This Is Why You’re Not Sleeping Well—and How to Fix It Fast

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

But the amyloid plaque, that sticky plaque that we secrete in response to inflammation or injury, if it accumulates, of course, it can damage surrounding neurons and is.

Associated with neurodegenerative disease and Alzheimer's disease. So in English, that means if you don't sleep, you're likely to get demented. It's definitely playing a role. Before we jump into today's episode, I'd like to note that while I wish I could help everyone via my personal practice, there's simply not enough time for me to do this at this scale. that's why I've been busy building several passion projects to help you better understand, well, you. If you're looking for data about your biology, check out function Health for real-time lab insights. If you're in need of deepening your knowledge around your health Journey, check out my membership Community, hymen Hive. And if you're looking for curated and trusted supplements and health products for your routine, visit my website supplement store for a summary of my favorite and tested products. Hi, I'm Dr. Mark Hyman, a practicing physician and proponent of systems medicine, a framework to help you understand the why or the root cause of your symptoms. Welcome to the Doctor's Pharmacy. Every week I bring on interesting guests to discuss the latest topics in the field of functional medicine and do a deep dive on how these topics pertain to your health. In today's episode, I have some interesting.

Discussions with other experts in the field. So let's just jump right in. So sleep is divided into multiple stages, but it's a state of inaction. No surprise there. We're not walking around unless we're sleepwalkers. and it's divided mainly into two general states. One is the early part of the night when we are mostly in slow wave sleep and our body is repairing itself. That's mainly growth hormone is released. That's a state in which our dreams tend to have very little emotional load and it's mostly about motor learning, physical repair of the body, et cetera. And then the second half of the night where we are in so-called REM sleep, rapid eye movement sleep, is the other major state. where the dream content tends to have a lot of emotional richness. The dreams are very intense. And we know that we don't release the molecule epinephrine, adrenaline during REM sleep. And it's sort of like a built-in every night therapy, exposure therapy. The argument we got into with somebody a few days ago, the challenge that we're going through in a relationship, an old thing wound or shameful thing gets worked out slowly over time in sleep. And we are confront, we're basically confronted with stuff in sleep, in this REM sleep, and we don't release the molecules that allow us to act on that. If you ever wake up from one of these dreams, you immediately get a surge of adrenaline.

It's very intense.

So it's kind of like built-in exposure therapy. It's not happening when you're sleeping. That's right. And then we wake up and we don't have a language for waking states the same way we do for sleeping states. So then we wake up and we don't have a language to explain the states that we go through in waking the same way we do for sleep. But there are two general features of states that I think are really powerful as an anchor point for thinking about states of mind and emotions, et cetera. And those are the ones that are regulated by the so-called autonomic nervous system. And the name is a real misnomer because it's this system in our body. It's sort of like a seesaw that takes us between different levels of alertness and calmness. Some people talk about these in terms of the sympathetic and parasympathetic nervous system, but we can just discard with the nomenclature for now. Sympathetic means more alert parasympathetic means more calmness essentially. And it's sort of like a seesaw. And so the way to imagine this is that throughout your day, you have varying levels of alertness and calmness. Now, if you are very alert, extremely alert, we call that panic or anxiety. But with that also comes something beneficial, which is focus. So we know that without alertness, there's no focus. And then there are states of deep calmness. Sometimes we think of that as fatigue. It could be fatigue at its extreme, but it could also be a nice feeling of tranquility. And in states of calmness, the mind and the way that thoughts are organized and feelings are organized is that there tends to be less linear structure. Actually, there's more creativity in calm states than there is in hyperfocused states. Hyperfocused alert states are great for implementing a strategy you already understand.

Like running from a tiger.

Like running from a tiger or performing surgery or your kid comes to you and has a problem and to them you can see that it's huge but you know how to navigate this problem because you have the perspective of having been a 14 year old before. So you say, okay, here's what we're gonna do, who talked to who, who said this. So there's nothing really creative about that situation. It's just kind of an implementation, what you already know. So again, we don't have a language to talk about what creativity really is at a neuroscience level, we can start to approach it or what focus is or what stress is. But if we all could understand that there's an undeniable truth about our nervous system, which is that our states of alertness and calmness set us up to be better or worse for certain kinds of events. So, for instance, if you want to sit down and do focused work, if you're too calm, too sleepy, that's not good. Your mind will drift. Similarly, if you want to relax and have a meal, if you're too stressed, if you're too alert, that's not good for all sorts of reasons as we know as well. So one of the things my lab has really been focused on is to try and figure out what are the levers, what are the entry points for people to be able to deliberately adjust their level of alertness and calmness in this kind of seesaw-like fashion. And then to just elaborate on the seesaw analogy a little bit, Try and imagine oneself not as the seesaw, but you're a person on the seesaw. So you're right all day long, basically you're moving back and forth. You're kind of surfing this seesaw between alertness and calmness. And one of the places where we see pathology, acute stress turns to chronic stress, or acute stress turns to chronic fatigue is when the hinge on the seesaw gets too tight. And the thing gets locked at one side.

Yeah.

Okay. And- A lot of people are locked in the stress state.

Locked in the stress state or locked in the fitness.

I think God, there's too many people.

I see walking around too calm and relaxed.

Right.

Because the hardest thing to do- and relax. Is an active process to be in the mid- to surf the seesaw.

Yeah.

This is what we, you know, the reason just a simple seesaw doesn't work as an analogy is because it's an active process. You're literally making adjustments all the time. Like surfing. Exactly. And what happens in sleep is it's as if we get to climb off the seesaw and relax for the night and then get back on there and we're able to surf the seesaw again. So we know there are a couple sort of foundational truths that can emerge from this model of how the brain works and how the mind works, which is that if we don't sleep, the hinge gets very loose on the seesaw. like stress, stress, stress, stress, exhaustion, stress, stress, stress, exhausted, it kind of bangs back and forth. And it gets harder to surf this seesaw. And so sleep is sort of the foundational element of all waking states. We often think about sleep as its kind of own thing, but sleep is the thing that allows you to deliberately access waking states in a really directed way.

We're gonna get really deep into sleep.

So that's the way I think about it. All of this serves as an entry point to discussions about plasticity, et cetera. But one thing to emphasize is that the seesaw and surfing the seesaw is not a brain thing, it's not a body thing, it's a brain-body thing, or more appropriately, as you said, a body-brain thing. It's a loop. So we can't say that our states of alertness are because of what's going on in our head because we've also got adrenal glands that are releasing adrenaline. We can't say that states of calmness are just about relaxing the mind because it also involves turning off a number of systems in the body. And the nervous system is really what is responsible for that. And so what's exciting is that there are now entry points where one can adjust the level of alertness or calmness that one can get better at surfing the seesaw, as I'm referring to.

Well, I've never really described like that, but I think that's a very good description of something I've learned to do to actually manage my brain and my physical states. And I developed all sorts of techniques over the years that work for me, and they're different for different people. But, you know, for example, if I'm, like, working on a project, I'm just foggy and stuck. I'll, like, take a steam and I'll jump on an ice bath. That'll change my state. Right. Well, the adrenaline from the ice bath.

Will definitely put you in a more alert state.

Yeah.

Yeah.

I meditate or I'll do yoga. or I'll get a massage, or I'll go sit by a river. There are mechanisms that I've learned that are ways to change my state. And then even using food to change your brain states, and using supplements, and using all kinds of hacks essentially to regulate the thing that we feel like we can't regulate. Because a lot of us feel powerless at the effect of our minds and the effects of our cognitive states. and we don't realize that there are all sorts of doorways that we can use to actually enter different brain and mind states by certain techniques, whether it's breathing or, you know, hot and cold therapy or all the things that I mentioned. So from your experience, you know, how do people start to learn those things? And what are the, what are the most important things you come across that are important for helping people to regulate the, that process, that seesaw where they, they're surfing instead of getting stuck.

Yeah, so there are approaches that are going to work very quickly and there are approaches that are going to be slower. And you might say, well, I just want the fast ones, but the sort of health of the seesaw, if you will, the integrity of the seesaw and the ability to surf it relies mainly on a couple of foundational elements. And these are going to be slow acting systems in the body that I don't want to bring in too many analogies, but the way I think about it is like if your well-being, if you will, is sort of like a boat on the shore and the tide has to be in for the boat to get off the shore. And so there are things that you can do on a regular basis that establish a basic ability to operate the seesaw, to surf the seesaw. And certainly sleep is going to be the number one variable.

It's amazing. Many people don't understand that.

It's a non-negotiable thing. I think that many people are afraid to acknowledge it because people have now, 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 set sleep anxiety. And so one of the things that I've been very active at, I've had for sure. Yeah, where you think, to be fair, the body and brain are resilient if you don't get it 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. So in terms of, 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 chronobiology 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 going to happen.

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

Well, they do actually. And a lot of people in Seattle need light boxes because if you live 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 brainstem 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, you know, flip on a bunch of artificial lights and then get outside once the sunlight is out. I'm just 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, 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 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 10:00 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 wanna 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 wanna 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, 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, 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 the 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 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.

So you don't have to be off from like 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. 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, they're 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 in my house last summer and we got power out for four or five days. 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 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. the three things that have made a tremendous difference. I profess, you don't profess. I profess, I don't prescribe. That's right. That's how 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, are 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.

You 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. He's 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 or 4 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. Yeah. 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 3:00 or 4:00 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, but 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 science. this discussion.

So, 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, right? 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 were about, you know, you weren't complete through your last ultradian cycle. But sleeping at 730 would be even better if you can, you know? So 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 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 want to 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.

Oh, no.

To try and sleep two hours, wake up, sleep two hours, wake up, sleep to around the clock. There are people 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.

You just do have these human bodies.

You got to actually. Yeah, you can't conquer that.

But.

But I think sleep is vitally important.

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I've built my life around sleep. Yeah, I will prioritize my sleep schedule over anything else. And so I do a few things. Like my bedtime routine starts the moment I wake up. So I do 10,000 lux of light in the eyes right when I wake up to cement my circadian rhythm. I'll eat all my food by 11:00 AM because I did a few hundred experiments of what kind of food I eat and when I finish eating and what my resting heart rate would be and how my sleep scores would be. And so now I just saw my best sleep is when I finish around 11:00 AM or noon with food. If I eat later, my resting heart rate goes up, my deep sleep goes down, my RAM goes down. Like I've tried so many times to test this and inevitably every single time. And so I eat earlier in the day. I also don't eat things like carbs, like breads and pastas. That will make my resting heart rate go up and my deep and REM go down. Am I awake after sleep onset go up? And I never drink alcohol. Even the smallest bit of alcohol in the afternoon or evening hours will wreck my deep sleep. And then for my bedroom, it's blacked out, so there's no light in there whatsoever. I have a temperature controlled mattress, eight sleep. I do a wind down routine every night, like 30 minutes or so, where Again, I do this self-talk where I say, okay, Sleep Brian is now in charge and we're going to say, Hey, work Brian, we appreciate your ambition for life. Thank you for wanting to do things. We're currently getting ready for sleep. So when you start reminding us about everything we need to do and the problems we need to solve and you're like, we can do it tomorrow, but I'm not gonna write it down. We're just gonna be Sleep Brian right now. And so I try to really focus my mind on the objective at hand because otherwise, My, I have a lot of ambition and so my mind is always popping off with like what it can do next and how it can work faster and how it can solve this and how it can solve that. And those things ruin sleep. Like if you hit your pillow thinking about work or thinking about a problem or if you're upset, you'll be in light sleep all night long just ruminating on that problem. You never go into deeper rant, like very little. And then you wake up the next morning, you feel awful. So yeah, those are some of the basics I do, but I really try to Nothing is more important in my life than high quality sleep.

Do you find EMS play a role in your sleep?

Sorry?

EMS, like technology, Wi-Fi, cell phone.

Oh, yeah.

Like you sleep at a Faraday cage.

I know.

I've recently been wearing lambs material. Lambs makes, they're here in Santa Monica. They make EMF protective clothing.

Oh, it's a company.

Clothing, yeah.

I thought you were taking like a lamb skin.

Yeah, they make EMF protective clothing. They have a whole, underwear, shirts, jackets, and I've been wearing that lately. I have it on now. And so yeah, I've been trying to do more EMF protected stuff.

Like in your house, do you turn off Wi-Fi at night or?

I don't.

And it doesn't affect your sleep.

Yeah, I also don't have a router in my room, so it's a certain distance away.

So sleep is when we're repairing the powers of both the mind and the body. Sleep is when we recharge. reduce inflammation, repair tissues. The discovery of the glymphatic system in 2012-2013 is this passive channel that runs alongside our arteries and veins in the brain that fills with fluid when we're in deep sleep and allows a washing out of debris we may have accumulated during the day.

Things like- so all those bad thoughts get washed out?

Well, not the bad thoughts. No, but the amyloid plaque, that's sticky plaque that we secrete in response to inflammation or injury. If it accumulates, of course, it can damage surrounding neurons and is associated with.

Neurodegenerative disease and Alzheimer's disease.

So in English, that means if you don't sleep, you're likely to get demented. It's definitely playing a role. And this concept of bidirectionality, we know that sleep disruption, circadian rhythm disruption, sleep apnea is present in two-thirds of people with insulin resistance, prediabetes, diabetes. And it is a chicken and the egg thing. driving the bus. We used to think, well, you get the sleep apnea because you have insulin resistance and gain weight. But if you have disrupted sleep, your insulins are higher, your cortisols are higher, your glucose is higher, you're looking for highly processed, quick energy dense foods and.

Less able to resist them. Wow, so not sleeping is a risk factor for obesity. Absolutely. And heart disease.

Yes. And cancer. And dementia. And flares of autoimmune conditions. And chronic pain and fibromyalgia and anxiety and depression. I mean, it really affects people.

Oh my God, if I don't sleep.

I'm depressed and anxious.

But the more you worry about it, the harder it gets to sleep. Yeah, it's true. Okay, so we have that chronic stress. What else is driving this insomnia pandemic, which is huge, right?

How many, 70, 90 million people are struggling with insomnia?

Right.

So I do think that there's a need to address underlying contributors to anxiety and depression independent of their impact on sleep. talking about what's going on, bringing in some kind of breath-based practice, whether that's yoga or tai chi or meditation, just to ratchet everything down. That's another important component of it. And thirdly, you've already touched on a little bit about the dopamine with the foam, but it's also the dysregulation in our circadian rhythms. You know, we think about how-- there's been a lot of research about how important it is to avoid light exposure at night, for example. But everything we do during the day and when we do it is ultimately gonna influence our ability to go to sleep when we want to and get the rest that we want to. So in other words, when we're eating all day long and snacking late at night and watching TV at night, that's signaling our- Computers. Yes, and on our computers, that's telling our bodies and brain that it's day, it's day, it's day. So we want to actually reestablish a consistent circadian rhythm. meal timing. So we're having eating earlier in the day and then building in a fasting interval before we go to bed.

So don't eat three hours before bed? No.

Interestingly enough, there's, as you know, there's a connection as well with digestive function that eating late at night not only disrupts your sleep, but it's contributing to higher reflux, which can also interrupt sleep. So everything's interconnected.

That happened to me last night, actually, because I went hiking and it's summer and it's so beautiful and it stays late and light. So we were like, didn't get down from the mountain till eight o'clock at night. And I'm like, oh, let's go eat. I'm hungry. But then by the time we ate, it was like nine o'clock. And I, like last night, I tossed and turned for a couple hours before I went to bed, which I usually don't do. It was the, you know, it was the sleeping late at night. So there's eating late at night, there's circadian rhythm disruption.

And this morning I went out and.

Sat on my deck and the sunshine was out. So getting light in the morning is so important. Absolutely. So we don't do that. We're all like on our phones or computers right away. We need the natural light to reset our brain. It makes a big difference. Light is medicine, right? It is. Light is medicine. It is. And also it could be bad medicine if it's the wrong light at the wrong time, right? Exactly. So we have all this like, there's this great book called Lights Out that I read years ago, Cindy, that was really talking about the advent of the.

Light bulb driving chronic disease because of the disruption in our rhythms and so on. It's interesting, they even looked at LED.

Street lights disrupting the circadian rhythm of animals and insects too. So it's not just humans that are.

Being impacted by this. And there's some other weird stuff that affects sleep that we don't think about.

Like what else?

Well, one of the conditions is restless leg syndrome. And that's, it's hard to diagnose. It's more of what we call a clinical diagnosis. People describe this creepy crawly sensation in their legs or this irresistible urge to rub their feet together. And typically it's treated with dopamine medications. It's connected to relatively low dopamine levels in the brain. You know, dopamine, yes, revs you up, but dopamine also seems to play a role with movement. So it's treated with some of the same medications they use to treat Parkinson's disease. But it turns out that that can be more prevalent in people who have autoimmune conditions, in which case we want to address the underlying autoimmune conditions. There are some nutrient deficiencies that are going to make the symptom of restless legs more significant. Low iron, low vitamin D, low folic acid, low magnesium. So we really want to look at somebody's nutritional status.

Yeah, and by the way, 80% of the population is deficient in vitamin D, 50% in magnesium, you know, like 20% iron. I mean, it's like a lot of people are deficient in the B vitamins and they don't even know it. Right. You know, and you go to your doctor and you have insomnia, they're not checking those things. Exactly.

And there's even weirder things in nutritional stuff, right? So if we identify a nutrient deficiency, for example, the next step is what's the why that somebody's nutrients might be low? And there we come back like so many other things to the function of the gut. And interestingly enough, there is a higher correlation in people who have small intestinal bacterial overgrowth also having restless leg syndrome, maybe because it's contributing to ongoing inflammation, maybe because it's also contributing to difficulty absorbing those nutrients from your food. So we're even going to go a step further and say, is there an underlying issue with digestive function, absorption and assimilation of nutrients that are- so if.

Your gut's a mess, it can also cause insomnia.

Absolutely.

And then heavy metals are another big one that we don't really hear about.

Right. Lead, mercury, things that are under the radar for many, many people and unfortunately can be a problem.

Yeah, and I had that. We talked about it on the show, but I've had mercury poisoning 30 years ago almost, and it really totally screwed up my sleep. What happened with your sleep? I just couldn't sleep. Like I just, I was just really couldn't fall asleep, couldn't stay asleep, never felt rested, had chronic fatigue syndrome. Until I got the mercury out, got my fillings out, chelation, everything, I couldn't sleep. And it really took a long time to reset that. Okay, so we've got all these different things that traditional medicine is ignoring, the hormonal fluctuations, the gut issues, heavy metals, nutrient deficiencies. I mean, doctors know about sleep apnea, but they often miss it in thin women because that's not the archetype of someone who actually like the Pickwickian figure with, you know, huge belly and a thick throat and size 17 neck. I mean, you know, so there's all these issues. And, and yet, you know, this continues to be such a struggle for so many people. And the, and the traditional treatments really are just stop Gap. They don't really address the cause. So in functional medicine, the way we think about things is to look at some of these other factors. So in your practice, Eddie, how do you start to dig down? What are the kinds of diagnostic things you look at differently? We talked about all these different factors, but how do you identify what's the problem in this or that particular person?

Well, I think it's the time to take a history and really understand all of the other interconnectedness that could be going on. For example, somebody with sleep concerns might also have digestive concerns, and then we might be thinking about assessing their digestive function, looking at a nutritional assessment. I think there's a time and a place and there's tremendous value in screening somebody with a portable sleep study because that gives you a tremendous amount of information. And we're using it, yes, to diagnose sleep apnea, but also to say, how often do you wake up during the night? How much percentage of time are you spending in REM sleep and deep sleep? Are you tossing and turning all night long? So it can give us a tremendous overview in terms of somebody's sleep throughout the night. and from that we can also decide, okay, what else do we need to explore? And then we do some testing, right?

You can look at nutritional levels. You can look at these vitamin D and magnesium and folate and iron studies. You can look at obviously the sleep apnea test and there's home test now you can do really great. We look at heavy metals, right? And the hormones, we can really get a sense of what's going on with hormones for people. If they're estrogens and progesterone is all out of balance. It just happens in menopause, you see. a lot of sleep issues, heavy metals, like I said, we can test. So there's, there's a lot of ways we can diagnose using functional medicine testing that you don't really get with traditional doctors that can help get underneath things. So tell me about this, this patient you had, because, you know, it sort of speaks to a lot of the issues that we're talking about, and it gives you a little unusual approach to insomnia, something you wouldn't really get from a traditional doctor.

Right, so this is somebody that, and one of the things I want to plant the seed for is sometimes we start with what we think is the most likely issue and we gradually uncover more potential contributing issues and peel the layers of the onion. And this was a woman that I had known for years. She was pretty healthy in terms of her lifestyle. She exercised, she wasn't overweight, she ate a healthy diet, she didn't drink any alcohol, she was treated with antidepressants, she was on a serotonin reuptake inhibitor and Wellbutrin for her depression. And she started, she was also on hormone replacement therapy. She was postmenopausal in her 60s, and she started complaining of fatigue and difficulty concentrating and just felt scattered. And by Sundays, she would have the need to take a three-hour nap. So, well, that's unusual. So we did some of the usual testing for causes of fatigue. We tested her thyroid. It was okay. We looked at her iron levels or sugar levels. They were okay. So I decided to do screened her with a sleep study. And it turned out you would not have looked at her and said, oh, yes, she is the poster child for sleep apnea. She turned out to have one of the most striking positional components to sleep apnea I've ever seen. When she was on her side, her sleep was normal. But when she was on her back, she had respiratory events that count as either a slowing of airflow or a stopping of airflow more than 60 times an hour.

Wow.

She should stop breathing 60 times in a minute. Yes, yes.

Like once a minute. That's a lot. No wonder she was exhausted, right? So, when you see a positional component like that, I have people who don't want to do a sleep study because they don't want to, I'd never wear that stupid mask. But for her, we said, okay, well let's start with retraining you to learn to sleep on your side. And she tried that. There's some commercially available positional devices. There are all kinds of strategies you can use.

There's a very, very sophisticated technology called the tennis ball.

Yes.

Strategy, where you sew a tennis ball into a t-shirt on the back. So if you roll over on your back, it makes you flip over to your side.

Or the fanny pack with the pillow stuffed in it. Yes. There's all kinds of strategies you could do. And of course, it's big business, right?

You can buy a slumber bump or a bumper belt.

Oh, I didn't know they had those. I was on the tennis ball track. Even more sophisticated, there's now a biofeedback device that's a strap around that vibrates when you roll on your back. So it's sort of autogenic nighttime training to get you so that's what she used, interestingly enough. And it helped a little, but she was still tired. So as we're peeling the layers of the onion, she had some digestive symptoms, a lot of bloating, a lot of discomfort, and she had, we had done a full sleep study. She had restless legs and periodic limb movements. She turned out to have a very abnormal breath test for small intestinal bacterial overgrowth.

That means bugs growing in your small intestine where they usually don't belong. Where they don't belong, right. Right. Which can cause inflammation.

Absolutely. And low iron. Her iron wasn't terribly low, but one of the sidebars here, I think the other thing we do in functional and integrative medicine is understand the difference between a normal blood test, I should put, quote, normal blood test and an optimal blood test. Ferritin is a classic example of that.

Ferritin looks at your total tissue iron.

And I think- How much iron is in your iron bank in your body? In your iron bank, your iron stores, right. And normal can be anywhere from 15 to 250.

Yeah.

So- It's a big range. It's a big range. And what we know the threshold is for somebody who's got restless leg symptoms is you actually don't wanna be normal. You wanna be over 100 because there's some evidence even comparing it head to head with those dopamine drugs we mentioned earlier, getting somebody's ferritin over 100 was as effective as the dopamine medications. That's amazing. That's amazing, right? As simple as correcting a nutrient deficiency not to the normal range, but the optimal range. for that condition.

You know, it's interesting is, you know, if, you know, heme iron is the best absorbed kind of iron, but that usually comes from meat.

Right.

And people are vegan, the plant forms of iron aren't as well absorbed.

Right.

And you often see very significant iron deficiency in these patients, especially women who are menstruating. And I think that, you know, I learned actually in traditional medicine that ferritin was connected to sleep, actually. Interesting. I learned that in a lecture on insomnia that I went to by some drug company. That's great. I was like, well, that's interesting. But yeah, I think it's something that's often overlooked and it's an easy blood test to check your ferritin, which most.

Doctors won't look at. And Mark, I think from the internal medicine standpoint too, it's equally important to say don't just correct the iron, figure out the why.

You don't wanna miss- yeah, she got colon cancer. Absolutely. A stomach ulcer, she just menstruating heavily, does she have a bladder cancer, like something, right? So I think that's really important, you're right. Just don't look at the symptom, look at the cause. Because low iron is a symptom, it's not a cause, right? caused insomnia, but what causes low iron. So that's what functional medicine does, it keeps going upstream. And you said something a couple of times that I just want to come back to, which is peeling the onion. So one of the principles of functional medicine from our mentor, Sid Baker, who is a cool old guy, Yale professor, erudite, super smart, one of the most thoughtful men in medicine, people in medicine, period. and he said, you know, we, we have the tack rules that help us sort of determine how to figure things out. One is, if you're standing on attack, it takes a lot of aspirin to make you feel better.

Right.

Take out the tack. So if, you know, the bacterial overgrowth is causing the Restless Leg Syndrome, you can take a lot of these traditional medications, but it's gonna take a lot of medication to make it away. Or if you fix the bacterial overgrowth and the, you know, that'll help. But then also, if you're standing on to tax, taking one of them out doesn't make you 50% better. So she had bacterial overgrowth and she had iron and she had the positional thing. So it's like usually three or four or five things. And the problem with medicine is we are so focused on the one thing, you know?

You know, there was one other piece related to her story that I think is also important to call out addressing all of those things. Her sleep quality was still not what she wanted to be. So we had a conversation and she relayed the fact that when she was growing up, things were pretty unsettled in her home of origin. There were a lot of late night parties, a lot of noise, and bedtime became a time where she didn't really feel safe and quiet and comfortable. So we also talked about referring her to a life management behavioral therapist to really talk about what it meant to be safe and regaining that sense of being okay being in bed. And I think that's that goes hidden as well that a previous history of trauma or not feeling safe can also show up with insomnia and difficulty sleeping.

Yeah, and I think that's a big thing for a lot of people. There's a questionnaire you can do online called the ACE questionnaire. It's Adverse Childhood Events. And you get a score. And if you have a high score, it means you've had a crappy childhood and you probably have some level of trauma. And different people respond differently to the trauma.

Of course.

But PTSD is so prevalent and our nervous systems are so jacked up in general. so it's sort of like acute on chronic.

Absolutely.

You know, we've got, like, our acute stresses on this chronic level of PTSD, and it leads to so many physical, psychological, emotional stresses for people that, and there's a lot of ways to sort of access that, you know? I mean, there's, you, you shared about how you use cognitive behavioral therapy or yoga or meditation or breath work or, you know, Emotional Freedom techniques. There's all kinds of techniques out there, but now people are exploring, you know, psychedelic assisted therapy, MDMA, psilocybin therapy. It's legal in Oregon now. And there, you know, there's some interesting research going on, Johns Hopkins and New York NYU and others are really looking at how do we help people with some of these chronic long-term traumatic events and experiences. And, and I think, you know, sort of listening to, it's just interesting to hear that you're dealing with, you know, something as simple as insomnia can be quite complicated. You have to look at inflammation in the body. It's like, where's it coming from? Is it the gut? Is it heavy metals? Is it hormonal changes? Is it nutrient deficiencies? Is it maybe it's food sensitivities or allergies? Maybe it's low thyroid. There's things that we just don't often think about. And so what's so satisfying with functional medicine is we're able to actually dig into these things and look and see the why. We say functional medicine is the medicine of why, not what, not what disease you have, which is helpful, but it's not the end of the story. We go, well, why do you have that disease? And that's the challenge with traditional medicine. It's like you make the diagnosis and you stop thinking. Okay, you've got depression. Here's antidepressant. You've got insomnia, take the C pill. Oh, you've got rheumatoid arthritis, take the rheumatoid pill. Not why do you have insomnia or depression or rheumatoid arthritis or migraines, but like why? And that's what's so powerful. So then you sort of, there's some basic sleep practices that are really good. We've covered some of this, but I think it'd be good to go over it. and I think, you know, and I think it's important to emphasize that everything matters, sleep, exercise, stress, you know, obviously your diet plays a huge role, nutrient status, and that's what we do in functional medicine, so we dig down into it. So talk about some of the other factors around sleep hygiene that we sort of haven't touched on in terms of diet and lifestyle and food exercise.

Sure. I think 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. 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 have 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.

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, 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 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 cortisol. 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.

Oh 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 6:00 and you go to bed at 10:00, it's probably not going to impact your sleep as much as.

If you have two glasses at 8:00.

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. 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 o'clock 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 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 re-regulate those circadian rhythms. So this, 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. Thanks for listening today. If you love this podcast, please share start with your friends and family. Leave a comment on your own best practices on how you upgrade your health and subscribe wherever you get your podcasts and follow me on all social media channels at Dr. Mark Hyman. And we'll see you next time on the doctor's Pharmacy. I'm always getting questions about my favorite books, podcasts, gadgets, supplements, recipes, and lots more. And now you can have access to all of this information by signing up for my free marks picks newsletter at drhyman.com forward slash Mark's picks. I promise I'll only email you once a week on Fridays and I'll never share your email address or send you anything else besides my recommendations. These are the things that have helped me on my health journey and I hope they'll help you too. Again, that's drhyman.com forward slash Mark's picks. Thank you again and we'll see you next time on the doctor's Pharmacy. This podcast is separate from my clinical practice at the Ultra Wellness Center and my work at Cleveland Clinic and Health, where I'm the Chief Medical Officer. This podcast represents my opinions and my guests' opinions, and neither myself nor the podcast endorse the views or statements of my guests. This podcast is for educational purposes only. This podcast is not a substitute for professional care by a doctor or other qualified medical professional. This podcast is provided on the understanding that it does not constitute medical or other professional advice or services. If you're looking for your help in your journey, seek out a qualified medical practitioner. You can come see us at the Ultra Wellness Center in Lenox, Massachusetts. Just go to ultrawellnesscenter.com. if you're looking for a functional medicine practitioner near you, you can visit ifm.org and search find a practitioner database. It's important that you have someone in your corner who is trained, who's a licensed Health Care practitioner, and can help you make changes, especially when it comes to your health. Keeping this podcast free is part of my mission to bring practical ways of improving Health to the general public. And keeping with theme. I'd like to express gratitude to the sponsors that made today's podcast possible. Don't forget, there's a way to listen completely ad free with Hyman plus on Apple podcasts. You can enjoy every episode without any breaks. Just open Apple podcasts and tap try free to start your seven day free trial.