Why Sleep Is MORE IMPORTANT Than Diet (FIX THIS TODAY!) | Mark Hyman

70 million Americans don't sleep well. We have to sort of face this square on because it's really degrading our health.

How much do you agree, disagree, and feel free to add in any nuances you want to that often for many patients, sleep is more important than diet.

Well, you know, I think, I mean, diet's important for sure, right? But sleep turns out is one of the most important things for regulating so many aspects of your biology and repairing and healing and regulating your mood, your brain function, your risk of heart disease, your risk of cancer, Alzheimer's. It's quite astounding how critical sleep is. And the problem is, is that 70 million Americans don't sleep well. It's a lot of people. And it's why we see this sort of plethora of sleep medications, over-the-counter prescription medications. And it's a really huge problem. So I feel like we, we have to sort of face this square on because it's really degrading our health. Historically, 100 years ago, we slept nine hours a night. Now we're sleeping an average of seven or less on the population basis. And that's not good. And it's driven, I think, because of this sort of over compulsiveness of our society, the sort of ever present flood of content coming at us. I think we have more content coming at us in one day as humans today than we had in our entire life you know, 150 years ago, and, you know, was watching movies on Netflix later, being on your phone, your screens, or just, you know, letting life bleed into the places where we shouldn't be bleeding at night to sleep. So we really have a crisis of sleep in this country, and we have a crisis of poor quality sleep, and that's creating a secondary Cascade of issues. I remember Drew reading years ago a book called Lights Out, which was a really interesting book about the phenomena of the light bulb. and how the light bulb is responsible for so much chronic disease because rather than following the rhythms of the sun and the moon and the daily cycles, we actually would stay up late and can disrupt our circadian rhythms and end up out of balance. So, I think this is a real problem and I certainly notice for myself if I don't maintain a certain strict set of practices around sleep that my sleep can get very dysregulated because of all these inputs.

Yeah, it finally feels like sleep is getting the attention it deserves, largely with a lot of individuals out there really sounding the alarm, people like Matthew Walker who you've had on your podcast before. And for many people that are listening, their diets are pretty good, but when your sleep is really off, it can hijack your entire life. So, what are three things, Mark, that you think that people can do today, starting today, that could radically improve the quality of their sleep.

I mean, it's a lot, right? So I think it's one, your sleep environment. It's two, your sleep hygiene and habits. And three, it's what you're consuming. So the first is your sleep environment. Your bedroom should be dark. It should have cool temperature, ideally 68 degrees. You should have quiet. So, if you're not in a quiet or dark place, earplugs and eye shades are the way to go. Keeping cool is also really important at night. You sleep better when it's cool. So, there's the chili pad and the cooler and sleep eight. There's a bunch of other technologies that actually can make you have a cool bed, which is a great thing. The second is your sleep hygiene. You want to make sure you're not on your screens at least a few hours before bed, two or three hours. You don't want to eat late, three hours before bed. You don't want to be drinking a lot of alcohol, caffeine late in the day. You want to make sure that your environment is good.

Take a hot bath or take a.

Cold that people are saying helps their sleep. There's a lot of simple practices and they've written lots of articles about this. I think you can link to them in the show notes about 20 things you can do to improve your sleep. And the next bit would be you know what you're doing in terms of your lifestyle. If you, you know, exercise late, if you drink coffee, if you're eating alcohol, if you're eating late, all these things will disrupt your, your biorhythms. Ideally, you know, keeping your, your blue light exposure low. That's also really important at night because, again, we're so exposed to artificial light, we're exposed to computers, and, and that disrupts our melatonin production. So, you know, those are, those are just a few things that you should think about in terms of sleep. But the more people can focus on regulating their sleep with a rhythm and regular sleep hygiene and the right environment and avoiding the things that we know screw up sleep, and people can often reset their sleep systems.

A lot of people don't know actually what good sleep looks like. So, talk to us about what good sleep should look like or actually feel like after you've had it and contrast that with what are signs that somebody might have poor sleep quality in their life? How does it show up with how they feel?

Well, you know, I'm reading a study where they looked at sharpshooters in the military like snipers and they found that if they slept eight hours, they'd be like 99% accurate. If they slept seven hours, they would be maybe 95% accurate. If they slept six, they'd go down to 60% accurate. If they're under six, they're like, less than 50 accurate. So it's like crap shoot, which is kind of astounding because these people are highly skilled people. But it's been said that not getting adequate sleep is the equivalent to being drunk or driving drunk. And I think that's true. I've experienced a lot of sleep deprivation in my life because of working in the emergency room, delivering babies, working as a doctor on call. I mean, it's just the thing, right? And you get so impaired. I remember almost, you know, driving into a ramp on an exit ramp. when I was falling asleep driving. So it's really, really important. Quality sleep is important. So you need deep sleep, you need REM sleep. And there are now all kinds of sleep trackers, whether it's the Oura Ring or Fitbit or Apple Watch or other trackers to see what the quality of your sleep is. Are you waking up frequently? Do you have interrupted sleep? Are you getting up deep sleep? Are you getting REM sleep? So you can start to look at these things and actually get a good sense of what the quality of your sleep is. but you'll feel it. I mean, if you wake up refreshed and energetic and your head's clear, you bounce out of bed, well, you probably had a good night's sleep. If you're waking up constantly flipping and flopping, you know, that is not gonna lead to a sense of well-being and abundance and feeling good. So, you know, often your body will tell you when you don't feel good.

From lack of sleep and getting good sleep is really the medicine that we need. Sleep is medicine. What are the consequences of chronically not getting enough Sleep. Is it just that you're tired or are there deeper issues that can have almost permanent damage on the body? Absolutely.

I mean, I think we were just recognizing the dangers of sleep deprivation in terms of its risk for chronic illness, heart disease, cancer, diabetes, Alzheimer's, depression, anxiety, mood disorders of all sorts. So it's a real thing. And I think if we don't take it seriously, we're going to be missing the boat on a very important intervention. helping to address some of these chronic diseases that goes far beyond diet or exercise. The other thing that happens is your brain at night has a system of cleaning, cleaning and repair. So you need to have the, what we call the lymphatic system working. The lymphatic system is like the lymph system of the brain. That's recently been discovered, and it's so important. It really is activated at night. So if you're not sleeping at night, you're not clearing out the brain waste, and you're going to have a brain full of sludge and waste products that are metabolic waste and toxins. So it's so important for that particular reason too to make sure you have adequate good sleep.

I know there's a little bit of controversy around this and a lot of different opinions, but from your perspective, how many hours of sleep should we be shooting for in the evening? I mean, it's very individual.

Some people do fine on six hours, some people need nine hours, and you need to find out what your number is. Everybody's different. But, the amount of sleep where you can feel good and energetic and your quality of sleep is deep. I mean, if you sleep six and a half hours and it's like, you know, ton of deep sleep, a ton of REM and really reparative and that might be enough for some people. Other people might need nine. I need about eight, nine I love if I can get it. But, it really makes you feel much more vibrant and healthy and functional. So, I think, you know, it's certainly more than seven ideally and probably between seven to nine hours is a good amount. And again, as I said before, you know, last century, About half of us, I mean, sorry about the average age of the average number of hours of sleep a night was like nine hours. Now it's seven or less.

All right, next question. What are commonly overlooked issues that drive poor sleep, unexpected things, things that people may not know that expand on that first list that you gave us when we were opening the episode?

Yeah, I mean, I think people don't understand the role of their overall pattern of being and living. So, first thing is when you wake up, you should get 20 minutes of sunlight without sunglasses on because it resets your pineal gland, which makes melatonin and regulates your circadian rhythm. So, we want to keep our circadian rhythms in balance. The second thing is our diet plays a huge role. and particularly, you know, if we're eating a diet that's, you know, high in starch and carbohydrate, we're having fluctuations in blood sugar. We may actually even at night get hypoglycemia and that can really disturb our sleep. We can get night sweats. You know, men often get night sweats, too, but that's often usually low sugar. And then the cortisol spikes and you get a spike in sugar in the morning. So that's a real problem. I think the other thing is, you know, people are probably consuming a lot of alcohol, caffeine. sugar, all these disturbed sleep, chronic stress. If you're not actually discharging stress, a lot of people go to bed tired and wired and a lot of people have adrenal issues. So they're pushing so hard in their life that they actually don't have a chance to reset and relax their nervous system. And that leads to incredible amounts of cortisol production, cortisol disturbs sleep. And if you take prednisone, for whatever reason, it's going to mess up your sleep. So stress plays a huge role. Exercise, I mean, you don't want to exercise too late in the day. That can often activate you. so there are, you know, a lot of things that can drive poor sleep, lack of magnesium, which is common in the country if we don't eat magnesium in the forms of grains and beans, greens, sorry, greens and beans, nuts and seeds, that we end up with magnesium deficiency, which affects about 45% of the population and people don't sleep well when they have low magnesium. It can be irritable, cause irritability and tension and stress and then plus caffeine and chronic stress and smoking a lot of other things will cause magnesium depletion. So you wanna make sure you're getting plenty of magnesium.

Talk about sleep in your life. What are the things that now at the age that you're at and your schedule, what are the things that throw your sleep off and what are the effects that you notice in your performance the next day when your sleep is thrown off?

No. Yeah. I mean, it's huge. I mean, if I'm traveling, you know, I'm trying to stay in one place longer, but it depends on the bed and the pillows, the sound, the noise, the temperature. I mean, I can get messed up. And given all the years of screwing with my schedule and sort of staying up all night, I definitely have sleep issues. But I've learned how to actually mitigate them by, you know, making sure I do a bedtime Wind Down Ritual, by making sure I take my bedtime supplements like magnesium, a little melatonin. and if I don't get quality sleep, I notice in the next day I can't focus, I can't think, my brain is distracted. It's hard for me to be present with other people, it's hard for me to feel motivated to do anything. I notice I get a little depressed, but it's not, I know I'm not depressed, I just notice I'm asleep like I'm asleep. So I think, you know, very attentive to sleep, but I think, you know, sometimes it's hard, you know, when you're out with friends and you're traveling, you're on vacation, it's a little tricky, but mostly I'm pretty good about getting to bed by 10:00, 9:30, 10:00, sometimes a little bit later and try to sleep, you know, read a little bit. I have a light which is a reading light that's kind of an amber light that has no blue light in it. So I don't have to leave the light bulb on on the bed. So I try to calm down from the light. I have blue blocker glasses at night I use. That really helps and so that all benefits me.

Talk to us about how conventional medicine typically treats poor sleep when a patient is going through it and contrast that with functional medicine and how a functional medicine doctor would look at addressing poor sleep quality with a patient.

So from a traditional medical point of view, I mean, there are reasons for people's lack of sleep that a conventional doctor will look at, whether it's sleep apnea, restless leg syndrome, there's sleep studies that doctors do that can be very revealing a lot of people have undiagnosed sleep apnea. The Ultra Wellness Center, we now have a home sleep study kit, which allows people to kind of get tested and do it at home, which is great. However, often there's really very little to do from a conventional perspective other than recognize basic sleep hygiene. And then there's a CBT sort of approach cognitive behavioral therapy, which helps people deal with sort of the mental aspects of insomnia. and that can be very effective. Cleveland Clinic has an online program called SOMReST, which is available. So there's a lot of really useful conventional approaches to help people reset their sleep. However, there may be a lot of other causes from a functional medicine perspective for sleep disruption. Traditional medicine just says, oh, do therapy or take these sleep pills or practice better sleep hygiene, but they don't really say, well, why is your sleep disturbed in the first place? This is why we're so effective in functional medicine 'cause we don't wanna know just what you have insomnia, we don't know why, why you're not sleeping. Is it because your thyroid's not working? Is it because you have chronic stress and adrenal burnout? Is it because you have low magnesium? Is it because your microbiome is inflamed and causing inflammation in your brain? Is it because you might be hypothyroid, which can cause a little bit of sleep disruption? Or is it because you have a bad sleep environment or because your sleep habits are terrible or because, you know, we go through all the underlying root causes. and then we dress those, whatever they might be. You know, it's amazing to me, Drew, I never would have thought this was a thing, but when we put people on the 10-day detox diet, when you put people on elimination diet and get rid of, you know, processed food, sugar, dairy, gluten, grains, et cetera, it's amazing how many people report, oh, my sleep got so much better. I'm sleeping so much deeply. I feel so much better. I'm like, well, wow, I don't know about that, but I think what happens is there's inflammation in the brain and inflammation will interrupt sleep.

And when you start to live an.

Anti-Inflammatory life, you actually will end up with a much better sleep quality.

Little anecdote is that my dad many years ago when we put him on a version of the 10-day detox and he had been eating bread his whole life because he grew up vegetarian and still was vegetarian when he was doing the program. One interesting thing that he noticed is that when he had cut bread out of his diet, he noticed this chronic back pain that he had at night that would make it harder for him to fall asleep went away because the inflammation went away. And that then made it easier for him to fall asleep. And so he got a better night's rest.

There you go.

Yeah.

Talk to us about another patient and a case study that you can think of where sleep was the missing link that allowed them to get into a better state of health. Anything that comes to mind?

Well.

I have two. One was this guy who was very smart editor of a major, major sort of Sunday kind of magazine newspaper. I mean, you would all know what it was. And, you know, his team was like, he's just falling asleep all day in the office. I'm like, it's terrible. He's not. He's not able to function well. It's annoying. I'll fall asleep in meetings. I'm like, well, tell me about your life. He says, well, I drink, you know, 12 Cokes a day and have 12 cups of coffee a day. I'm like, oh, okay. Well, maybe caffeine is a problem. So we got him off the caffeine and we put him on an anti-inflammatory diet. And it was amazing. He just completely turned around and was able to, you know, be able to function again. There's another case. I remember young. We're not young. He was about a 50 year old. He's young to me now, but 50 seems very young.

Me.

And he was a lawyer and I'm like, well, tell me how you're doing. He's like, well, I want to lose weight. I'm kind of overweight. He had the big belly and pre-diabetes. And I'm like, well, tell me about your life. And he said, well, you know, I said, you sleep okay? Oh, yeah. But, you know, during the day, I use a standup desk. This is before standup desk where even a thing. And because if I sit down, I'll fall asleep. while I'm working. And I'm like, wow, okay, you probably have sleep apnea. So I said, let's test you for sleep apnea. And he sure enough had sleep apnea. We put him on a CPAP machine, which is a breathing machine to sort of stop CPAP. He literally lost 50 pounds just like that and felt so much better. And, you know, we corrected these underlying issues around sleep and metabolic Health. The thing is, if you don't sleep, you also crave carbohydrates, you crave sugar, you crave you know, all the junk that's gonna make you gain weight. And we know this even from studies on young healthy adult college males who were not overweight when they deprived them of two hours sleep a night compared to the control group, the ones that had the two hours sleep deprivation ended up having higher levels of ghrelin, which makes you hungry, and PYY was lower, which is the appetite suppressing hormone. And so they had hormonal changes that made them crave more carbohydrates, eat more food, be hungrier, gain more weight. And so really the key to often healthy metabolism and weight is actually sleeping.

A lot of people at night notice that their mind is running and it just won't get quiet and that impacts their sleep. I know you have a lot of experience with meditation and different protocols that you've used either personally or recommended to people in the past, but is there something that you could suggest that those individuals could try when it comes to winding down at night and getting ready for bed. Absolutely.

I mean, I think, you know, when you think about it, it's kind of silly. We like, go, go, go. We're answering emails at 11 o'clock at night. We're looking at our screens. We're engaged in all kinds of stressful, emotional, psychological things with your work or whatever. And then we're like, okay, lights out, boom, go to sleep. And people are exhausted, but they'll often fall asleep and then often wake up frequently because they got the stress hormones going in their body. So, I think really having a sleep ritual at night is so important for me. It's very important. I get off screens at least a couple hours before bed. I often will take a hot bath with Epsom salt and lavender, which calms my nervous system down. I'll put the little kind of amber light that has no, it's like a reading light that has no blue light. Turn all the other lights off. I'll read a little bit in bed and the reading and the calming down just calms it down. The other thing I can do often is I'll write a little before bed. So, I'll literally dump out whatever in my head. I'll just write it all out and I'll just completely purge anything that is a negative thought pattern in my head or my worries for tomorrow, what happened that day, whatever, whatever. And I just try to let go. And the other thing you can do is a little yoga stretching before bed, a little deep breathing exercises before bed, get a little massage before bed, you know, all those things can help. You know, if you're a partner, you can rub each other's feet. That's a very relaxing thing to do. I have a Theragun. I'll often use that to kind of relax my muscles. nervous system, you have to find out what's right for you. But it really requires some level of decompressing and unwinding before you get into bed because if you just plop into bed after running 100 miles an hour, it's like you're not gonna fall asleep or you'll fall asleep because you're exhausted and then you wake up because you're under chronic stress.

You chatted about this earlier, but talk about your morning routine and how crucial it is for you to set up your circadian rhythm for the rest of the day. What are the things that you do that you found work well in the morning that end up helping you have better sleep at night?

I mean, I think the key is, you know, I tend to meditate in the morning for 20 minutes. I'll have a cup of tea or maybe I'll have coffee and I'll do a little journaling and writing and just sort of get myself grounded for the day. And then I'll often try to take a walk or be outside in sunlight for 20 minutes without sunglasses on to reset my circadian rhythms. And, then I'll have a very low starch sugar breakfast, mostly protein and fat, you know, their avocados, eggs, olive oil, or I'll have a protein shake that I make with fat in it. That really helps me sort of set up my system for the day so I'm not craving the wrong food, so I'm not going off the reservation, and I'm actually keeping my system in balance.

All right, Mark, this is the part of the episode where we go to some questions from our community. and let's jump in with the first one. Is going to bed at the same time every night important? How do you discover what sleep time frame is right for your body?

Yeah, I mean, historically, we used to.

Go to bed with the sun, wake.

Up with the sun.

That's probably a good thing, you know?

And I think the advent of the light bulb and work schedules, it's just, it's kind of screwed us up, so. Historically, if you really want to look at proper sleep hygiene and the way to set up a good sleep rhythm is to go to bed at the same time and wake up at the same time every day. And generally the sleep you get before midnight is much better. So I would say 10 is at least 10, maybe 9:30 in the bed, sleep by 10, get up at 6, 6:30. That will often help you sleep much better, sleep much deeper. then if you sort of stay up till one or two in the morning. But there are people who are whose circadian rhythms are shifted and they may do better as night people versus the morning people, that's okay. But in general, I think it's really a key to sort of establish a good morning routine to get yourself set up for a good night's sleep the rest of the day.

All right, next question. Is there a particular reason that we wake up intermittently as we age? And there's two sub questions underneath it, which are, Is it normal to wake up and go to the bathroom every night? And the second question, what should I do if I'm going to bed early and still suffering from frequent wakeups throughout the evening? So this is all a question around waking up at night, especially at increasing as we age. So as we age, a bunch of things happen, right?

We tend to have more belly fat. We tend to have loss of muscle. And when that happens, you get higher levels of insulin, more fluctuations in blood sugar and lower growth hormone. and the reason that kids sleep so much and babies sleep so much is they have huge amounts of growth hormone. But when you lose muscle, you lose growth hormone and you get higher cortisol and you get higher insulin. Cortisol will prevent you from sleeping. So when you, when you lower growth hormone and raise cortisol through the aging process, you will actually have disrupted sleep. The, the reason that we do that is because we just don't, we're not active enough. Our diets aren't good. And so we're eating a high start sugar diet. We're not weight training and strength training. But the truth is at any age, you can maintain your muscle mass. I'm very, I'm now I have way more muscle mass than I did 10 years ago or 20 years ago. And it's possible if you know what to do. So I'm very focused on maintaining my muscle math, which helps growth hormone, which helps my testosterone, helps cortisol stay low. Very, very important. I think if people are waking up frequently, even if they go to bed in time, there may be something else going on. There may be, there may be metabolic issues around blood sugar, there may be chronic stress that's not really being fully addressed. There may be other factors that cause frequent awakening. As far as urinating at night, it depends on when you drink, how late you drink, how much you drink, if you have a prostate issue or not, if you have an irritable bladder or not. Normally, people can go through the night without peeing. Sometimes you get up once to go pee, it's not terrible. People can go back to sleep. But if you're going a lot more than that, it's worth getting checked out because you could have prostate enlargement if you're a man or cystitis if you're a woman. and it's good to make sure you get that check because unless you're, you know, if you're getting up two, three, four times a night to go pee, that's a problem.

All right, next question. Can a person catch up, so to speak, from a previous night of poor sleep? I think yes and no. I mean, I think, you know, people.

Anecdotally will say, look, if I didn't sleep six hours and I sleep 10 the next day, I feel better. So I think people will feel better. But, but the, the basic medical opinion is that, no, you really can't catch up on lost sleep. You've got to just keep you know, sleeping and then putting sleep in the bank and actually, you know, over time you'll feel better, but you really have to make sure you're not creating a lot of sleep debt and that you're actually sleeping more when you need to, but realize that that's not necessarily going to fix all the sleep that you've had. So, you know, it's not great to say, well, I'm just going to step in, you know, six hours a night or five hours a night during the week and I'll sleep 10 hours on the weekend. It doesn't work like that.

All right, next question. Does Dr. Hyman use a sleep tracker? And if so, which one?

Well, you know, I use a lot because I'm kind of skeptical about these things because, you know, you do three.

Different sleep trackers, you get three different results.

You know, so I use, for example, Oura Ring. I'll use a app on my phone called Sleep Cycle. There's something called Sleep Watch. That's with my Apple Watch. And, you know, I kind of amused at how variable they are and I, and how, I don't, I don't really know how accurate they are. I think the aura ring is probably the most accurate. It measures heart rate variability, it measures RAM sleep, deep sleep, breathing and so forth, movement. So there's benefits to it. And it'll give you a sense of what's happening. Like, for example, I know that, for example, I don't, I haven't been drinking alcohol much at all. And the other night I had, you know, somebody ordered a bottle on the table and had a glass, and maybe I had glass and a half of white wine with dinner. And I noticed the next, that night that my, my heart rate didn't lower, my temperature didn't lower, that my sleep was more disrupted and I'm like, Ooh, is it really worth it? I don't really know if it's worth it. I don't really like drinking that much. And, you know, I prioritize my sleep.

So it's a really important thing. Do you want to know my secret.

For living a long and happy and healthy life?

Well, all I have to do is check out my weekly newsletter, Mark's Picks, where I share my favorite tips for health, longevity, well-being, and lots more.

Check it out and link below. Does Dr. Hyman have any tips for moms to help maintain their health while enduring sleep deprivation.

I mean, yes, have a good partner who can spell you to get some more sleep. Take a nap when your baby's napping. That's what I recommend. And do the best you can to take care of yourself within all of it because, you know, your quality of parenting it's regulated by the quality of your energy and your presence in your family. And if you're sleep deprived, you're not going to be a very good company and able to really function at a high level. So prioritizing sleep is important and figuring out the support you can get at night, whether it's for your spouse or your partner, to help spell you and getting naps when your baby's napping and taking that time is really important. But it is a tough period, and I encourage people to sort Know, do the best they can, but no, it passes.

All right, next question, which is actually about napping. Do you practice napping? Are there some days where you will embrace napping? And any recommendations for people who find napping difficult to do?

Yeah, I mean, I used to do the nap pretty well. Lately, I just can't nap so well if I'm really tired of my bibbly nap. and napping is fine to do. I think it's fine if you like to nap. I think it can be, you know, you don't want to overdo it 20 minutes, half an hour. If you sleep for long periods of time, it can make you really groggy and it can affect your nighttime sleep. But I think that people who, who feel like they can and want to nap, it's so fine. And I think, you know, people can often just go down and they wake up 20 minutes later and they're refreshed. And I think that's a very good thing. I tend to meditate for me, meditating is like taking a three-hour nap sometimes. Like, I just closed my eyes for.

20 minutes, I wake up completely refreshed. All right, supplements and sleep aids. There's a few questions about them. Are there any supplements that you recommend? What are your thoughts about melatonin or other things that people might be using at night to help them get better sleep?

Yeah, so there are a lot of things you can do to help improve sleep through supplementation. So magnesium is my first go-to. A lot of people are low in magnesium that can cause insomnia. I think melatonin, anywhere from half a milligram to up to three milligrams can be a great adjunct to sleep. There's other amino acids like GABA, derivatives and theanine from green tea that can also help. There's adaptogenic things like ashwagandha, rhodiola, there's other herbs that can help as well. Valerian, passionflower, magnolia, all these lemon, lemon balm, all these can be very helpful for sleep. So I encourage people to try different things. People should not probably use chronic sleep aids like benzodiazepines or Ambien. Occasional is fine. Like if you're traveling and you want to sleep on a plane, I'll use it. But really rarely, rarely. And I think it's important for people to sort of know that these can cause long-term cognitive issues. It can cause long-term health consequences. Not getting sleep is also a problem. So, you know, it's a kind of a fine line to figure that out. But I encourage people to sort of try some of these alternative things. And I think, you know, I wrote an article years ago about the 20 tips on how to get better sleep, including a lot of the supplements, the doses, where to get them, and so forth. Also, we have a sleep masterclass that we created and people can access that. I think it's free, right, Drew? So, people can just get to the sleep masterclass and learn more about what to take, what to do, and how to regulate their sleep. It's really important.

Fantastic. What about CBD? Do you like it and who would you recommend or not recommend? try using it?

Well, CBD is a derivative of the marijuana plant, and people are using combination of CBD or CBD plus THC, which is basically pot. And that can be very effective. And I, you know, often when many other things don't work, people can take, you know, capsules or tablets or even smoke vapor or actual, you know, a marijuana cigarette. And that, that can actually help with regulating sleep and help getting to sleep, deep sleep. It helps relax them, decrease anxiety. And, I found that very helpful as well. So, I think there's room for that.

As a therapeutic tool.

And, you know, there are questions about what's the long-term consequences of CBD, THC on the brain. But, in the meantime, I think it's a very simple, easy intervention that you can do that they can help with mitigating a lot of sleep issues. And, I recommend it to my patients.

It can be very effective. It doesn't work for everybody, but it.

Can be very, very good.

Hey YouTube, if you like this video, you're gonna love the next one.

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 beautiful and it stays late 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 a late night. So there's, there's eating late at night. There's, there's circadian rhythm disruption. And this morning I went out and sat on my deck and the sunshine was out. So, you know, getting light in the morning is so Absolutely. So we don't do that. We're all on our phones or computers right away. We need the natural light to reset our brain. 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. 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, Andy, 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 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 tests 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 their estrogen 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 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 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.

Stop breathing 60 times 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 that. 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 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 should- 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.

Yeah.

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, you know, if heme iron is the best absorbed kind of iron, but that usually comes from meat. And people who 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 they went to by some drug company.

That's great.

I was like, wow, 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 want to miss colon cancer. Yeah, she got colon cancer. Absolutely. 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 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.

Ariadite, 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 rest of 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 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 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 it 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 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, 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.

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 they're, 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 I think, you know, sort of.

Listening to, it's just interesting to hear that dealing with, you know, 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, you know, 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. You know, 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? Like, you know, and that's the challenge of 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. Like, 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, 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, I think first and foremost, we have to recognize that sleep, you know, you and I trained in an era where sleep deprivation or how little sleep you could buy on was a badge of honor.

Yeah.

We need to shift that internal dialogue that, that we all have that, oh, if I'm not 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, go, hop in bed and turn it off like a switch, that doesn't work either. So building in a transition to rest and relaxation. If you can do an hour, that's great. And getting off the devices, not watching TV, maybe reading a book or journaling or doing something, taking a bath, stretching in the tub, I mean, there's all kinds of wonderful ways to ease into rest. I like the hot Epsom salt bath.

And lavender drops because the lavender lowers your 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 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.

Yeah. So if you had a glass of wine at six and you go to bed at 10, 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 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 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 noon cup of coffee. With food, it's really about quality, quantity, and timing of food. It's all 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. 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, you know, 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, Some of it has to do with stereotypes on the part of clinicians of thinking about sleep apnea being a man's condition, especially.

If they're overweight, right?

Especially putting weight on around the waist. But lean women can get sleep apnea too, and it may show up very differently. There's also the idea that when we look at times of hormonal fluctuation for women, whether that's before their periods or during pregnancy or the postpartum or the menopause transition, that can also cause an uptick in disrupted sleep. So hormone balance and regulating hormones can play a huge role in improving sleep quality. And finally, 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 elder 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, and, and, 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. Right. And, or maybe they'll give you an antidepressant.

Right, right, right.

And of course, those come with side effects. They're absolutely. They impair cognition. They have all kinds of long-term effects. I mean, the benzos are like valium and 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 there over the years, you know, there are things we've really uncovered in functional medicine that play a role in sleep that are mostly ignored. So you share 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 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 stress.

What's that?

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.

It's a run.

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. The phone is like a dopamine.

Pump.

It's like a dopamine pump that keeps your blood pressure up. I mean, when people are dying in the intensive care unit, the drug we give them to keep their heart going is dopamine.

Right?

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

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

You know, the best thing I ever did for my sleep issues, because I struggle with them as well, is.

Putting.

My phone and my watch off, like just taking everything out and not knowing what time it is. I'm 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? And when you get a good night's sleep, it's like the world just looks rosy.

And when you don't, it looks depressing. Gray. And you know, that's an important thing too, if you pay attention to how you feel. So you mentioned the 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 a... My sleep is horrible, my sleep is terrible, my sleep is 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.

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The Sumerian wheat that our ancestors ate was quite different than the wheat we're eating today. How it's grown, how it's processed, how it's milled. And, I mean, we didn't even have refined grains until the flour mills back in the 1800s. So we never.