Hello, hello, and welcome to today's podcast. Today we're going to be talking about sleep — or the lack of it. It happens at the end of the day, but it really determines how our next day plays out and sets us up for health. So many things happen during sleep that need to happen during sleep, and hopefully we can shed some light on the causes and what you can do to help.
Why Sleep Matters
Why is sleep so important, and what actually happens while you're asleep? In a nutshell, sleep is a way for our body to recover. Everything is recovering — whether from daily stress or physical stress. It's the brain's way to clear and clean itself up and reboot the system. There are many stages of sleep, but it's really the missing piece. If I had to state one biohack, it's getting sleep — sleep will improve your longevity, period, and it's better than any supplement you'll ever take.
Sleep is one of those things we often put on the back burner. We say, "I'll catch up on the weekend," or "I only need five hours" — which I've never said in my life; I need a lot of sleep. I used to think I didn't need much, but I'm sure it affected my mental and physical outcomes. I worked overnight for several years — 12-hour shifts — and always thought I was a night owl. But I had a hard time getting home without falling asleep in the morning, and I was also going home to two kids. Back in residency, lacking sleep or working through the night, you'd definitely notice a difference the next day in cognition and remembering things.
What Happens at Night
At night, your tissue repairs, growth hormone is working, your immune system is calibrating, your brain is cleaning up memories and emotional stuff, and insulin sensitivity and general metabolic control are optimized. Your body repairs and recalibrates, which boosts our immune system.
Midlife amplifies sleep difficulties: increased stress load, hormone imbalances with perimenopause and andropause, and alcohol sensitivities and recoveries all change our ability to get a good night's sleep. Add stress and cortisol changes, hormone shifts, and overtraining with under-recovery. And beyond midlife, blue light is really detrimental to sleep. Life in general plays a role too — a new puppy, a new baby, teenagers driving home late, or caring for aging parents can all rob you of sleep. A lot of it is outside our control, which makes it so important to key in on getting the best quality and quantity of the sleep you do get.
Cortisol levels increase and spike in the early morning hours, which is what wakes us up. But if you're under chronic stress, cortisol dysregulation can affect your sleep pattern — your spike comes at 2 or 3 in the morning, or you have a lot on your mind, so your cortisol stays higher and you lose that cyclical rise and fall. Hormonal shifts exaggerate the problem too.
Sleep Apnea
Something much more prevalent these days is sleep apnea, which absolutely gets in the way of a lot of people's sleep. Basically, someone tries to go into the deeper zones of sleep but can't because they obstruct. You start to snore, then obstruct, and that wakes you up — often subconsciously — so you constantly undulate in the upper layers of sleep and never reach the deeper layers where the biggest part of immune balance and hormone regulation occurs.
Obstruction typically happens in three areas: the nose, the throat (where the tonsils and palate are), or the base of the tongue and neck area. Being overweight can contribute to obstruction. Sleep apnea is significantly underestimated and underdiagnosed — the prevalence is quite significant, anywhere from 10 to 40% globally, and the older we get, the more likely we are to have it.
Some signs to look out for: since you're asleep, you don't always notice, but if your partner says you snore, that's something to think about — and ask them if you stop breathing when you sleep, which a lot of people don't know. There's also the partner who can't sleep because of the snoring, so it's a two-sided coin. Sleep apnea can cause daytime sleepiness, irritability, high blood pressure, dry mouth, morning headaches, waking to go to the bathroom a lot, and not feeling rested when you wake.
How Much Sleep and Heart Rate Variability
A good average is 7 to 8 hours. Sleep also affects HRV — heart rate variability — which is kind of the recovery report card. HRV is a good indicator of our stress load and the balance of our autonomic system. The parasympathetic system is our "rest and digest," and people who can rest also recover better, which increases HRV. People with insomnia often have too much stress, so the sympathetic "fight or flight" mode is exaggerated.
HRV is often best monitored overnight, when things are more stable. If a wearable tracks it during the day, it looks different because of all your activity — workouts, recovery, work, stress. HRV is just the time between beats; when that gets shorter, it's a more stressful situation. We have a whole other episode on HRV, but for sleep, the good thing is knowing your baseline so you can watch your trend. If you're trending lower, that may indicate you need more recovery time. Alcohol, illness, overtraining, and poor sleep habits all affect it.
Sleep Studies
What options do we have for sleep studies? One is a home sleep study test. It used to be that sleep studies had to be done in a hospital or clinic, but now a lot of detail can be extracted from home data to predict your sleep apnea rate, listed as the AHI (apnea-hypopnea index). When obstruction lasts more than 10 seconds, that's an apnea, and as it becomes more significant it can lead to metabolic, heart, and blood pressure problems. Home sleep studies are now very comparable and easier — it's easier to sleep in your own home with fewer wires than to have someone watch you in a lab.
Your regular doctor can order an in-home sleep study, and there are reasonable self-pay options. Sleep Doctor offers a one-to-three-night study, and Empower Sleep offers a 30-day study — you wear the device for the first seven days, then meet with a sleep coach or doctor to talk about interventions as you continue. That test is about $500, and parts may be billed to insurance. Self-pay home sleep studies are under $200, around $150 to $175, so at least they're affordable. Oxygen saturation is a big component — when your brain and heart dip in oxygen, it's recorded. Restless leg syndrome and restless sleeping may also be picked up, and those keep people from good rest because they're constantly moving.
Treating Sleep Apnea
Treatments range from avoiding alcohol (especially in the evening) to weight loss — which is one reason a sleep apnea diagnosis can get a GLP-1 approved through insurance. There are oral appliances that pull the jaw and tongue forward to open the airway (the tongue attaches to the front of the jaw and relaxes back into the airway during sleep). There are many types of appliances — reach out if you have questions. And CPAP and APAP are options if your AHI is high enough. Treating sleep apnea can be a real game-changer for your overall health. As a general rule, people with poor sleep who don't reach deep layers don't dream — you'll ask someone if they dream and they'll say "never," but they wake up in the middle of the night gasping for breath.
Insomnia and CBT-I
Now let's talk about general insomnia, where you just can't sleep. Without getting into sleep medications, the gold standard people don't think about much is CBT-I — cognitive behavioral therapy for insomnia. Its benefits far outreach sleep aids; done properly, some studies suggest an 80% success rate in improving sleep quality.
We're not experts, but some pieces of CBT-I include a consistent sleep and wake schedule — going to bed and getting up at the same time, even on weekends, to let your brain know when it's time to sleep. Reduce your stimulus at bedtime — no screens, reduce the scroll and swipe. Sleep restriction can be counterintuitive but effective. Regarding naps, many good programs don't necessarily support them; if you nap because you can't make it through the day, know that you're stealing from your next day. They'll often tell you to power through and go to bed earlier.
Here I'd interject that we each need to use our own intuition about how our body feels. Everyone is different — if you can take a 20-minute nap, feel rested, and still sleep at your regular time, that's probably okay. That's the thing about CBT-I: it's truly individualized. There are things you can do to reduce the worry and panic that comes with trying to sleep. In some cases they say if you've been in bed 20 minutes and aren't asleep, get up and do something non-strenuous and calm — don't get on the internet or do emails — and come back. We'd love to have a CBT-I therapist for a good conversation.
Circadian Rhythm
Let's talk about circadian rhythm. There are many circadian rhythms — not only the 24-hour rhythm, but monthly and seasonal ones, and traveling from coast to coast changes yours. Your waking hours are what you use to reset that rhythm and make your body want to sleep.
One of the best things is getting morning light on your eyes within an hour of waking (or within an hour of sunrise if you wake earlier). There are light devices you can get too. Light is a great trigger for your brain to know it's daytime — and it only takes minutes. Get light on your eyes several times throughout the day if you can; a lot of us are stuck inside. When the sun is shining — or even when it's cloudy — get outside. If it's dark when you get up, you can spend a little money on a device giving 10,000 lux of artificial light, though it's not as good as the real thing.
Morning movement helps emphasize the early-morning cortisol spike and regulate the system — get that movement done while cortisol is high, and it slowly drops throughout the day. In the evening, dim the lights and avoid blue light. There are blue-blocker glasses if you can't avoid your computer, and a lot of phones have a night mode. I have blue-blocker readers, and they make a difference in my mood — they even set the tone during the day.
Stop caffeine earlier in the day — some say noon, 2:00 at the latest. Give yourself a chance to become unwired before bed. I use decaf, which still has minimal caffeine. My biggest thing is eating: having your biggest meal at night, especially within two hours of bedtime, is hard — you get reflux and disrupted sleep. A lot of people go out to eat late, often with wine or alcohol, which adds insult to injury. Alcohol not only disrupts sleep but can cause night sweats and hot flashes. You can choose alcohol and sleep poorly, or skip it and sleep well.
Exercising in the morning helps get cortisol up so you have a longer way to fall during the day, but if you work out at night, just be mindful of how it runs into your sleep — real life means doing things when time allows, so work with it. Make the bedroom nice, cool, and dark — better curtains, and sometimes even the clock on the nightstand is too much light.
Non-Sleep Deep Rest
Let's address non-sleep deep rest, similar to yoga nidra — a mindfulness practice where you take time midday or early afternoon to relax and train the parasympathetic nervous system. It's a trade-off for a nap. We're going to offer it at the Revelation Community Space once a week, maybe more — a short 10 to 20 minutes of relaxation, getting into your body and resetting. It's great when you're wired and overstimulated, and you'll often see HRV trends improve over time.
A Practical Sleep Repair Plan
To bring it together — a practical plan you could start tonight. If you can only do one thing, do one thing consistently for a while and see what it does for your sleep quality. The best starting point is picking a consistent waking and sleeping time (harder for those with shift work). Experiment with giving up alcohol for a week and see how it changes your sleep. Practice your wind-down routine: limit screens, get the room darker and cooler, and let your body know things are winding down.
Don't try to power through — "as soon as this show's over I'll get up off the couch and go to bed." If you're sleeping, go to bed, because you're interrupting your sleep by napping in the chair. If your symptoms suggest sleep apnea, get that sleep study. A lot of people are scared off by CPAP, but it's better to know, because there's a lot you can do.
That reminds me of one thing we didn't touch on: Inspire for sleep apnea — a surgically implantable neurological stimulator for the tongue that brings it up out of the airway. It's not an APAP, CPAP, or oral appliance, and everyone needs to meet indications for it, with extensive consultation.
If insomnia is persistent, seek out CBT-I help. And if you're a cognitive behavioral therapist or know a good one in the Kansas City area (or anywhere), please let us know — we'd love someone to refer to. Some can be individualized, some group settings, and even online, but good ones are busy and not easy to get into.
Wrapping Up
That wraps up sleep. Just know how foundational sleep is for recovery, repair, hormones, and general metabolic health. It's something the majority of people experience difficulties with and have to find ways to get through. Have a healthy day, and sleep well.