How To Improve Your Sleep

Coming up on this episode of the Doctor's Pharmacy.

We really have this sleep epidemic problem.

Getting bright light exposure, ideally from sunlight within 30 minutes of waking up, is vitally important for getting sleep later that night.

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Episode of the Doctor's Pharmacy.

Hi, this is Lauren Fagan, one of the producers of the Doctor's Pharmacy podcast. Inadequate sleep quantity and quality is a.

Major problem for so many of us.

Not only does it leave us feeling bad, it's also detrimental to our overall health. Poor sleep can lead to everything from.

Mood swings to blood sugar imbalances, hormonal.

Imbalances, weight gain, poor memory, and much more. In today's episode, we feature three conversations from the Doctor's Pharmacy about the importance of sleep and how to improve it. Dr. Hyman speaks with Andrew Huberman about habits that set us up for the best sleep, with Dr. Cindy Guyer about overcoming insomnia, and with Shawn Stevenson about.

How stress impacts sleep quality.

Let's dive in.

Once you really appreciate how vital sleep is and how great life can be if you're getting good sleep and how terrible it is for our health, both immediate and long term, if you're not, I think then it creates its own sleep anxiety. And so one of the things that I've been very active in that for sure. Yeah, where you think, To be fair, the body and brain are resilient. If you don't get a good night's sleep every once in a while, it's fine. You can manage that. Certainly new parents do just fine over time, although it's challenging. But there are a few things that really help with sleep. And there are a lot of causes of insomnia and things. So they're the basics, like avoiding caffeine in the afternoon, if you're caffeine sensitive, et cetera. But one of them is to start to understand that this state of sleep is not something that you should be able to drop into unless you do a couple of other things properly. And based on the research done in part by my lab, but mainly a guy out at the National Institutes of Mental Health named Samar Hattar, he's the director of their cRonobioLogy unit. He's done these beautiful studies showing that light exposure early in the day, getting bright light exposure, ideally from sunlight, within an hour, ideally within 30 minutes of waking up, is vitally important for getting sleep later that night. And the reason is, is it basically once every 24 hours, you're going to have a spike in cortisol. It's non-negotiable. It's built in your genome. It's gonna happen.

So do people like Arizona sleep better than people in Seattle?

Well, they do actually. And a lot of people in Seattle need light boxes. 'Cause if you're living in an area where you can't get sunlight first thing in the day, feel free to flip on artificial lights. But you want, basically the rule is you want as much bright ideally natural, but if you can't get natural, artificial light would be fine early in the day. And what that does is it basically times this cortisol spike to wake you up. That spike in cortisol isn't to stress you out, it's to wake you up. And then it sets a timer on your melatonin release. So 14 to 16 hours after your bright light exposure, you're going to get a pulse of melatonin, which is the hormone, of course, that promotes sleepiness and puts you to sleep. independent of any supplementation of melatonin. Light inhibits melatonin through a direct pathway through the eyes to the brain stem and then up to the pineal. It's a well-established pathway. So, the number one thing is get bright light exposure to your eyes. So, no sunglasses, eyeglasses or contacts are fine early in the day. How long? Well, it depends on how bright. So, anywhere from two minutes to 10 minutes, Ideally, you're not looking at your phone during that time. Ideally, it's sunlight, but if you wake up before, flip on a bunch of artificial lights and then get outside once.

The sunlight is out.

You're outside taking a walk. You're not looking at the sun, right? You're not looking directly into the sun. You don't want to burn your retinas out. Indirect exposure is fine, but there's a class of neurons called the melanopsin ganglion cells that reset your circadian clock and time things nicely. They time the cortisol all the time, the melatonin. So, that's the number one thing for, I wouldn't just say for, sleep, but also for optimizing levels of alertness throughout the day. The other thing is that you really want to avoid bright light between the hours of 11 p.m. to 4 a.m. If you're on a standard schedule, shift workers is totally different. The reason is Samer's lab and a guy named David Berson at Brown University have shown that bright artificial light of any color, blue blockers or no, if there's bright artificial light, it's activates a pathway in the brain involving this brain structure called the Habenula. When I was an undergraduate, actually someone asked in neuroanatomy, what's the Habenula do? No one knew. The Habenula is involved actually in generating our feelings of disappointment. It suppresses dopamine release for several days afterward. Now, if you have to go to the bathroom or you have to pull an emergency trip to the supermarket or something in the middle of the night, you don't have to worry about crushing your dopamine long term. It's a chronic thing. but you really want to dim the lights in the evening starting at about 10 p.m. And so you're saying those.

Blue blocker things that doesn't work?

Well, the blue blockers will work, but if the lights are bright enough, it doesn't matter what wavelength they are. And this is because these melanopsin cells, these neurons in the eye, they do respond best to blue light, but they're very broad spectrum. The wavelengths that they will respond to, you can shine bright red light on one of these cells and it will signal to the brain time to wake up.

Amazing.

So it's really key to just dim things down. And I always say blue blockers are terrific, but you don't want to wear them during the morning and early part of the day because blue light is the optimal stimulus for this wake-up signal. So we took the blue blocker thing is great in principle, but people kind of took it too far. So bright light when you want to be awake and alert and dim light when you want to be asleep.

So how many hours before bed? Because people are up on their TVs and their screens and computers and phones.

Yeah, so the subtle things that people can do are to start dimming the lights in the evening, right about the time the sun goes down, is when you want to say, oh, well, the sun is going down outside and if it's overcast, it's getting dark. Well, that's a time to dim the lights in your home. The other thing is because of where these neurons are situated in the eye, overhead lights will activate this wake-up signal much more readily than lights down low. So the Scandinavians have it right. In the evening, you want desk desk lamps, most people aren't going to have floor lighting in their house. Desk lamps in early in the day and throughout the day, that's when you would want overhead lights. So those two things are going to be very beneficial. A lot of bright light, overhead light throughout the day, ideally from sunlight. And then in the evening, avoid bright lights of any color, any kind between 11 p.m. and 4 a.m. Don't get neurotic about it, but many people find that just making these changes.

You don't have to be off from six o'clock at night?

No, no, no, no. And there's actually the third tool, which is also grounded in really nice work, a paper published in Scientific Report, shows that if you get some sunlight in your eyes in the evening, right about the time of sunset, and if you can't get it from the actual sunset, just go outside. You don't have to see the sun setting. You just need the light, the ambient light, the outdoor light in the morning is sufficient. There's so many photons out there, even on a cloudy day, you'd be amazed. In the evening, if you see or get outside and get some sunlight or you get some light in your eyes, that has an effect of lowering the sensitivity of the retina of the neural part of the eye and provides you a kind of insurance. It offsets a little bit of the late night bright light exposure. I call it sort of your Netflix inoculation. It kind of protects you against some of the ill effects. Now, if someone's schedule is really messed up, I mean, not sleeping. They're really screwed up. There's a study out of the University of Colorado that showed that this is a little extreme, but going camping for two days reset these melatonin and cortisol rhythms for two weeks. It's pretty incredible.

It's really incredible. I noticed when I go camping or I go out in the wilderness or far away from technology, I just sleep way better. We had a storm, my house last summer. I mean, we got power out for four or five days and we just had candles at night. And it was unbelievable. I loved it. And it felt so good to not have all that bright light at night and to go to sleep and sleep better and deeper. Yeah, you really reset.

And you mentioned, I'm glad you mentioned candlelight. Candlelight in the evening is fine. Actually, not to turn people into geeky scientists, but there's a great app. I have no relationship to it, but it's completely free. It's called a light meter. and you can run this experiment, you can download the app, you go outside on an overcast day in Boston in January and press the little button on light meter in the morning and it'll show you that even though you don't see the sun, it looks like dense cloud cover, there'll be something like 5,000 lux of light. You'll go inside, you'll point the thing at a really bright artificial light and it'll say 300 lux. Close the window to the outside and it reduces it by about 50 fold. So you don't want to do this through a window or a car window. And then you say, well wait, you just said that there's very little light intensity coming from artificial lights. Why is it so bad at night? I should be able to turn on every light in the house and it won't reset. Ah, but the clock and your eye get more sensitive as the day progresses. So you have to control it at both ends. And candlelight is fine, dim light in the evening is fine, but throughout the day you really want to try and get some bright light exposure. and for many people whose schedules are just really screwed up, anchoring to these two or three things of bright light exposure and avoiding bright light in the evening hours between 11:00 p.m. and 4:00 a.m. often, not always, can really reset people's ability. And once you're sleeping well, everything else gets better. So that was kind of the first question you had. The other one is that I'd be remiss if I didn't mention that there are things that people can take, I'm sure you're familiar with, with several of these as well. Obviously, well, we have a doctor right here, so talk to a doctor. Obviously, I'm not a physician. I'm a professor, so I don't prescribe anything. But the three things that have made a tremendous difference. You profess, you don't prescribe. I profess, I don't prescribe. That's right, that's what I usually say. Profess lots of things. The three things that I've certainly benefited from, and I know a number of other people have, and for which there's really good research, Apigenin, A-P-I-G-E-N-I-N, which is, it's very inexpensive, it's chamomile extract. And it basically turns on a chloride channel mechanism in the brain. It turns off thinking. It's kind of the equivalent of an alcoholic drink. It just turns off thinking. You could still drive on the stuff.

But it makes people drowsy.

So drink chamomile tea or you have to take a concentrated. Some people get that benefit from chamomile tea. Other people like the Apigenin. And the other ones are the magnesium Magnesium and magnesium threonate and by glycinate in particular, threonate spelled T-H-R-E-O-N-A-T-E and by glycinate, I won't spell out, but just as it sounds. Those cross the blood-brain barrier more readily because you're ingesting this obviously into the gut and then that magnesium needs to get into the brain. And basically the magnesium seems to act as a precursor to GABA. the inhibitory neurotransmitter. And so for people who have a hard time turning off their thoughts, that can be very beneficial. So there's the kind of light, which is a kind of ancient mechanism by regulating alertness and getting into sleep. And then there's the modern thing, which is supplements. And there's something sort of in between worth mentioning, which is there's a great tool that was developed by my colleague who's our associate chair of psychiatry at Stanford. His name is David Spiegel. he's actually a clinical hypnotist, has done a lot of work on pain management and even breast cancer outcomes from hypnosis. And he's developed a free app that's on Apple and on Android called Reverie, R-E-V-E-R-I. It's a 15-minute hypnosis that you do in waking, which trains the brain to sleep better. And I think that a lot of people hear hypnosis and get a little bit freaked out, but there are a lot of clinical data showing that this can help people to learn to turn off their thoughts and to relax and go to sleep. And there's some other nice hypnosis scripts in there as well. It's David's voice and he kind of walks you through it. So those are, aside from the supplements, the light and the hypnosis are free resources that I think most everyone could benefit from. If I wake up in the middle of the night, oftentimes I will do one of these hypnosis scripts. And just one other thing about sleep, a lot of people wake up at 3:00 or 4:00 a.m. and can't fall back asleep. Okay, I never understood why that was and then I talked to the folks in the sleep lab at Stanford and I talked to the chronic, here's probably the reason. There's an asymmetry in this seesaw that we all equipped with internally, which is that we can all push on and stay awake more easily than we can just force ourselves to sleep, right? That's true, right? At some point we fall asleep, but if you're waking up at 3 or 4 a.m., unless you're drinking too many fluids and that's the reason why, chances are you are running out of melatonin at that point. The levels of melatonin in your blood are dropping. And what it means is you stayed up too late and you probably are one of these people that should be going to bed at 8:30 and waking up about 3:30 or 4:00 a.m. And people don't like that answer because they think, no, but I want to be the person that goes to bed at 11. And there are ways to shift your circadian rhythm that we could talk about. Try and go to bed one hour earlier and chances are you will wake up feeling better at 3:00 or 4:00 a.m. Now, it's not exactly a solution, but if you're in an argument with your spouse or something about going to bed at one hour or the next, you can leverage biology or cite this discussion.

Wow. So we really have this sleep epidemic problem and people are struggling with figuring out how to deal with it. And your lab, and you have worked really a lot on how do we navigate the landscape of sleep? Because as we're having this conversation, whatever I ask you, you keep coming back to sleep, which is fascinating to me as a foundation. And we always think diet's the foundation, exercise, Foundation, meditation. But sleep is sort of that neglected.

Fourth leg of the, of the table. Well, and it's the thing that we've been encouraged to push through. And, I mean, there are some elements, I mean, that We could get down into the fine science of it. We sleep in 90-minute cycles, ultradian cycles. Better to wake up after six hours than seven, for most people, for sake of alertness. So waking up at the end of one of these 90-minute cycles, you're going to feel more alert than you would say if you slept into seven hours would mean you weren't complete through your last ultradian cycle. But sleeping at 7:30 would be even better if you can. Getting the right amount of sleep is it it's a process that you want to master on average, right? You know the one occasional all-nighter you'll be okay. You drink coffee too late, you'll be fine. But on average you want to be sleeping most people it's going to be anywhere from five to eight hours a night. Naps in the afternoon seem to be okay. The hypnosis script and the other things will really help people get centered around this. I think that the The idea of breaking up one's sleep, there were these crazy sleep cycles that were promoted, not to be confused with Huberman, they called it the Uberman schedule. I just wanna be very clear, not Huberman schedule. There was a study that came out recently that showed that it's incredibly detrimental to all sorts of inflammatory cytokine markers. To take a nap in the middle of the day. Oh, no, to try and sleep two hours, wake up, sleep two hours, wake up, sleep to around the clock. There are people that they found they could compress their total sleep time. this was kind of a Silicon Valley thing, like trying to master one, you know. You just have these human bodies, you gotta actually- yeah, you can't conquer that, but I think sleep is vitally important. Then I think, I do think that foundational diet and supplementation, and from the literature I've seen, I'd love your thoughts on this, the literature that impresses me the most in terms of diet and the brain and brain states, are the studies that look at EPA, essentrial fatty acids, and the gu microbiome. Those are the two things that to me, it's like it's undeniable. I don't understand how anyone nowadays could even question the idea that getting proper lipid intake, you know, essentially lain is fat. Yeahs. These Omega threes are so important. I mean, in in a double several double blind placebo controlled studies that I've read it appears that getting 1,000 milligrams or more per day of EPA, so not just taking 1,000 milligrams of fish oil, but making sure that you're getting above that threshold of 1,000 milligrams of EPA from quality sources, compares just with similar effect as SSRIs, prescription antidepressants, but without the side effects, which is incredible. And that if you are taking SSRIs, it allows you to take a much lower dose to still be effective. To me, incredible data. And then the other one is that ingesting fermented foods one or two servings a day.

Sauerkraut for the brain.

Yeah, sauerkraut for the brain or whatever given culture. Because what I learned, and this is very new and emerging data, there's a guy at Duke, he's incredible. He was a nutritionist, but then he has PhD in nutrition, excuse me, and now he's a neuroscientist. His name is Diego Borges, not to be confused with the Argentine writer Borges. He's Ecuadorian and he found that there are neurons in our gut of the vagus nerve. So these are neurons that live in the gut and to endothelium and they sense three things. They fire electrical signals to the dopamine centers of the brain in response to fatty acids, right? When fats are, you know, meats and things are broken down in the fatty acids, amino acids of other kinds, so from protein, and sugar.

Sure.

And so these neurons can easily be tricked into signaling the brain to release more dopamine, because dopamine is really the molecule of craving, into craving more of whatever activated those neurons. And so if you give these neurons enough EPA or enough amino acids, so protein and essential fatty acids, the dopamine centers of the brain are just firing like clockwork, which is going to enhance mood, innovation, energy. I mean, dopamine in proper amounts is a beautiful thing. Too high, obviously, you don't want, but.

You'Re not going to get it too high.

People don't get addicted to chicken breast, but they get addicted to sugar. Right. And I think that's, I actually think that's because they're, they are, these neurons seem to be responding best to particular amino acids. They seem to want glutamine of all things. They seem to want the Omega-3s and what's interesting is that even if they numb the taste so that people can't taste sugar. If people ingest sugar, these neurons- Sugar.

Receptors in your gut, right?

And they crave more sugar even if they can't taste the sugar. So I always thought that the dopamine release to sweet things was because it tastes so good. But the Borges lab results and some other work on dopamine more generally from my colleague Anna Lemke at Stanford shows that dopamine isn't so much about pleasure. including myself, were taught it's about pleasure. Dopamine is about craving more of whatever it is triggered dopamine release.

Yeah, whether it's heroin or cocaine or sugar. Right.

Or sugar. And so these neurons that trigger dopamine release, they are powerfully affected by these quality omega-3s and by amino acids. And then what's really interesting is that They trigger the release of dopamine, but then you say, well, okay, that should be pretty simple. Like you said, people don't get addicted to chicken breasts. And I wonder whether or not that's either because omega-3s are too low, so these neurons are not, the full concert of these neurons is inactive, or it could be that for some reason that the other things that people are ingesting has messed up these neurons. And so the whole brain-body relationship is disrupted. And it's, I guess Robert Lustig is his name at UCSF. Yeah, yeah. And others are now showing that some of the emulsifiers in foods and other things like that. What they do to the gut endothelium, I never really understood how the gut brain thing works. But what I realized is that these microbiota, they don't care about us. What they do is they're trying to find conditions in the gut where the mucus is, pH of the mucus is just right. And that if people ingest emulsifiers and sugars, what happens is these neurons and Borjeslav has shown this, that these neurons that are in the gut endothelium and can sense amino acids and can sense essential fatty acids, they actually start to retract their processes into the deeper layers of the gut. In other words, if you ingest the wrong things, pretty soon the neurons in the gut remodel the bad kind of neuroplasticity, and you lose your gut brain sensing system. And so it's not just a matter of giving it the right things. It's really about, for many people, it's going to be about repairing this system. and allowing this portion of our nervous system to grow back. Now, the nice thing about peripheral neurons is that they grow back. So, in any way, I just gotta.

Unpack that because what you said was just so profound right there. Basically, you're talking about uncoupling the natural ability of our body to sense its environment and to self-regulate in the right way to create health. when we eat processed food that contains ingredients that screw up the gut microbiome or the lining, and all of a sudden that the brain in the gut, or whatever you want to call it, the neurons in the gut, start to change as a result of the crappy food we're eating and make us less able to seek out and want the foods that are good for us and tend to make us seek out and want the foods that are bad for us.

Exactly.

That is a massive, like, brain state shift for me because I never really understood the mechanics of how that happens. But it's clearly true when people are eating bad foods, they want more bad foods and they keep eating more and more of them. And there are many reasons for that, but the gut story is just fascinating.

First and foremost, we have to recognize that sleep, you and I trained in an era where sleep deprivation or how little sleep you could get by on was a badge of honor.

Yeah.

So we need to shift that internal dialogue that we all have that, oh, if I'm sleeping, I'm wasting my time and I'm not getting my stuff done. So first, honor the importance of sleep for your overall health and well-being, and even your ability to stick to your intentions around choosing healthy foods and sticking to your exercise plan. Then create a sanctuary that's really conducive for rest and relaxation. Dark, quiet, cool, ideally electronics out of the bedroom or turned off if you can. getting rid of all of the light exposures, even your chargers, you know, that had that.

Yeah, like those like lights, like this red green lights on different devices. I'm like, that drives me crazy.

I used to, I had a patient who told me she traveled around with black electrical tape whenever she went to a hotel and she would put it over all the little light sources.

That's a great idea. I travel with eye shades because you.

Never know where you're going to be. So those two, quiet, calming. And I think this idea that you go, go, go, go, go, go, hop in bed and turn it off like a switch, that doesn't work either. So building in a transition to rest and relaxation. If you can do an hour, that's great. And getting off the devices, not watching TV, maybe reading a book or journaling or doing something, taking a bath, stretching in the tub. I mean, there's all kinds of wonderful ways to ease into rest.

I like the hot Epsom salt bath and lavender drops because the lavender lowers your cord is all the magnesium relaxes you and the sulfur and the Epsom salt helps you detox.

That'S my favorite as well. And then you go to your cool bedroom and you do your legs up the wall yoga, restorative yoga position and bingo, you've got your transition to rest and relaxation.

So powerful. And alcohol obviously is a big factor for people.

Yeah, that's a tough one. That's a tough one. So the rough analogy is this. It's funny when they asked partners of people with insomnia how many of them were suggesting that they have a drink to go to sleep. It was about a third of them. So people think alcohol is gonna help you sleep and it might make you fall asleep, but then as it clears out of your system, there's an arousal that can exacerbate hypoglycemia. It makes you wake up, it's gonna make sleep apnea worse. If you're a woman in midlife, oh boy, it's a bladder irritant, it's a hot flash trigger. So it's really affecting sleep in a lot of ways. The rough equivalent is there's about an hour of sedation followed by an hour of arousal. Yeah. So if you had a glass of wine at six and you go to bed at 10, probably not going to impact your sleep as much as if you have two glasses at eight or like your late dinner last night, if you had a glass or two of wine.

You had a beer. Yeah.

That has another impact on your sleep.

I just noticed it actually, I had an aura ring for a while and I was tracking my sleep and I noticed whenever I drank, my sleep's pattern was so disrupted. Quality of sleep, the depth of sleep, the amount of REM sleep, deep sleep, snoring, you know, all that.

It's really interesting. And then caffeine also is another big one, right? Yeah, absolutely. And we're all different in terms of our caffeine metabolism ability. Some people are really fast metabolizers, sorry, fast metabolizers. I happen to be one of those. But if you're a slow metabolizer, half of your cup of coffee from noon could still be in your system at 9:00 at night. And most of the time we're not thinking back to that new cup of coffee. With food, it's really about quality, quantity, and timing of food. It's all three. Yet another area that's impacted with the health of the gut microbiome is sleep. And data is suggesting that people who eat a wide variety of colorful fruits and vegetables tend to have better sleep quality, whereas a highly processed standard American diet is associated with more sleep disruptions and less deep sleep. So quality matters. We already touched a little bit on the timing of eating. So eating your calories earlier in the day, also helps reregulate those circadian rhythms. So the clocks in the brain and the clocks in the body that are ideally going to be working in sync with each other, they're influenced by light, by movement, and by food. So when we line all those things up during the day, it's going to help us get the rest that we need at night.

So important. This is such good information. Let's talk about what are the challenges that you see in your clinical practice around women and sleep and what are the main reasons that you're finding and some of them aren't expected. And then let's go into how, you know, they would be traditionally approached by conventional medicine. And then we'll dive into functional medicine.

Sure. So I think the first thing is that some common sleep conditions like insomnia and restless legs, they disproportionately affect women and they can have a connection to lifestyle. Sleep apnea, interestingly enough, gets underdiagnosed for women. And there's a lot of reasons which you can dive into it, but some of it has to do with stereotypes on the part of clinicians of thinking about sleep apnea being a man's condition, especially if they're overweight, right?

Especially putting weight on around the middle.

But lean women can get sleep apnea too, and it may show up very differently. There's also the idea that when we look at times of hormonal fluctuation for women, whether that's before their periods or during pregnancy or the postpartum or the menopause transition, that can also cause an uptick in disrupted sleep. So hormone balance and regulating hormones can play a huge role in improving sleep quality. And finally, disproportionately in the past, caregiving demands have fallen on the shoulders of women. And I think that really became manifest or evident during the COVID-19 pandemic when you saw a bigger proportion of women than men experiencing an uptick in insomnia, anxiety, and depression. So they're all interconnected.

Yeah.

So women take on the burden of the families. They often, especially during the perimenopausal years, become the sandwich generation between raising their kids and taking care of their older parents. you're kind of in the middle of that a little bit towards the tail end of it, but you kind of went through that. And it puts a lot of stress on women. Also, I think there's some unusual causes of sleep that get missed by traditional medicine. And so, like if you were a woman and you went to the doctor, like, I'm having insomnia, what are they.

Going to tell you? They'll probably tell you to take a sleeping pill.

A little Ambien.

Little Ambien. Little Valium. Right? Or maybe they'll give you an antidepressant.

Right?

Right.

And of course, those come with side effects. They're addictive. They impair cognition. They have all kinds of long-term effects. I mean, the benzos are like Valium, Lorazepam, or Ativan. They may lead to increased cognitive problems like dementia when you get older. Ambien, you know, we heard all the stories about people wandering around doing stuff they shouldn't do in the middle of the night. It's unfortunate that there are other things too that traditional medicine misses that affect sleep. You talked about the big ones, which are the stress and the sleep apnea and the hormonal issues, but there's really more that we know about sleep disruption. And the difference with functional medicine is that we tend to take a detective approach. We don't just stop at the diagnosis. Insomnia is a symptom. It's not a disease.

Right.

Right. And so we go, oh, I know it's why you can't sleep. You have insomnia. No, that's just, The name of it, silly, that's not the cause. And so we kind of have a different approach. And over the years, you know, there are things we've really uncovered in functional medicine that play a role in sleep that are mostly ignored. So you shared a little bit about it earlier when we were chatting, but what are the kinds of other things.

That we see underlying the root causes of insomnia? So if we think about insomnia, about 80% of people who develop chronic insomnia, there's an initial inciting event, but it leads to a stressful event, for example, and there's sleep. Like a death or divorce.

Right.

Or a transition with the job. I think the pandemic has contributed to it as well. But then what happens is there's this upregulation of the HPA axis and this chronic overproduction of cortisol is hypothalamic pituitary adrenal axis.

So it's the brain's command center that tells the body what to do.

Absolutely. So it's that connection between what our brain is registering as a threat and how that impacts our need to respond to that threat by pumping out these hormones that then in turn keep us ready to deal with a threat that may not be there anymore.

So basically, if you're in fight or flight, your job isn't to go take a nap.

It is not. Stay on alert and wait for the next thing that's going to threaten you.

So that activated sympathetic nervous system is huge. And our culture just does that. The phone is like a dopamine pump. It's like a dopamine pump that keeps your blood pressure up. you know, when people are dying in the intensive care unit, the drug we give them to keep their heart going is dopamine.

Right?

And that's what.

Great analysis.

You know, and so, like, it's like at the very end of life, like, if you can't, if everything else, epinephrine failed, everything, you give dopamine because it's so powerful at keeping you awake and alive. And so what everything in our life is the sugar, the phones. all the new, I guess just we're constantly in a dopamine barrage.

You know, it's funny you said that because I've had people tell me, I wake up at 1:30 every night. I said, well, how do you know it's 1:30? Because I look at my phone and it says 1:30. And that, again, perpetuates the cycle because then you're thinking, oh, it's 1:30. Oh, crap. I'm awake.

I should be asleep. And then it just becomes... Yeah. You know, the best thing I ever did for my sleep issues, because I struggle with them as well, is is putting my phone and my watch off, like just taking everything out and not knowing what time it is. And just letting my body do its thing. I think that's brilliant, Mark.

And even sleep trackers, for some people, it can be a double-edged sword. Yeah. Because you're thinking, okay, what's my tracker showing me? How well did I sleep last night?

When you get a good night's sleep, it's like the world just looks rosy. And when you don't, it looks depressing.

Gray. and you know, that's an important thing too, if you pay attention to how you feel. So you mentioned the aura ring. People ask me, how good are these trackers for telling you about your sleep? They don't diagnose a sleep condition, but sometimes you can gain some insights for you. You gave a great example of this. You found, oh, look at this one. I've had alcohol. My sleep is not a... My sleep is not a... Heart rate variability, everything. And then you pay attention, well, how did I feel the day after? Yeah, I was more tired. Yeah, I was more irritable. I was looking for different foods. So I think the more you build that internal awareness of that connection between your sleep and how you feel the next day. That's a win. That's really how you learn to prioritize it.

Yeah, just take home here is that sleep is the most underappreciated fourth pillar of lifestyle medicine.

I agree.

It's diet, exercise, stress reduction, and sleep. And it really is important. And I think I feel like a lot of my health issues in part were driven by black of sleep. And, you know, I think as doctors, we were just so trained that overcome our natural instinct to sleep. We have to stay up all night alert, seeing patients, either pound the coffee or you just will your way through. And I remember, I remember, like, working the ER and weird shifts, like 11 to two in the morning. And I'd be, like, driving home with, like, tooth holding my eyes up like, like this, forcing myself to not fall asleep and. that just messes with you.

Today, more than ever, there's an epidemic for sure with sleep deprivation. And we're seeing this show its face in so many different areas. I think the first step is actually understanding the value of sleep. And so for example, you know, real talk, nobody's waking up in the morning like, you know what? I want to look terrible today. You know, everybody wants to look good. And if we understood just how much our sleep quality and affected our body composition. I think it would start to push that conversation forward. So there was a really cool study.

I was done as a sleep and weight are connected.

Oh, my goodness. University of Chicago did a really fascinating study. So they took folks and they put them on a calorie restricted diet, which is what I was taught to do in a university setting, which doesn't necessarily work, by the way. Exactly. But they put them on this calorie restricted diet, and during one phase of the study, they allowed them to get eight and a half hours. so sufficient sleep. Another study, another phase of the study, same people, same exact diet, they're not cutting any more calories, they're not exercising more or less, and now they sleep deprive them. So now they're getting five and a half hours of sleep. They take three hours away. At the end of the study, they compiled all the data, and they found that when folks were getting a sufficient amount of sleep, they lost 55% more body fat just from sleeping. Yeah.

All right.

And I didn't say weight, they lost actual fat mass. Not muscle. which is crazy. Like how I'm not saying you're doing like eight days a week CrossFit, right? You're just sleeping better. And the question for me is immediate like, oh my goodness, how? How is that happening? And so it's during sleep that we release, this is crazy, melatonin, this super glorified sleep hormone, which it really isn't that. It's kind of a regulator of your circadian rhythms, period. but it actually is a really profound fat burning hormone as well. So the Journal of Pineal Research found that melatonin-- and that's that gland in.

Your head that releases melatonin.

It's like-- Pineal gland, correct. Which that's not the only place. So we'll get back to that in a moment.

It's like your third eye gland, basically.

So the pineal gland-- and it responds.

To light and all the artificial light.

And the fact runs-- It suppresses it. It has to have darkness. so the Journal of Pineal Research found that melatonin increases your mobilization of something called brown adipose tissue or brown fat. And this is a type of fat that actually burns fat that increases your metabolism.

Yes.

And the reason is brown versus the white adipose tissue is kind of the stuff we think about when we're trying to get rid of fat. Brown adipose tissue is brown because it's so dense in mitochondria. Right. These kind of energy power plants. I know you've talked about many times on the show. but it's such a metabolically active tissue. And so if you're not getting adequate sleep, you're not producing that hormone, nor you get your greatest secretion of human growth hormone during sleep. This is the most, it's also known as the youth hormone in a way. It's the repair hormone. Kids have so much HGH. This is why they have so much energy. It's muscle sparing and also it's a big component of you healing and recovering. And so you're missing out on that. And cortisol, that's another one. So if you're sleep deprived, one of the very first things we see is.

An increase in your cortisol levels.

That's the stress hormone. Exactly, exactly. And cortisol has this interesting ability to literally break down the muscle that you're.

Working so hard to build.

Oh, it's terrible. Gluconeogenesis, a process called gluconeogenesis, break down your valuable muscle tissue and turn it into fuel because it's this stressed, hyper alert, cautious, dangerous state your body thinks.

You'Re in because you're sleep deprived. And I can go on and on. I'll share one more. I always say stress is, is bad because when you have high cortisol, it does everything you don't want, right? It shrinks your memory center in your brain, causes Alzheimer's, it causes you to lose muscle and gain fat, it causes your sex hormones to get screwy, it has so many horrible effects and it's not worth getting stressed about stuff. It doesn't matter. You know, like stuff, there's stuff that does matter that you have to worry about. But the truth is most of the things we react to and stress about are just our beliefs or thoughts. They're not really real, right?

Yeah, that's a, and I even focused on that as well because a lot of folks have what we call clinically just a lot of inner chatter. You know, the brain is a very vocal and kind of noisy organ.

Yeah.

You know, and so the great thing is a lot of our needs are met, especially if people are listening to this right now.

It's like the crazy ant that lives in your head, you know?

Right. Right.

Yeah.

But, We have so many things covered in our lives that our ancestors didn't have to worry about. But the human mind is so expansive so we can manufacture things to worry about. And that worry can push us. And I often tell people, you know, when people are coming into my clinic, that you can overeat your way fat, you can under exercise your way fat or under move your way fat, you can under sleep your way fat, and you can also over stress your way fat for sure. It has a huge component for our overall health and our body composition. position, too, so. But I was going to share Stanford University.

Yeah.

They found that just one night of sleep deprivation has a dramatic effect on suppressing leptin.

Yeah.

Right.

And that's that kind of glorifies hunger. I mean, I'm sorry. Satiation hormone. And ghrelin on the other side has this uptick. And that's that hunger hormone.

Yeah.

Right. So just one night and I.

And it makes you crave a ton of carbs.

I want to ask you this. I was gonna say. I know you've been up late before. Oh yeah. But I don't know if it's me or if anybody else listening. Have you ever been up at like two o'clock in the evening, maybe at a party, maybe just kicking back watching TV, and you're like, you know what? I really want a salad right now. Nope.

No.

If that's ever happened, please inform me. I don't get a craving for broccoli. I want salty, sweet, crunchy, like I want- Carbs. Yes, yes. Because your brain is literally starving for glucose. Just one night of sleep deprivation, we're seeing about a 14% reduction in glucose reaching your brain.

Yeah, I know it's true. I remember working many nights in the emergency room, delivering babies, being up all night, and the next day all you want to do is eat carbs and sugar. You know, I'd go to McDonald's and get the apple turnovers and the french fries in the middle of the night. Apple turnovers. That was the only thing that was open in the hospital. It was only closed between two in the morning and six in the morning, otherwise it was open 20 hours a day. It was the only thing open in the hospital.

Can you leave it? And I would go, you know, be sleep deprived and stay up all night.

And I totally craved carbs. Wow.

And you did that work on that food, and now what you're made of now and the work that you're doing is just like exponential. Like you see that. I thought about this the other day. We're putting folks in space on vending machine consciousness, right?

Astronaut food.

Just imagine if we can get people on really healthy, real food and what we can create as humanity. It's exciting.

So what's exciting about your book about sleep is that you break it down. You talk about 21 strategies. that are very specific to actually fix your sleep. Because I'm sure many people listening, maybe even half or more, have sleep issues, whether it's not enough sleep, whether it's disrupted sleep, whether it's poor quality sleep, whether it's more serious things like sleep apnea, people often don't know they have it. So can you walk us through some of the key strategies and what really matters?

Sure. So I've been really working to press this into public awareness for about five years now. and this was because seeing people in my office coming in and, you know, they're struggling with their blood sugar, for example. And we had about right around 75 success rate with, you know, getting folks off, you know, lisinopril and metformin and all this and working along with their doctors.

Those are blood sugar and blood pressure pills. Yeah.

And here's the thing that 25 of folks who weren't getting those results, ironically, that really bother me. And I know you've probably felt the same thing.

Yeah.

Ironically, kind of keeping me up at night.

20%. What are you missing?

And so it took about five years in practice, maybe a little longer before I had the audacity to ask, how was your sleep?

Yeah.

And what people would tell me blew my mind. I couldn't believe they're even sitting there.

Yeah.

And so, and this is another thing that we know is that folks don't really want to change too much to get the result they want. And I knew that. And so I just dug into the research and I wanted to find clinically proven strategies that people don't have to turn their world upside down. And once I implemented those with the patients I was working with, it's like the floodgates would come off, the weight would finally come off, their blood pressure would finally come down, their symptoms of depression would start to dissolve. And I was just like, this is really something special. I need to tell more people about this. And so eventually it's compiled into these 21 strategies and For me, again, some of these things are going to be a reminder for folks today. But I want to talk about something that a lot of folks still don't have a big awareness of. And this is the fact that your gut and the health of your microbiome has a huge impact on your sleep quality.

So your poop and sleep are connected?

What a concept. In a way. Okay, let's stick into that one. Don't do the two together. No, that's not, you know, that's called...

That's gonna blow people's mind and even my mind. mind. Tell us how the microbiome and your gut affects your sleep and what you.

Can do about it. Absolutely. So let's start with the basic component. And I know again, these are gonna be things people have heard about before probably on your show. But let's start with serotonin.

Okay. So it's pretty well known-- by the.

Way, there's more serotonin in your gut than there is in your brain. Exactly. Upwards of 80 to 90% of your body's serotonin is actually located in your.

Gut, produced by your enterochromaffin cells, by the way. All right, so-- those are special cells.

In your intestinal lining.

I'm just translating all the big words.

I like that, we're like flipping places, because I would do this for you. So here's what's so interesting is that serotonin, we talked about melatonin being important for our sleep and our circadian rhythm. Serotonin is a precursor or a seed to make melatonin. So already right off the bat, your gut environment, these cells in your gut are helping to make this compound that's related to your sleep quality. And with melatonin is what I want to liken it to. It's like that manual gear shifter for you to go through your sleep cycles properly and to actually get recovered. You need melatonin to be produced. And we'll come back to that.

So that's number one, serotonin.

You can't just take melatonin? I'll answer that in a minute.

Okay, okay.

That's tricky. Okay. So, well, I'll just tell you. So I looked around because some of our colleagues would feel that, and this was just a theory, that if you take supplemental melatonin, it's going to reduce your body's ability to produce it itself. And that's actually, I couldn't find that anywhere. There was no evidence of that. What I did find was taking supplemental melatonin, taking too much or too frequently, can down regulate receptor sites for melatonin. So your body can still produce it, but the receptor sites that actually do something with the melatonin can get down regulated.

The key is there, but the lock isn't.

So we do need to be mindful of that and we can come back and talk about that. But here's the biggest probably aha moment hopefully of this episode is that it's not just serotonin is producing the gut. And so check this out. And I just came across this. I'm gonna share this with you today. This was in the World Journal of Gastroenterology. Listen to this. They found that there's upwards of 400 times more melatonin in your gut.

What?

Than in your brain because you talked earlier about the pineal gland. That's what I was taught in school. It's produced by pineal gland in the story. This study found that you can actually have a pinealectomy, which is the removal of your pineal gland, which I don't recommend, by the way, don't do that. It's like a frontal lobotomy, you know, go there. And you don't actually lose those levels.

Of melatonin that's located in your gut.

So you have a gut brain and a brain brain. Exactly. And that's something really important to understand too. your gut is really, it's often referred to as a second brain. You know, it's, we can call it the enteric nervous system. There's like 30 neurotransmitters just like your brain.

It's like a mass of nerve tissue, 60 of your immune system and most.

Of the genes in your body as well.

Yeah.

That vagus nerve. So UCLA research has found that the vagus nerve, which we thought was just kind of like the brain communicating more, telling the gut what to do, 90 of those, the, the communication from those nerve fibers from the vagus nerve to the brain is your belly, your gut telling your brain what to do in many ways. Totally nuts.

And the other thing people should know is that when you're stressed, not only is your cortisol high and you lead to more fat accumulation, it's towards belly fat, but it actually blocks your cells ability to burn calories because the nerves from the vagus nerve help you metabolize your food, which is a relaxation nerve. It also has the effect of decreasing absorption of nutrients. So not only are you not absorbing, but your metabolism just slows down, which is amazing. It's just because of the nervous connection between your stress nerves and your relaxation nerves and all your gut function.

So profound. But this is just getting out of that isolation thinking. This is what I was taught in school as well.

That'S functional medicine.

The body's a system. Yes. Everything is interconnected, and it's a beautiful Symphony if everything's working well. So Caltech researchers, to kind of get to how does this all connect, they discovered that. And this was just. I mean, it's been around for years, but this is more of a recent, like, okay, meta analysis. Now we know that certain bacteria in the gut communicate with cells that produce these sleep related hormones and neurotransmitters. so your gut cascade, your microbiome, has a huge impact on your sleep quality. And so now the question is, what do we do about it? How do we protect or support our microbiome? And that's one of the things that's going to help to improve your sleep quality. So let's just go through a couple. The biggest thing, in my opinion, is avoiding things that mess it up. All right, so one of those would be eating processed foods. So that crazy amount of sugar has a tendency to feed pathogenic, opportunistic bacteria. Right. So that's one thing. Avoiding haphazard use of antibiotics. They have a place, but we shouldn't be using antibiotics every time you get the sniffles.

Right.

And that's literally what, when I was a kid, just give them some antibiotics.

Right.

We would even, like, if my mom had some antibiotics, you know, just totally negligent.

Yeah.

Give them whatever's in the cupboard also. pesticides, herbicides, rodenticides, metals. Yeah, these things, side literally means to kill, by the way. But these have a pretty, because they're meant to kill small things, guess what your microbiome is made of, you know?

And so, and how many millions and millions of people are taking acid blockers, which also terribly disrupt your gut microbiome.

Yeah, we're looking at that the wrong way as well. And so, just avoiding those things. But also what I want people to do is support their microbiome by, you know, and this should be just captain obvious at this point. And me working at a university for so long as a strength and conditioning coach before I did my clinical work, I worked with people from all over the world and I would ask them about their fermented foods and every culture had something. Yeah.

Right.

So whether it was like some kind of kefir or like, yeah, pickled, whatever. Right. And so making sure that we're getting us at least You know, every couple of days get a serving in of some fermented food or beverage.

Gotta eat the kimchi. Yeah, I got a jar in my fridge.

I love kimchi and my mother-in-law makes it for me and she's from Kenya. So they had like fermented, a fermented, like kind of similar to kombucha. Like she knew about this like 20 years ago and I'm like, what is this weird stuff she's growing? Yeah, yeah. And the kitchen is freaking me out. She had grab, like first time I came to visit, and they were growing grass, you know, like it was wheat grass. But I was like, hey, why has your mom got grass in here? Is she getting high? I didn't know. So anyways, different kind of grass. I didn't know. But that is a big component here is like shifting gears and having a more targeted perspective about supporting that gut microbiome. But also, and this is a really cool takeaway for everybody today is making sure we're getting in servings of what I call good sleep nutrients every day.

Yeah, what is that? Because eating for sleep, nobody really talks about that.

So what does that look like? The first one I'd share, and this one is from the Public Library of Science. And so they found that vitamin C, which we know about vitamin C, we tend to associate it with the immune system, right? That's powerful antioxidant. But they found that folks in this particular study that were deficient in vitamin C had a tendency towards waking up. more frequently. And getting vitamin C levels elevated reverse their symptoms. All right, so that's just one example.

So iron is the other one.

If you have a little ferritin is another one. Yeah, that's oh my goodness. That's huge. And especially more so for women. Yeah, it tends to be. And another one, this was published in the journal Sleep. All right, this is the big journal. And what they found was Calcium, right? So this goes back to that story that I was told about calcium. It is important for sure, but folks who were deficient in calcium had more interrupted sleep patterns as well. And so by getting those calcium levels up, but how do we go about that? I'll just pass it over to you.

Yeah.

Rather than drinking like homogenized, glow in the dark, you know, like from a mutant cow. Like, what other sources of calcium do we have?

Oh my God, you know, when you look at the data on calcium, it actually isn't as great as we thought for bones, but the best absorbability in use is actually from greens like arugula and greens that we can have dark green leafy vegetables. Also, there's some great sources like tahini, which is basically ground sesame seeds. Also, different things people might like, I like which is sardines with the bones in them and salmon with the bones in them, like canned salmon. Those are really great to eat. 'cause they have a lot of great absorbable calcium.

Exactly. Calcium is kind of like an end product from this biological transmutation. So, bones have a great source of it.

But, you know, people say, oh, you need milk. I'm like, well, where do you think a cow gets their calcium from?

It has strong bones.

They eat grass.

They eat grass. They should eat grass anyway. It's this really fascinating process. It's kind of like a biological transmutation of sorts where certain things come together to create bone.

Right?

So like you need silica, you need.

Boron, boron, vitamin K2, yeah.

All of these things come together to make this magic happen. So by the way, I want to give some sources with vitamin C. Obviously we know about citrus, fruits like strawberries, sweet peppers, but there are these quote superfoods as well, like camu camu berry. This might be the highest botanical source of vitamin C. Super tart, tangy, fruit. It's like an Amazonian thing. Amla berry, Acerola cherry, those are super, super high sources of vitamin C. Another one, and this was, this is the last one I'll share. There's a whole list in Sleep Smarter. So this was a study conducted by University of Oxford found that Omega-3s can help folks to get deeper, more restful sleep. All right. So it helps with those modulating those rhythms, which it makes sense because it has to do with your brain.

Yeah.

Right. Your brain has these gates. You know, we have the blood-brain barrier, but the gate allows in certain VIPs. And it's only like 30 things, right? And one of those is a megachip.

Although you can have a leaky brain.

And then you get more trouble. Oh my goodness. You know about the leaky brain issue? This is like, you're already, you're getting into some territory here. This is super fascinating stuff, right? Leaky gut, leaky brain. Who knew? Who knew? So exciting. And also, there's some research that just came across The brain kind of has its own nerve immune system in a way. Yeah, it does. It has its own lymphatic system, which.

Is like to clean the brain every night and guess how you do that? Sleeping.

Yep. It's 10 times more active. I mean, we know if you don't.

Sleep, you're at much higher risk of Alzheimer's because you can't clear out the.

Garbage and your brain gets toxic. It's fascinating. It's run by the glymphatic system. So that's like little shout out to the glial cells that help to run it. The body is just incredible. So eat plenty of good sleep nutrients every day.

Magnesium, though?

Oh, that was the last one actually.

Okay, that's the first one I go to with my patients.

This is the big one. I was saving the best for last. I first learned about the benefits of magnesium probably from you.

Okay.

And this was again, like, you've been talking about this for like 15 years.

Yeah, I'm getting old.

And I was like, holy crap. because it's responsible for so many biochemical processes. Oh, I got 300 enzymes and yeah. And so what that means for people is just like, so magnesium is responsible for these, well now we know like over 325 processes. What that means is there are 325 things your body can't do or can't do properly when you're deficient on it. Yeah.

And by the way, magnesium deficiency affects 48% of Americans and it's caused by stress. Chronic magnesium deficiency. It's caused by stress, it's caused by coffee, alcohol, and not having enough in our diet, which comes from mostly plant foods, beans and greens, nuts and seeds.

Absolutely. And this is one of the things that we can do something about.

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