What Is Driving Your Poor Sleep And How Can You Fix It? with Dr. Cindy Geyer

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

The clocks in the brain and the clocks in the body that are ideally gonna 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 gonna help us get the rest that we need at night.

Hey, everybody, it's Dr. Mark.

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Welcome to the Doctor's Pharmacy. I'm Dr. Mark Hyman, and that's Pharmacy with an F, a place for conversations that matter. And if you struggle with sleep, you better listen up, 'cause this conversation is for you. And it's with my friend and colleague, Dr. Cindy Geyer. Cindy is an extraordinary woman who I've known for decades now, hired originally at Canyon Ranch to be a doctor there. She became the medical director and has been there for 23 years leading the way there in functional medicine and has recently joined the Ultra Wellness Center. We're just so happy to have her. She's triple board certified in internal medicine, integrated medicine, and lifestyle medicine. She's on the faculty of the Center for Mind Body Medicine, teaches all over the country in the world, and is one of the best doctors I know. And I am just so excited, one, that she's joined the Ultra Wellness Center, and two, that we're having her here.

On the Doctors Pharmacy Podcast. Welcome, Cindy. Thank you, Mark. It's my honor and pleasure to be here.

All right, so we're in a special episode of the Doctor's Pharmacy called House Call, where we dive deep into clinical topics and talk about how functional medicine takes a little bit of a different approach to thinking about diagnosing and treating problems than traditional care. And why traditional care often misses the boat for things that are mostly driven by lifestyle and environment and are not acute illnesses. You get hit by a truck, you go to the emergency room. You have pneumonia, you need an antibiotic. But most of the stuff we're dealing with is lifestyle or environmental driven. And really we struggle to take care of these things. We push all these pills on people and often it misses the underlying cause. And it's often not what you think. So today we're gonna talk about sleep concerns, particularly for women. Because if you haven't noticed, men and women are different. And actually there was an NIH director, the first woman, Bernadine Healy, she was a cardiologist, and she was like, you know, we really haven't done much research on women. We just do all our studies on 70 kilogram white males from Iowa, and maybe we should think about studying women. And she initiated the Women's Health Initiative, which was a billion dollar study and just really started the whole conversation, which you think would have been started a long time ago. So 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 are expected. And then let's go into how there 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 stereotype 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. Yeah. 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 and improving sleep quality. And finally, you know, 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. And you're kind of in the middle of that, a little bit toward 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, Valium.

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

Right? Right.

And of course, those come with side effects. They impair cognition. They have all kinds of long-term effects. I mean, the benzos or things 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, there are things we've really uncovered in functional medicine that play a role in sleep that are mostly ignored. And 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 such- Like a death or divorce.

Right.

Or a transition with the job. And 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 gonna threaten you.

So that activated sympathetic nervous system is huge. And our culture just does that.

Absolutely.

The phone is like a dopamine, you know, pump. It's like a dopamine pump that keeps your blood pressure up. I mean, 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's great about it. You know, and so, like, it's like at the very end of life, like, if you can't, if everything else, epinephrine fail, everything. you give dopamine because it's so powerful at keeping you awake and alive. And so 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, you know, I wake up at 1 30 every night. And I said, well, how do you know it's 1 30? Because I look at my phone and I 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, 'cause I struggle with them as well, 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. Because you're thinking, okay, what's my tracker showing me? How well did I sleep last night? So it's that learned pattern.

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. So 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 going to 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, 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 8 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 9 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 impressive. I was like, oh, 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 and 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. 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. 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 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. And you go to your doctor and you have insomnia, they're not checking those things. Exactly.

And there's even weirder things than nutritional stuff, right? So if we identify a nutrient deficiency, for example, the next step is why? 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. 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. 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 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, a huge belly and a sick throat. 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, so in your practice, Andy, how do you, 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. But 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, and then let me do some testing, right? You can look at you can look at nutritional levels. You can look at these vitamin D and magnesium and folate and, 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 and just happens in menopause, you see a lot of sleep issues, heavy metals, 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 patient you had because 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 had 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 screen 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. Stop breathing 60 times an hour. 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, you know, I have people who don't want to do a sleep study because they don't want to, I don't, I'm dead, 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 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 can do. 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 really don't belong.

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 want to be normal. You want to 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, 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. 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 blood cancer.

Yeah, she got colon cancer. A stomach ulcer, she just menstruating heavily, that she have a bladder cancer, 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? Low iron may cause 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 wanna come back to, 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 have the TAC rules that help us sort of determine how to figure things out. One is if you're standing on a TAC, it takes a lot of aspirin to make you feel better, right? Take out the TAC. So, if 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, that'll help. But then also, if you're standing on two tacks, 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 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. You know, 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, you know, PTSD is so prevalent and, and our nervous systems are so jacked up in general, so it's sort of like acute on chronic.

Absolutely.

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's some interesting research going on, Johns Hopkins and your NYU and others are really looking at how do we help people with some of these chronic long-term traumatic events and experiences. And I think listening to, it's interesting to hear that you're dealing with something as simple as insomnia can be quite complicated. You have to look at inflammation in the body. 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 arthritis 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 and 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 had that light.

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 are you gonna 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, 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 practice 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 going to 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 going to 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 ten, it's 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. 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 nine 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'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 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. I want to close by something we probably should have done at the beginning, which is why is not sleeping so bad for you and why is sleeping so good for you?

Probably should do that, yes. So sleep is when we're repairing the powers of both the mind and the body. Sleep is when we 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 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 dementia. 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, pre-diabetes diabetes. And it is a chicken and the egg thing. It is 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. Yeah. And chronic pain. And fibromyalgia. So, and anxiety and depression.

I mean, it really affects- 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. So, it's like when you get a good night's sleep, 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 Oura 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 My sleep is not perfect. Sleep 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 lack 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 2 in the morning and I'd be like, Driving home with like tooth holding my eyes up like this, forcing myself to not fall asleep. And that just messes with you in a big way. I remember the box of donuts at.

The nurse's station because you needed the quick energy to stay awake. And then the bottle of NyQuil locks right next to it because your stomach just felt awful and you'd wolf the donuts, swing the NyQuil, and go do your work.

Sounds like a great lifestyle plan, Brandon.

Hasn't it, right?

You have to unlearn all of that. well, Cindy, so much fun having you on the doctors Pharmacy podcast on this special episode of house call. We are so thrilled that you're joining the Ultra Wellness Center. For those of you listening, if you love this conversation and you're struggling with sleep, well, we are here at the Ultra Wellness Center to help you. And now we're doing a lot of virtual consults. Unfortunately, we have a long waiting list, but we're working on that and figuring out ways to help get you in. We would love to hear from you. Please share comments about how you've overcome your challenges. Subscribe wherever you get your podcast. Share this with your friends and family. It might help them, too. And we'll see you next week on the doctor's Pharmacy. Hey, everybody, it's Dr. Hyman.

Thanks for tuning into the doctor's Pharmacy. I hope you're loving this podcast.

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