#233 - AMA #42: Optimizing sleep - bedtime routine, molecule regimen, sleep trackers, sauna, & more

Hey everyone. Welcome to a Sneak Peek, Ask Me Anything or AMA episode of the Drive podcast. I'm your host, Peter Attia. At the end of this short episode, I'll explain how you can access the AMA episodes in full, along with a ton of other membership benefits we've created. Or you can learn more now by going to Peteratti md.com subscribe so without further delay, here's today's sneak peek of the Ask Me Anything episode. Welcome to Ask me anything episode 42. I'm once again joined by Nick Stenson. In today's episode, we cover a bunch of questions, but all of them on one topic. Sleep. Sleep is something that we've talked a lot about on past podcasts, mainly with Matt Walker. However, we haven't done a Sleep PODC podcast in over two years. In that time we've collected a lot of questions around sleep and we cover those in today's episode. These include questions around my pre bedtime routine as it relates to various behaviors that I use to optimize my sleep. We've got a lot of questions about my current molecule regimen. So what are the meds, supplements, etc that I use to help with sleep, both for routine use and maybe sometimes what I would describe as unusual circumstances such as great jet lag and things like that? Talk about how I use sleep wearables, including both the positives and potential negatives of using such trackers for sleep. Now, if you're a subscriber and you want to watch the full video of this podcast, you can find it on the Show Notes page. And if you're not a subscriber, you can watch the sneak peek of the video on our YouTube page. So without further delay, I hope you enjoy AMA number 42.

Peter, welcome to another ama. How are you doing?

Doing well. How are you?

I'm not too bad, not too bad. How's the week going?

It's good. We're still struggling with this decision about to read or not to read the books. I guess that's the thing that's on my mind today at least.

Anyone listening if they have a strong preference either way, if Peter should read it or not, let us know and we'll tally up the votes.

That's an uninformed vote because I think people would naturally tend to vote for the author to read the book, but I have information that they don't have, which is I've already heard myself read a sample of it and it's absolutely horrible. So it's really just a question of can I be coached into reading it better or is it just flogging a dead horse and is it better off to just have a professional do it?

No, I think there's anything about you, it's that you're coachable. So I think you could get there. It'll still be interesting to see what people think.

Yeah.

All right, so Peter, today's AMA not going to be about the book, but what it is going to be about is sleep. So sleep subject that, I mean we've had a lot of podcasts on, especially with guest Matt Walker, but it's been about two years since we've had any type of content on it. And it's a topic that we get so many questions on and we continue to get so many questions on. So what we did is kind of compiled all those questions for today and we're going to kind of discuss all of that. So that will include questions around your pre bedtime routine, your behaviors as it relates to how you you're currently improving your sleep. We'll talk about the molecules that you currently use, pharma over the counter supplements, and how you think about that with not only you and your patients. And then we'll also talk about wearables. What are some of the pros of them, how can they be helpful and at the same time what are some of the potential dangers of them in terms of what people think about. So with that said, I think we'll just start jumping into it with question number one.

Yep, that sounds great.

Perfect. So you shared a bit ago on Instagram, kind of your thoughts not only around sleep trackers, but also some changes you made to your pre sleep routine which have been really effective. And we received a lot of follow up questions from the audience where they just wanted to dive deeper into that. And so I think what maybe be helpful is just start with what does your current pre bedtime routine look like, especially if you're really trying to optimize your sleep for that night.

You know, this is kind of the result of many years, certainly of tinkering and also a luxury that I have today that I didn't have pre Covid, which is the luxury of not traveling, at least not with any regularity. I mean, I used to spend 150 to 180 days a year or a night a year in my own bed prior to Covid and that's completely changed now. It might be 340. So I'm really able to kind of dial in what I do at home. And it's also something I just gravitate towards paying a lot of attention to. So a lot of these insights are not necessarily new, but it's just a question of being diligent around putting them in place. So one of those, of course, is alcohol. Very difficult to have a good night's sleep. If you have alcohol in the proximity of bedtime, or even if you have two or three drinks several hours removed from bedtime, it still will linger. And that'll manifest itself in a number of ways, but probably most notably is kind of a reduction in the quality of sleep. So you'll trade more deep sleep and REM sleep for light sleep. And then the other thing you'll see is much more frequent wake ups. If you're really trying to dial in your sleep, you're going to have to basically say I'm not going to drink in the evening. For many people that just means not drinking, period. Because most people are not drinking too much in the daytime and then cutting it out in the evening. The other thing that I think I learned a lot when I was fasting like crazy is how much the low glucose empty stomach impacted sleep. It was profound. I mean, one of the things that amazed me when I was fasting was how my sleep quality improved in ways that I'd never seen before, frankly. And so I generally eat dinner early. Ish. And in large part that's because we have kids, so they're going to bed early, so we're eating all kind of early. But I noticed that if I pay attention to it, when I go to bed I'm a little bit hungry. And I think in the past there were times when I would have just had a little snack. And now I don't. Now I just say I'm going to go to bed with a little bit of a hunger pang. That's also a very positive effect on sleep. We've talked a lot about sauna. Not to get too far into this rabbit hole, but as you know, I've kind of taken a 180 on sauna. So I would say six years ago, seven years ago, when we first really did our deep dives into this, I came to the conclusion that there was really no benefit to sauna that wasn't captured in a healthy user bias, meaning all of the epidemiologic benefits associated with sauna, which are numerous. Let's be clear, there are immeasurable benefits that come from sauna if you buy the epidemiology, in particular an enormous reduction in cardiovascular mortality and mortality associated with dementia. But I really felt that that was mostly a healthy user bias. And I think over the years, and we do this every two or three years, we go back and internally revise our white papers on this. And I think it was the 2019, late 2019, early 2020, revisit this literature. When I kind of changed my mind a little bit and I started to say maybe the magnitudes of the benefits associated with sauna are being amplified by these biases that can't be controlled for. But the direction of them, the consistency of them across studies, led me to believe there's probably something there in addition to the plausibility of the mechanisms. It's a long winded way of saying I've become a pretty diehard sauna convert over the last couple of years and we have one at home now, which I always get asked questions about sauna. So I guess I'll give a bit of a digression on what kind of sauna we have. And does infrared, does it have to be dry? All those things? Let's park that and we'll come back to it in a second. But I do try to get into that sauna at least four nights a week, if not five or six. I'm really only limited by how much work I need to get done, but it's become a great tool and I like it before bed. So I know that there are a lot of people who like to do their sauna in the daytime. They like to do it right after they exercise. I think that's great. But I've been using it basically for two purposes. One, I do buy that there is some mortality benefit that comes from it. But empirically, the impact this has had on my sleep is insane. So much so that I've often wondered, is the mortality benefit of sauna largely attributed to the sleep benefits that come from its use? I don't know the answer to that question. Of course, these would all be very easy experiments to do if you lived in a resource unconstrained world.

Is there an ideal amount of time that you try and have between when you last ate and when you go to sleep? It's going to change from person to person. But just a relative rough number I think would be helpful for people.

I strive for about three hours between when I finish dinner and when my head hits the pillow. And again, I just want to be clear on all this stuff. It's super important not to go psycho on this. And I know that when I talk about it this way, it sounds like I'm going psycho. I'm not. I want to be really clear, like last night my wife and I went out to one of her friends was having a birthday party and we went out and truthfully, I probably ate an hour before going to bed. It didn't faze me. It's not like I was sitting there at the restaurant looking at my watch going, oh my God, where is the food? No, no, no. So you can do this most of the time and not be a psycho. And I think that's the broader lens you want to look at through this, which is these are general principles that are going to get violated quite often, but you want to kind of revert back to them whenever you can. This weekend you're going to be in town, Lacy's in town. I mean, we got tons of friends in town. This is going to be a bananas weekend. I promise you there will not be a night I'm going to bed this week where I will have had three hours of rest between my last meal and there probably won't be a night that I'm going to bed where I won't have had a drink. But guess what, we have a bunch of friends in town and that's the way it's going to be. But that's not the norm. So I just think with sleep in particular, there's such a psychological component to this that you just don't want to get too wrapped up in your head about this sort of stuff, because I think that can cause more harm than good. So you need to be flexible in this regard as an individual and I think. And not terribly rigid. I just hope people can interpret what I'm saying as guidelines that we try to stick to, but we have the flexibility to deviate.

I think that's really good. And it kind of fits back to what I believe was the last AMA we did, where we kind of talked about how you think about doing everything together and how sometimes you have to make concessions to live your life so you don't have to be so robotic all the time. And on that note, we have a question coming a little later on, which is maybe some of the dangers of sleep trackers. Not dangerous in the sense that it causes physical harm, but more so like the psychological piece. So I'll save that for then. But the other question that I had is, I know you like to think about things in a risk matrix a lot, like a two by two, like are you picking up a gold coin, Are you picking up a penny? Are you picking it up in front of a tricycle or a freight train? And it kind of creates that two by two matrix that you like to put into boxes. What's your current view on sauna use in terms of risk reward? Have you thought about how you would quantify that based on that risk matrix?

Yeah, I mean, it's going to depend on the individual. I do think that there are probably some people who would need to consult with their doctors before getting into a sauna. Because to be clear, when I get into a sauna, it's hot. I mean, our saunas, we run it at about 198 degrees Fahrenheit. My typical routine is 15 minutes and then a cold plunge and then 20 to 25 minutes. By the end of that second stint, you're really sort of taxed. There's clearly a subset of the population for whom that might be a little too taxing. Outside of that, I think, look, the biggest risk of sauna is there are other risks. I've heard horror stories of people that have had accidents in saunas and things like that. So we'll bracket that all of those things are possible. But like anything else, it comes at an opportunity cost. If I think about how much time I actually spend from the moment I decide to get in the sauna until I'm ready to go to bed, it's about an hour. So then the question is, what else could I be doing with that hour that would be potentially better for me? And in my case, I don't think there's much because my wife and I do it together every night. It's actually a way to spend time together and talk. And so we get that basically that hour to talk when we probably wouldn't have otherwise. I probably would have been glued to my computer working, and she would have been reading or something like that. But I think for some people that might not be the case. For some people, that opportunity cost might be too high. Maybe it's taking them away from an hour of sleep that they otherwise need, whereas I'm still able to structure it in a way that I'm still going to get eight hours in bed. That's where I think each person needs to figure out what they're giving up for that amount of time. Now, of course, it could be less. You could spend half an hour in a sauna, all told, you want to spend 20 minutes in, call it a half an hour. But at least in my world, I think every minute counts. I think that's probably true for most people. So I would say time is a big opportunity cost. Of course there's a financial cost. I think to easily utilize sauna in one form or another, whether it's dry or infrared or whatever, there's a financial investment in putting one of these things in your home or your apartment. So that also needs to be weighed into it. And again, I don't know that that's so much a risk in the way that we think of a drug or something like that, but it's certainly a cost. And then as far as the benefits go, I think there are benefits. Some of them are kind of soft benefits. So again, not to harp on this idea, but spending more time with your spouse, if that's something that you guys can do together, there's no biomarker that's going to tell you that that's a good thing. Improvement of sleep, I think, is a tangible way to assess benefit. If you fall in the camp of people whose sleep is improved by that. As far as the hard numbers that we've covered before in other podcasts around the reduction in mortality, I'd be hard pressed to believe that they are as strong as they are demonstrated in the finished data sets. But if they're half that, they're still pretty good. So it's harder for me to kind of quantify those benefits. That's where I would sort of put sauna. So let me give you another example, Nick. I wouldn't put sauna as valuable as exercise. When I start to think about what are the levers. An hour of exercise, I think is better for you than an hour of sauna, if you're really playing the game of inches.

And then the other follow up I had written down is you kind of mentioned it a little bit. But your view on dry infrared temperature, you like to keep it at that kind of stuff. Where do you kind of end up on there?

Well, I get asked this question a lot, and my answer is I don't think we know if infrared and dry have the same benefits. They're a very different mechanism. They produce a very different feeling if you're in them. And the literature is mostly on dry saunas. So for that reason and just for the fact that I wanted to have a pretty large sauna and I like the experience, the cedar, the rocks, the dumping water on it, that whole thing. That's just why we went with a dry sauna. But not everybody has the space for one. And the infrared devices, they sell devices that are relatively inexpensive, relatively small, such that if you live in a tiny apartment, you could still have one, you might only be able to seat yourself in it and nobody else but I still think there is a benefit there though it's going to be much more difficult to quantify by attribution to the literature.

I've also heard Matt Walker talk about this, which is even though as it relates to sleep benefits of a sauna can be there, but for those people who don't have access, can't get access, even a warm bath or even a hot shower can still have some of those sleep benefits that it's worth people testing before they go to bed. Those types of activities, correct?

Absolutely. And I think that's just kind of the broader theme around sleep is you have to kind of try things several times and realize if they work for you or not. I think there are probably some people who, if they do sauna before bed, it would probably have a negative impact on their sleep, whereas if they did it earlier in the day, it might produce a better outcome. So I think you just have to. Again, it comes back to flexibility and being kind of experimental in how you think about stuff.

And then the last follow up question I had wasn't planning on asking it, but it's kind of come up a few times from various episodes. I mean, mainly like strong convictions loosely held, where it's kind of like where has your opinion changed? And in one of the recent AMAs you talked a little bit about time restricted feeding and how your opinions change and the importance of protein. And even in this episode, you know you're talking about your view on sauna has kind of changed over time as new information becomes available and as truthfully what you see with your patients in practice. A lot of times you're taking what the literature says and seeing how it applies to people. And there's always going to be that small group of people who are like, why does your opinion change? How can you change your opinion? How can you speak about something now in this way and then change it? How do you think about that in terms of your journey and how you work with patients? To tie back in a previous ama, you talked a lot about how the biology of aging is so confusing and so complex that there's always going to be changes. Any advice you would have for people who are maybe a little more rigid and not open to that change in their opinions or their ideals.

I don't think it's anything I haven't said before. I think it just comes down to what you anchor to. If you anchor to being right or if you anchor to knowing the truth. If you can be more in the camp of the latter, it's easier for you to accept change. If you anchor to being right, you can sometimes get the right answer. But if that answer changes, it becomes difficult to change. I think part of it is also understanding the nature of science and the scientific process, which is that even the best experiments don't produce certainty. They just increase the probability of one idea being more likely than another. And in that sense, there really isn't much that's black and white in science. Most things are shades of gray. Now some things are really, really dark shades of gray. I mean, it's really clear that we code from DNA to RNA to protein. It's called the central dogma. But turns out there are a couple of little exceptions with viruses that go the other way around. So on the edges, there's always going to be exceptions potentially for things that are even sort of ironclad. And very few things are that ironclad. Again, we could go down the rabbit hole of whole debacle of COVID How many things were deemed absolute certainties when they had no business being deemed certainties. So if there was a little bit just more acceptance of how uncertain things are and operating in a world of probabilities, it would just be a lot easier for people to kind of navigate the changes that are coming. And I will say this, I don't find at the level of interacting with my patients that this poses a problem. I have a hard time thinking of an example where a patient was frustrated or disappointed that we were changing our point of view on something in the face of new information. I think they appreciate that.

Definitely. Anything else you want to touch on regarding your behavioral pre sleep routine before we move to your current sleep molecule regimen?

Yeah, I think the last thing I'd say is really trying to be as unstimulated as possible before I go into bed. So I even like floss and brush my teeth before doing the sauna. So that once I'm done with that sauna, it's dark, I basically just go to bed. I'm not even going into the bathroom, turning the lights on. I'm certainly not looking at my computer or my phone or anything like that. That's probably another part of why this sauna is beneficial to sleep. There's so many reasons here, and one of them could simply be that it's a forced hour of bringing myself down as opposed to working right up until the last minute. Brushing teeth, flossing teeth, jumping in bed. I think that's also a big part of this is just dialing down the rheostat of stimulation before bed.

No, I mean that makes a ton of sense. So what about the molecules then? What is your current sleep molecule regimen.

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