before bed, in your opinion?
- MBDr. Michael Breus
I think it's huge, um, and I think it's a big, big issue that a lot of people don't look at. So a lot of people might have their dinner at a normal time, let's say 6:00, 6:30, 7:00, but what a lot of people don't take into account is snacking, right? And so a lot of people are late-night snackers, and they end up eating things that are so complex that their body is digesting and that makes it very difficult to sleep. I mean, Rangan, I've got a one patient who actually wakes up in the middle of the night to eat, and then eats something, and then is able to fall back asleep. We, we, we started to look at it, and what we discovered was is they were having a blood sugar drop in the middle of the night, and then their cortisol was kicking into gear and waking them up. A- and so we keep now a few saltine crackers by her bedside, and guess what? She wakes up, she has a little orange juice. She's diabetic, so she has a little orange juice there, a little cracker. She takes it, she's able to fall right back to sleep. That's the extreme case, but for most people, again, let make sure you check with your doctor, you should probably stop all food three to four hours ahead of time. Alcohol for sure you want to have stopped three to four hours ahead of time, uh, and probably water at least two hours ahead of time, and make sure you go to the bathroom at least once before you, you lay down.
- 58:57 – 1:20:57
Wearables, sleep stages, aging, and menopause: what data can (and can’t) tell you
- RCDr. Rangan Chatterjee
Okay. Rachel says, "How accurate are the sleep scores on-
- MBDr. Michael Breus
[laughs]
- RCDr. Rangan Chatterjee
... fitness devices and wearables?"
- MBDr. Michael Breus
S- I love this question. So to be clear, they are not. They are not accurate. However, they're still useful. So and that sounds like a little bit of an oxymoron, me saying they're not accurate, but they're still useful, so let me explain to everyone. So you can see I've got an Oura Ring on, I've got an Apple Watch, you know, people have got Fitbits or Whoop straps or whatever the tracker of the day happens to be, right? So I wanna be super-duper clear. Trackers, and if you look in the medical literature you can find the studies, are decent at telling you when you fall asleep and when you wake up. They're not particularly good at depth of sleep, so they're really not good at telling you how much deep sleep you got and how much REM sleep you got, and the reason is is 'cause we measure those from brainwaves. We measure those from EEG. It's really hard to get EEG from your finger, right? From your wrist. So what ends up happening is they take a piece of data that is accurate a- in those particular areas, and then they approximate what they think sleep stage you might be in. And so what ends up happening is you have a bit of variability there. So what I tell people all the time is do not, I repeat, do not look at your tracker information every day. First of all, you're gonna drive yourself crazy. Um, I'd say once a week, probably Sundays is probably the best day. You wanna look at across the week, and you want to look for the trend. You do not wanna look for individual numbers. Dude, I can't count the number of people who walk up to me and they're like, "Dr. Breus, my ring says I got a 37 last night. Am I gonna die?" Well, yeah, you're gonna die, but probably not from that, right? You know, like, uh, "I only got 37 minutes of deep sleep." Well, what did you get the night before? "35." Okay, well, what did you get the night before? "40." Then you're fine, right? Like, it's being consistently inaccurate, right? What I wanna know is if you went from 40 minutes every night to three minutes, I wanna know what happened that night.
- RCDr. Rangan Chatterjee
Yeah.
- MBDr. Michael Breus
Right? So I'm looking for the delta. I'm looking for the deflection in the data. If you're consistent, even if it's consistently inaccurate, I don't think I care. However, I will tell you that I think these are gonna get more accurate as time goes on.
- RCDr. Rangan Chatterjee
Yeah.
- MBDr. Michael Breus
Um, I feel like we're starting to see, um, these companies are putting out bigger, better algorithms. They've got more AI, more machine learning behind it, and I think, I would argue probably in 12 to 18 months we would probably start to see the accuracy level start to increase in many of these, uh, you know-
- RCDr. Rangan Chatterjee
Yeah
- MBDr. Michael Breus
... uh, tracking devices. Um, so I'm, I'm a fan, but I'm not like live or die by your data type of, type of person. At least this data, because it's got so much variability to it.
- RCDr. Rangan Chatterjee
Yeah. Yeah, I spoke to Tommy Woods, uh, recently.
- MBDr. Michael Breus
Uh-huh.
- RCDr. Rangan Chatterjee
He's a neuroscientist, medical doctor, and he also, like you, likes the approach that you look at this stuff once a week, right?
- MBDr. Michael Breus
Yeah.
- RCDr. Rangan Chatterjee
You look at it for trends, not for that day-to-day variation. A- and it can drive you crazy, and it can drive certain personalities more crazy than others.
- MBDr. Michael Breus
Yeah.
- RCDr. Rangan Chatterjee
Uh, and of course, going back to the three things you want lowered if you're gonna sleep, right, one of them is anxiety. So if your wearable-
- MBDr. Michael Breus
[laughs]
- RCDr. Rangan Chatterjee
... is increasing your anxiety-
- MBDr. Michael Breus
Don't
- RCDr. Rangan Chatterjee
... it may be informing you of your sleep, but it may not be helping you get more sleep. And, and again-
- MBDr. Michael Breus
Exactly
- RCDr. Rangan Chatterjee
... to be clear, I like wearables, right? I personally choose not to wear them all the time because I don't ever want to become dependent on these things.
- MBDr. Michael Breus
Sure.
- RCDr. Rangan Chatterjee
But I have learned a ton, and I think one thing I'm, I'm sure you've found with your clients as well, Michael, is that when a wearable shows you what alcohol late in the evening is doing to your sleep-
- MBDr. Michael Breus
[laughs]
- RCDr. Rangan Chatterjee
I've seen that change people's alcohol habits-
- MBDr. Michael Breus
Yep
- RCDr. Rangan Chatterjee
... like nothing else.
- MBDr. Michael Breus
I bet.
- 1:20:57 – 1:53:16
Special cases and rapid-fire Q&A: shift work, pregnancy, ADHD, restless legs, and a 5-step sleep reset
- RCDr. Rangan Chatterjee
Okay. Then there are a series of questions to do with supplements and prescription medication.
- MBDr. Michael Breus
[laughs] Okay. Sure.
- RCDr. Rangan Chatterjee
So-
- MBDr. Michael Breus
Let's talk
- RCDr. Rangan Chatterjee
... le- let's start with Dave's question, which is, "Since taking SSRIs-"
- MBDr. Michael Breus
Yep
- RCDr. Rangan Chatterjee
... um, a very common, uh, you know, class of what would colloquially be called antidepressants, for people who don't know that term. "Since taking SSRIs, I wake up at night a lot."
- MBDr. Michael Breus
Yep.
- RCDr. Rangan Chatterjee
"Do you have any idea why?"
- MBDr. Michael Breus
Great question. So first of all, to be clear, I am not your doctor, so I cannot tell you what to do or not do about your medications. However, if you were a patient that came into my clinic and you said to me these were some of the problems, one of the very first things that I would look at is what is the timing of your administration of your medication. As an example, some SSRIs are very alerting. Uh, for example, something called Wellbutrin, which is actually technically an SNRI, um, is one of those medications where if you took it in the evening time, it would be disruptive of your sleep. So in some cases, one of the first things I do is I tell the patient, "Hey, who is your prescribing doctor? Let's talk with your prescribing doctor and say, 'Can we take this medication in the morning?' Or if I'm taking it in the morning, 'Can I take it in the evening?' And see over the course of a week, does that have a big effect?" So that's step number one, is timing of administration. Step number two is talking with your doctor about could you change to a different sleep-friendly SSRI, because different people react to different medications in different ways, and so you might find one that still works with your depression and anxiety, but doesn't have a level of disruption to your sleep, right? Now, in the most extreme cases, um, there are situations where we would actually consider administering a sleeping tablet during that particular period of time. So as an example, if I have somebody who's a bipolar person, right, who's on significant medication for their mental health situation, they may require a Stilnox or an Ambien or a, a, a sleeping tablet because of their mental health situation. And I wanna be very, very clear, there is nothing wrong with taking a sleeping tablet. If you and your doctor have come to the conclusion that that is something that makes sense for you in your particular situation, don't beat yourself up about it. Take the medication as directed, right? I, I tell people all the time, 'cause a lot of people come to me and they're like, "I don't wanna take a sleeping pill. I don't wanna get addicted to sleeping pills." I'm like, "Totally understand where you're coming from. Let me give you a scenario." I believe that insomnia, in a lot of ways, is like high blood pressure, right? So you can eat right, you can exercise, you can still have high blood pressure and need to be on a medication to lower your blood pressure. Look, if you do all the right sleep hygiene things that we've been talking about, you get in bed at the right time, and you still can't sleep, you might need a sleeping pill. Does that mean you're addicted? Is anybody addicted to their blood pressure medication? Probably not, right? So I don't want people to, uh, you know, make these assumptions and necessarily go in the, in the wrong direction here. Um, but yes, there are situations where if you're taking an SSRI, I would talk with your doctor about timing of administration and maybe swapping it out to see if there's something else that could be, uh, more effective and less affecting, um, your sleep.
- RCDr. Rangan Chatterjee
Some, uh, sleep researchers, Michael, would say that if you fall asleep after taking a prescription sleeping medication-
- MBDr. Michael Breus
Right
- RCDr. Rangan Chatterjee
... you're not getting the same quality of sleep as you might do if you were falling asleep naturally. What's your take on that?
- MBDr. Michael Breus
So I would argue that they're correct, but some sleep is better than no sleep. So I, I, I agree with you that most of the medications out there have an effect on what we call sleep architecture.
- RCDr. Rangan Chatterjee
Yeah.
- MBDr. Michael Breus
So they change the amount of stages of sleep that you get. So as an example, if you're taking an older something, what we call a benzodiazepine, uh, which would be like a Restoril or a Xanax or an Ativan, um, those medications actually change deep sleep. You actually get less deep sleep. Uh, in, in fact, um, SSRIs, like what we were talking about before, those decrease REM sleep. So there are many different medications out there that can have a pretty decent effect on your deep sleep or your REM sleep, and you need to just be thoughtful in understanding those.
- RCDr. Rangan Chatterjee
Hannah is asking, does magnesium-
- MBDr. Michael Breus
[laughs]
- RCDr. Rangan Chatterjee
... really help with sleep?
- MBDr. Michael Breus
Such a great question. So here's what we know, is if you have a magnesium deficiency, it does. If you do not have a magnesium deficiency, it's not nearly as helpful. Now, here's the thing. Most people [laughs] have a magnesium deficiency.
- RCDr. Rangan Chatterjee
Yeah.
- MBDr. Michael Breus
Um, and so the very first thing I... And so this gets us into the topic of supplementation, which is one of my favorite topics, and my very first thing I tell everybody that talks to me is, "Go do blood work." Okay? Like, remember, the whole idea behind supplementation is if we're not getting it in our diet, then we supplement it with these powders or pills, which are usually a combination of vitamins, minerals, and herbs, right? Now, to be clear, depending upon what you're trying to supplement, you don't oftentimes know unless you do the blood work, so blood work becomes very important. So before anybody does any supplementation, here's the three to four things I would recommend. You wanna look at your magnesium, you wanna look at your vitamin D, you wanna look at your iron, and you wanna look at your melatonin if you can. Melatonin's a little bit more difficult to- from a blood work standpoint. A lot of times you have to do a saliva test, and you have to do it at night, 'cause melatonin [laughs] only comes out at night. But if you just did those three, which is magnesium, vitamin D, and iron, uh, if you have deficiencies in any of those areas, I would argue, dude, 15 to 20% of the time, all I do is fix those deficiencies, sleep gets better, and I don't have to do anything else.
- RCDr. Rangan Chatterjee
Yeah. I think the problem with magnesium, certainly if I look at it through a UK lens, it's not that easy. If you went to your NHS primary care doctor and asked them for a magnesium check, you, you know, I, I don't think it's gonna be-
- MBDr. Michael Breus
Might be hard to get
- RCDr. Rangan Chatterjee
... easy for people to get. And, and also I think with magnesium, it's not just a serum magnesium you're looking for. I think to get a really accurate idea, you've gotta look at red cell magnesium and-
- MBDr. Michael Breus
Yep
- RCDr. Rangan Chatterjee
... and so I, I get it. At the same time, I don't think for most people supplementing magnesium is harmful.
- MBDr. Michael Breus
I agree with you. There's only one caveat, is for some people, if you have too much magnesium, you can get diarrhea, and that can be problematic as well. So I, I try to tell people keep it within, like, a 200 to 250 milligram range. It may change during the summertime. One of the things that I've looked into the literature on is that if you're a heavy sweater, uh, and you do a lot of outside activity, you may need extra magnesium. Um, so as an example, when I work out every day, and I sweat a ton, and so I lose a lot of magnesium. So I only take three supplements a day. I take magnesium, I take vitamin D, and I take omegas. That's it.
- RCDr. Rangan Chatterjee
For people who wish to try a magnesium supplement for sleep-
- MBDr. Michael Breus
Mm
Episode duration: 1:53:16
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Transcript of episode 95CxiesAKNY
