The Importance of Sleep - with Petteri Lahtela | The Empowering Neurologist EP. 86

Well, hello everyone. Dr. David Perlmutter here. Welcome again to The Empowering Neurologist. About a year ago, I was at a conference and people were all talking about this ring that they were wearing that was giving them information about their physical activity and more importantly about their sleep. We know there's a lot of wearable devices out there, certainly become very popular, but I was very fascinated with what was called— is called the Oura Ring, O-U-R-A Ring. So my wife and I ended up buying an Oura Ring. Here's what it looks like. Doesn't look like anything exciting, but interestingly, you'll notice that there are some transducers within the ring itself that sends information that is then uploaded to your smartphone. What we've been using the Oura Ring for has been mostly to evaluate the length, duration, and quality of our sleep. I wanted to learn more about the Oura Ring, so I decided I would reach out to the CEO, the creator of the device, Peter LaTella, and he is the subject of our interview today. Let me tell you a little bit about him. He is the CEO of Oura. and the co-founder as well. He is what we call a serial entrepreneur. He's been involved in this sort of idea over the past 20 years, creating and marketing high-tech products, as well as, in this case, building an international business along with other international businesses. Oura, the Oura Ring, brings together his passion for developing products for real human well-being understanding physiology and creating products that do good and products that people love. Oura is the world's first wellness ring. It combines obviously style and comfort— you don't really know you're wearing it— along with an incredible level of technology that we are going to explore today, technology that has been 3 years in the making. So let's just jump in and say hello. Well, hi, Petteri. Really glad to have this opportunity to chat with you today.

Great to meet you here. Thanks for the invitation, Doctor.

As I mentioned during the intro, we learned about the Oura Ring a year ago. We ended up, my wife and I, buying them, and then we've had really some interesting experiences with them. I'd like first to take our viewers back to a time when Either the light bulb went off in your brain or somebody's brain that this might be a cool thing to create. How did that all get started?

Yeah, so there are several themes that, that kind of are in the core essence of creating this kind of product. One of them is my own background in creating IT systems for chronic diseases prevention and management. In which context I learned that how this current healthcare system is not very capable of helping people to prevent the onset of chronic diseases. And the other theme comes from being in international business for more than 20 years. We have seen so many people burning out in their work and not kind of being capable of leveraging their full potential to live up their dreams. So that's another kind of theme which actually they both support each other. So we wanted to develop something that would help people understand that how their body is responding to their lifestyle so that they could find daily choices and develop habits that would help them to really leverage their full mental, physical, and emotional potential to live up their dreams, to kind of unleash their full potential. So those were the themes for us to start developing the solution. So we wanted to develop something that integrates to daily life of each individual. And, and then it's a tool that helps you to reflect, self-reflect, that what's happening in my body, how my body is responding to whatever choices I do during the day. And we figured out that, that the measurement during the night, not only the sleep quality measurement, but also the body responses They reflect to us that how my daily choices affected my sleep and the restorativeness of my sleep and what other things we can derive from that, those insights.

So, you know, I would say that the ring obviously gives information about your daily activity as well, your, you know, how active you are, et cetera.

Yes.

But what did you do just now? You focused on your opening statement here on the importance

Yes.

And I really would love to explore that because it's so underrated in our modern society. In fact, it's almost derogated to the— coming into, I think, conflict with our sense of being creative and being productive, that people think the less sleep, the better. I'm going to stay up late, get up early, and really, you know, hit it hard. But I think we're seeing a real revolution in our understanding of the importance of sleep. And I think Dr. Matthew Walker is also accredited, I think, with helping to bring about this incredible new level of understanding and appreciation as to its value. And as I said in my introduction, getting this information about my own personal sleep has been extremely important and helpful because, as you say, as you just mentioned, so important that I can then modify certain of my lifestyle choices And see what immediately the next, that night, see what, uh, what effect that has on, on sleep in this case. So you really did, it looks like you really spent a lot of time and dedication targeting specifically sleep. Why did you do that?

Yeah, so, um, what I found out when working in the context of chronic diseases and, and especially trying to figure out the, the the actual reasons why people develop chronic diseases. What are the reasons for the onset of this disease? So pretty common theme was that the different stressors of life, they kind of caused this kind of prolonged state of imbalance, especially in the autonomic nervous system. So, and then depending on the individual and their, their own, of course, genotype, phenotype, chronotype, and so on, the body reacted in different ways. So some of them started to develop chronic disease, some of them reacted in other ways with depression or, or some other ways. In any case, those stressors that each one of us have in our life, we started to look at them from the perspective of recovery. So how we can help people understand what are the actions that you could take to ensure full recovery from those stressors that you are experiencing in your life. And of course, from the perspective of recovery, sleep is one of the core factors there. So we had to get access to the data during the night, understand in high accuracy and in a very comfortable, non-intrusive way as a longitudinal perspective that how you sleep and what kind of patterns you have in your sleep. And also even going deep into the biology to understand how you are, how well you are in sync with your chronotype and the timing of your sleep and waking up and how consistent it is. So going to the root causes that affect sleep and the restorative of sleep. So all that comes from this kind of recovery process of the stressors, both short-term and long-term.

Well, it's interesting then that, you know, you're really characterizing sleep as a recovery modality. You know, allowing us then to be able to tolerate the various influences, stressors, if you will, during the course of the day. We know that one of the benefits of sleep that was only recently described by researchers at the University of Rochester is the activation of what's called the glymphatic system. Yes. And that is the system within the brain that allows itself to purge itself of toxins, if you will.

Exactly.

And I wonder if you could walk through when in the course of sleep that occurs and why it's important.

Yeah, it's great that you mentioned that because actually here in Oulu, where our company comes, in the University Hospital of Oulu, they have been doing this same research at the same time. And actually, they have co-written those articles with related to the glymphatic system. So our rings are being used in that research. And that exactly kind of describes our intent and willingness to be in deep understanding of the actual restorative of sleep. And actually what we found out is that there is some synchronization between sleep stages And lymphatic circulation, or kind of effectiveness of this system. But also, what was even more meaningful for me was that the revolution of finding that HRV, the heart rate variability, plays an important role there. Because as we know, there's no lymphatic system like elsewhere in the body. But this glymphatic circulation is actually the movement of the liquid between the brain mass. It's modulated by heart rate, breathing rate, and HRV is a kind of modulator that brings this kind of randomness into that cleansing process in the brain. So, as mentioned in those articles, the brain mass actually shrinks up to even, even 60%. So there is more space for this cleansing mechanism to happen. And then, then it— this movement of the, of the, this liquid in between, it becomes important from this cleansing mechanism perspective. And for me, it was very meaningful finding that HRV plays

And this typically occurs during deep sleep, non-REM?

Yes, that's the current understanding. But as we know, this sleep staging is a pretty old kind of mechanism to understand sleep. So even some papers, they say that there are at least 21 different stages of sleep. So, so, um, um, I wouldn't directly put them in, in this kind of a current, uh, sleep staging of deep sleep, REM sleep, light sleep, uh, connotation, because there seems to be much more happening. And we are not yet there to really understand how these different stages actually, what they indicate and how in relation to depleting pattern your heart rate pattern, your HRV pattern, together with all those other signals that we can get from EEG, EOG, and so on. So how they actually sync and what they eventually tell about the actual glymphatic system effectiveness and therefore the restorative needs of sleep.

I'd like to get back, if I could, to the notion that understanding this, where a person is, and getting this information allows that individual to make changes. And, you know, you indicated that the impetus for this was looking at what's going on globally in terms of chronic degenerative conditions, which the World Health Organization ranks as the number one cause of death on the planet.

Yeah.

You know, we in our world are concerned that it may be here in America that The number 3 cause of death after coronary artery disease, cancer, is Alzheimer's disease. But, you know, in many regards, these 3 things are all lifestyle-related.

Yes.

Certainly, coronary artery disease and Alzheimer's have a strong relationship to inflammation, but also have a strong relationship, along with diabetes, to non-restorative sleep. Yes. But to get back to the idea that having this information available via the Oura Ring technology allows people to make changes. I have been surprised at times to note that if indeed there is some activation of the glymphatic system during deep non-REM sleep— let's take a look first at this first image. This is— I sent you from my iPhone.

Yes.

screenshot of a particular night of my sleep. And what can you tell us about this? What would you learn from this data? It looks like my deep sleep, which generally in most people occurs early on in their sleep cycle, is not as good as it perhaps could be.

Yes. 20 minutes of deep sleep And 1 hour 26 minutes of REM sleep for that night. And total sleep time, 7 hours 8 minutes. Efficiency, 92%. And there seems to be a latency of 18 minutes. So it's pretty— it took a while for you to fall asleep. I can see that there is some delay in getting to the deep sleep. So there may be some jet lag or something that is still affecting or something else. Because normally, normally the, the, the maturity of the deep sleep comes pretty soon after we fall asleep. So there's something to do with the circadian alignment there, that what is your optimal bedtime.

Typically, um, my latency is about 3 or 4 minutes. So

yeah, yeah.

What I'm going to tell you a little bit about that one night that, that our viewers just saw. And I was up a little later than I should have been. And even worse than that, I was finishing, uh, a— putting together a keynote presentation. So I was on the computer and made the mistake of not having the, uh, the amber light on the mode on the computer.

Yeah.

And, uh, did it affect me? It looks like it did. And the following night, I didn't do any work on the computer. I read with natural light, uh, or rather incandescent light for a little while, but I put it away and I went to bed earlier. So let's have a look at that image and then tell us what you see as a difference.

Yes, there is a big difference, um, there. So, so definitely what you described, it has had at least 2 effects. So the melatonin secretion hasn't been that effective, and also that you have kind of lost this first part of deep sleep. Because as we know, in our body we have a kind of intrinsic memory so that if you keep consistent bedtimes and consistent wake-up times, then your body starts to learn that, okay, this is the time for me to go to the deep sleep. And if you kind of lose that, that window, then you lose the chance to get the amount that you otherwise would get. So that's why the consistency in bedtimes is so important.

And to me, it was very important. And having a family history of Alzheimer's disease and knowing that one of the things in terms of function of the glymphatic system is helping reduce beta amyloid, I think, again, Dr. Matthew Walker has talked about that and demonstrated that in the cerebrospinal fluid of individuals who were sleep deprived. Yeah. A dramatic increased level of amyloid, and I think perhaps phosphorylated tau, though I'm not sure. But nonetheless, these abnormal folded proteins that are associated, at least, with Alzheimer's disease. So, you know, my mission, my own life, not mentioning just my outreach, of course, for my own self is to do what I can to reduce my risk of Alzheimer's. Certainly, offloading the beta amyloid risk factor is important. Hence, the need to make sure I get enough of that deep sleep because it's related to the glymphatic system.

Exactly.

What I did that night, again, was I made changes the very next night, which I just described. With the use of the Oura Ring, I was able to see that my changes had an impact. So often, we make changes in our lifestyle and, well, we're starting to take this nutritional supplement. whatever it may be, and hoping just based on what we read that that's going to do some good. But I think that what we really need, and you have hit upon it from the beginning of our conversation, we need the feedback, uh, in terms of what we're doing. And it's so reinforcing to get that feedback. And I want to just say one other thing and hope that you'll comment on it. We live in a time, uh, that we're seeing these positive feedback loops. And what I mean by that is When we don't sleep, our decision-making ability is compromised, number one. Number two, blood sugars are elevated. Number three, we gain weight. All of those things then feed back, no pun intended, to compromise our sleep, and we get into this vicious cycle where we're not sleeping well, our blood sugars are going up, we're gaining weight, and again, we're not sleeping well, so it gets worse and worse with time. I think that's really kind of fundamental as it relates to inflammation, and it relates to some of the most common causes of death on planet Earth. So again, I'm praising you here for calling it out and giving people a powerful tool to get to know what is the momentary influence of these lifestyle decisions that they're making in terms of How did you sleep last night? And then, you know, raising our awareness as to why that's important. You've been talking about hypnograms and I think we have, I think I sent you an image of one of my hypnograms. What can you tell us about that?

Yeah. So, so the hypnogram is, is one of the ways to describe exactly those sleep stages, that how much deep sleep, REM sleep, light sleep, and how much wakefulness there is during the night. So, during the time you are in bed. So there are multiple different parameters, or so-called contributors, that we can tell about that time in bed. That, okay, how quickly you fall asleep and also how much you get certain sleep states, and also what is the overall pattern of your sleep. So Normally, when the circadian alignment is right and you have consistent bedtimes and so on, then we see most of the deep sleep coming in the first half of the night. And then most of the REM sleep comes on the second part of the night. And depending on your chronotype, whether you're a morning person or evening person, then especially for morning persons like myself, And these morning hours are, let's say, the sleep is lighter. You get most of REM sleep, but you also wake up easily at that time. And because also your kind of stress hormones starts to pick up and starts to wake you up. So all these are kind of interlinked into this, I would describe, 24/7 hormonal cycle. Or hormonal cycles that are happening in our body. So this hypnogram kind of tries to describe that whether you were— whether your body was in right state to sleep well and get restorative sleep in this time window that you were in bed. And also referring to this intrinsic memory that how consistently you go to sleep. same time and wake up at the same time. So how the patterns change. And also, like, in today's world, many people suffer of this social jet lag so that they go to sleep later during the weekends and also wake up later during the weekends. And we have actually shown through our studies and research papers and articles that after 2.5 years of collecting our data with tens of thousands of users, we can show that it has huge effect actually at how consistent your bedtimes are. And for those social jet laggers, that their, for example, resting heart rate, it never drops to the same level during the weekdays. than for those who don't suffer of this social jet lag.

So let me just make sure that's really clear then, and that is, you call this social jet lag. You haven't crossed any time zones, but you've imparted on your physiology this stress of suddenly going to sleep at a certain time for 5 days a week, and then on the weekends you disturb the system. It's as if you took a trip. Yes. 2 or 3 hours different time zone.

Exactly, yes.

And you're seeing some effects from— and I think you said in terms of heart rate.

Yes, exactly. Even the resting heart rate. So the Oura shows the lowest resting heart rate, what you get during the night. So for those who are kind of social jet laggers, we can see from the data that their resting heart rate curves over the weekdays then kind of they start to go down from the weekend, but they never reach the level as for those who live more consistent life. So it means that in practice—

So if you're not practicing, you're not challenging yourself, then you have a, a lower, uh, heart rate, uh, when you're sleeping. I think that I'm— I sent you an image of my heart rate. Let's take a look at that.

Yes, yes, yes, yes. There is the picture of, of your heart rate over the night, and it seems that About 4:00 AM, you have reached the lowest value, which is very meaningful. So 43 at that night at 4:00 AM, and you woke up about 7:26. So you had good time to kind of recharge your batteries at that night because that moment when your body reaches the lowest resting heart rate, Mm-hmm. The rest of the hours that you sleep, it's really like recharging your batteries. So for those people who reach their lowest resting heart rate just before they wake up, they basically lose all that kind of a possibility to recharge their batteries during the night. So the most optimal— and actually in our website, there are articles that describe that what kind of models of your resting heart rate during the night, what are the kind of most optimal for you to get restorative sleep. So even this lowest resting heart rate indication, it tells a lot about the quality of our sleep and the restorativeness especially.

Some people say that they are okay getting up early or they feel like they've slept an enough. But it— but in looking at these hypnograms and just the general knowledge base, it looks like we tend towards more and more REM sleep later in the night as opposed to the deep sleep happening earlier.

Yes.

So if you do get up really early to be productive, you're compromising that really important time for REM sleep, one would think. Why is it— why is REM sleep looked upon as being so valuable?

Yeah, you mentioned earlier this Alzheimer's disease, and it seems that not only the deep sleep but also REM sleep contribute to this glymphatic circulation. And from a kind of mental recovery perspective, REM sleep is really important. And what we've seen through our data, that for those people who have lots of, lots of kind of mental load from their work or whatever is causing that, they seem to need more REM sleep. And therefore, if you always kind of shorten your night, then you lose this chance to cleanse your brain and kind of recover from this mental load, which is the basis for the clarity, mental clarity during the day as well. So, so we wouldn't encourage people to kind of shorten their sleep because it's, it's, um, I would say that it's so important to understand your own, uh, chronotype. So whether you are a morning person or evening person or intermediate, like Dr. Breus is talking about this, uh, lion or, or wolf or dolphin and so on. So we can describe them in different ways, but anyway, there is there is biology behind so that this, our internal clock is in the body level, it's in the cell level, it's in the organ level. And we should appreciate that and kind of understand what is optimal for us because it has huge effect on our hormonal balance and the sleep quality and the restorative use of sleep.

You talk about the chronotypes. and, uh, whether we're a morning person or a night person. And I wonder, is there any data you can use from what's put out by your Oura Ring to determine what you are?

Yes, actually, uh, about a year at least, we have, we have provided so-called optimal bedtime calculation to our users. And, and when we released that, uh, in the beginning, uh, maybe 1/10 or 15% of the users got this optimal bedtime suggestion. The others got just a recommendation. And the reason for that was that those who couldn't get the optimal bedtime suggestion didn't live consistent enough life to be able to calculate what's your optimal. But then what happened in just a few months was that then already more than 50% of our users started to get optimal bedtime suggestions, recommendations. So in practice, it meant that they followed the guidance by the app to build more consistency in their life. And eventually, they started getting this optimal bedtime calculation. So one big reason for us collecting this let's say, very rich data from all our users is to use it for this personalization, personalized guidance to help each individual to find what is optimal for them. Because there is no such generalized guidance that could be given. There are some— we of course try in, let's say, National Sleep Foundation is willing to give some guidance that, okay, what we can tell as recommendations for people about sleep. And basically the only one is that adults should sleep about 7 to 9 hours every night. But then already in the next sentence, they say that there are people that survive well with less and those who need more. So we thought that it's best to To see each one of us as unique individuals and then have a system that reflects back in your context that how your body is telling about this.

Well, I think it's good to also look at epidemiologic information. And like with so many other parameters, we see that with sleep there is what we call the U-shaped curve. In terms of Alzheimer's risk, for example, under 7 hours a night in general is associated with increased risk. But interestingly, greater than 9 hours is also associated with increased risk of Alzheimer's.

Yes.

Now, what we don't know, and I think it's really a very important question, is, is cause or effect? Is Alzheimer's or other— are other neurodegenerative conditions early on affecting sleep regulatory centers in the brain? Or is the fact that we ultimately develop a disease, a neurodegenerative condition, a manifestation of not just our sleep issues, but other lifestyle choices conspiring to ultimately manifest that disease? So very interesting. So we didn't touch upon, and I'd like to in the time we have left, what are you learning about in terms of daytime activity?

Yeah. From the very beginning, we have kind of tried to form a picture of 24/7 view to our life and helping people to understand this balance between rest and load. So we took it as our first step to build a as holistic a picture as possible to this, uh, that how much rest you get during 24/7, uh, kind of 24 hours. So first part of that, of course, is getting sleep, but then, then we do certain actions during the day as well, like meditation or taking naps. or even walking outside in nature. That kind of restorative moments exist in our daytime as well. And we are passionate to build this kind of more holistic picture to our users that, okay, what kind of moments during the day would help you to build more consistent kind of a lifestyle that would help you to build this balance between load and rest? And I can show you one example. We have this so-called moment feature in our app that we released about half a year ago, and with that one you can do also measurement during the day. So in this one, I can send you the screenshot later on, but this is a 20-minute session, presence session, For me, it shows my heart rate during that session. Also, it shows my HRV figure during that session. And also, the commercial app doesn't show this yet, but it also shows the peripheral temperature change during that 20-minute session. So we try to help people to kind of understand that How these daytime moments that you select yourself, how they help you improve your sleep and restorative of your sleep. Because we have done early findings that, for example, doing relaxation exercise or meditation a certain time of the day, it has huge effect on how your sleep quality kind of improves. But are you

able to look at, for example, changes in heart rate variability acutely during an exposure to nature during meditation? I mean, is that data that you're able to harvest?

Yeah, that's exactly— we are going to that direction that we want to, let's say, build this kind of coherent view to those biosignals that we get, that what they tell about That how your body is responding to these moments and also how they build you, how they help you to build kind of habits that help you improve your sleep overall. And so there are multiple different kind of findings. And first, we have concentrated to the, let's say, 3 or 4 hours before you go to sleep, because for example, the mealtime and meal timing and the amount of food that you eat and the quality, of course, affect your sleep quality. So if you eat too late, too much, or the kind of quality that your metabolism system doesn't handle well at that time of the day, then it has huge effect on your sleep quality. Yeah. So you mentioned about these causal relationships That is what we want to bring up and bring visible to users so that they would get this feedback loop to understand that, okay, how this action, how this choice, how it helped me.

You know, we live in the information age, and it can be, for many people, overwhelming. You know, we talk now about orthorexia where people are just over-the-top concerned about their food. It's good to have a level of understanding which translates from a level of concern, and then becomes implementation. Some people might not want to get so engaged with technology, for example, because it's just too much information. I would say that that might describe me to some degree. I have been really comfortable with the information I'm getting from your technology, from the Oura Ring, because, again, it gets back to the immediate understanding of, through feedback, what my lifestyle choices are doing. Yeah, it's good to know what we should be eating moment to moment, whether that's based on analysis of my microbiome and its interplay with my genome, how that relates to my chronotype, etc.

Sure.

That can be very overwhelming when you couple this with other levels of understanding via technology.

Yes.

I've been very, very satisfied with this technology. It's really been helpful for me, if for no other reason at this stage of the game, that it has really doubled down on my understanding of the value of restorative sleep. Mm-hmm. I think that's a really important concept because it isn't just the length of sleep, the time you are in bed, but it's what's happening when your eyes are closed and you go into sleep. What are the parameters that are unique to you? Then what are your daytime lifestyle choices, and how do they influence the level of restoration that you get during that activity? The other thing I'm really impressed by is how dynamic your technology is when you now are describing to All of our viewers what's in the works and what the future looks like. So, um, you know, it's, uh, it's really, I think, exciting that we can, uh, we can participate in that moving forward and really look forward to these, uh, you know, advances in your technology that are going to be made available to us. I am particularly looking forward to what we just talked about, and that is gaining almost a moment-to-moment or hour-by-hour, probably more meaningful. understanding of things like my heart rate variability as they relate to my day-to-day experiences, especially nature exposure and meditation. Yeah. We have a new book called Brain Wash, and those 2 choices are really explored in great depth because I think people are just not participating in those activities as much as they could, and they are powerful. I, you know, they're, they're right up there with sleep, perhaps not as powerful as sleep, but they are powerful nonetheless in allowing us to reduce those mechanisms like inflammation that are so fundamental in terms of these chronic degenerative conditions. And that circles back to our original time together today. So

yes.

We will look forward to hearing more from you as this develops. I think we should agree that every 6 months or every year we'll touch bases. Hopefully when we do, we'll be able to share it with our audience in terms of what's, what's going on with you and what's going on with, with Oura Ring, because it's, it's really very exciting.

Yes, I would be happy to. Definitely. There's so much that we can share. Also finding out from, from people— we have customers in more than 100 countries— so how How we are similar, how we are different also, and also how we can see this kind of even seasonal effects and different kind of rhythms. How the different rhythms affect us as human beings.

Absolutely, Peteri. Where can people go to learn more about what you're doing?

So our website is ouraring.com. O u r a So there, there we have several articles and blog posts related to all these things what we discussed about.

And tell me the genesis of the name Oura Ring.

Oura is, is, uh, it means kind of old, uh, Finnish-Swedish language, uh, and it, it's, it describes a bedrock. So, so we, we wanted to develop a bedrock for people so that they have a good basis for their life.

Well, I think that bedrock is information. Yes, it is. At the end of the day and at the beginning of the day. Well, listen, thank you so much for your time, and congratulations on your success and all that you're doing. And I meant what I said, we got to touch bases again real soon.

Yes, yes, thank you.

Okay, talk to you soon. Bye for now.

Thank you. Bye-bye.

Well, what an interesting gentleman he is, and in fact, what an interesting experience it is— it has been for us participating in the use of the Oura Ring, learning about ourselves, and most importantly for us anyway, learning about how well and how long we sleep. Sleep has been underrated in terms of how important it is for health and longevity and disease resistance. So many factors are now really evident that we've underrated the value of sleep. So, really important to learn as much as you can about what's going on with your sleep. Well, thanks for joining me. I'm Dr. David Perlmutter. We'll be back soon. Bye for now.