Hey, everyone, welcome to the Peter Attea drive. I'm your host, Peter, into you. Theo Drive is a result of my hunger for optimizing performance, health longevity, critical thinking, along with a few other obsessions along the way. I've spent the last several years working with some of the most successful top performing individuals in the world, and this podcast is my attempt to synthesize what I've learned along the way to help you live a higher quality, more fulfilling life. If you enjoy this podcast, you can find more information on today's episode and other topics at Peter tia MD dot com. Everybody welcome to this week's episode of the drive. I'd like to take a couple of minutes to talk about why we don't run ads on this podcast and why.

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I want my supporters to get the best deals possible on the products that I love. And as I said, we're not taking ad dollars from anyone. But instead, what I'd like to do is work with companies who make the products that I already love and would already talk about for free and have them past savings on to you again. The podcast will remain free to all. But my hope is that many of you will find enough value in one the podcast itself and to the additional content exclusive for members to support us at a level that makes sense for you. I want to thank you for taking a moment to listen to this. If you learn from and find value in the content I produce, please consider supporting us directly by signing up for a monthly subscription. Welcome back to the three part series on Sleep with Professor Matthew Walker, professor of neuroscience and psychology at the University California, Berkeley, and the founder and director of the Center for Human Sleep Science Math. You earned his undergraduate degree and PhD in neurophysiology in London and subsequently became a professor of psychiatry at Harvard Medical School before moving to Berkeley. His research examines the impact of sleep on human brain function in healthy and disease populations.

Today he has published over 100 scientific studies. He has received numerous funding awards from the National Science Foundation, National Institutes of Health, and he's a fellow of the National Academy of Sciences. He's the author of the international bestseller Why We Sleep, which also happens to be the favorite book of my not yet two year old son. He holds many patents covering various consumer base sleep recordings, sleep tracking and sleep simulation. He's asleep scientist at Google, where he helps the scientific exploration of sleep in health and disease. He is also an enormous fan of Formula One and my hero, Ireton Santa. And in the third part of this installment, we actually spend quite a bit of time discussing this. In the second part of this series, we discuss sleep and cardiovascular disease,

sleep and how it affects diet, sleep and reproductive function, the risk of deliberate sleep deprivations, sleep in cancer, the lack of sleep within the medical profession, school start times and sleep deprivation, sleep patterns and light, the biochemistry of sleep and naps. Efficacy of various medications on sleep. As a reminder at the end of this series, we're going to take questions for a follow up a m A with Matthew asking questions on the A. M A forum and listening to the A. M. A podcast with Matthew along with all I am is will only be available to subscribers. So if you haven't signed up yet, you can do so now at Peter Attea MD dot com forward slash Subscribe.

So without further delay, here is part two of three. Professor Matthew Walk. Okay, there's, like, literally 100 more things I want to ask you about. So can you make the case for why cardiovascular disease is worsened by or accelerated by sleep deprivation? And then same question. I'm gonna ask you in a moment for cancer. Just pick the best, like because again you could write a book on

those going todo book. But let me just give you one example for cardiovascular disease. There is a global experiment that is performed on 1.6 billion people across 70 countries twice a year. And it's called daylight Savings Time. And what we've seen is that in the spring, when we lose an hour of sleep, there is a subsequent 24% relative increased risk for heart attacks that following day, 24% in the full. When we gain an hour of sleep opportunity, there is a 21% reduction in heart attacks that

follow. How long has that been known? I mean, I remember the first time I saw that I was like, That can't be right.

And you know, when you see it by directionally like that, it's very diff. You know, that seems like a very robust manipulation that's being known for probably about 10 years. What's also interesting And I won't get away from cardiovascular disease. Don't worry, but just simply to mention that when you look at that same transition, you seethe. Same profile for car accidents. You see the same profile for suicidal attempts on suicide completion as well. What's also interesting, by the way, is that you see it in terms off. A federal judge is handing out harsher sentences they hand out harsher sentences on the Monday after that time change in the spring because they're Maur moody, emotional, irrational,

unless sort of, you know, empathetically sensitive because of that one hour of lost sleep and in the full, more lenient sentences, So

does this effect last for two or three days?

So there is a blast radius to it that you can see it, that it's better but still worse in the spring, which is where you lose that heresy. The effect is still worse. On the second day on, it's almost recovered by the third day and finally comes back to what looks like a baseline by about day for So there's a blast radius and this is, you

know, you know this interesting. Yeah, and here's the other thing I always found amazing about that statistic in the Northern Hemisphere. You would predict the opposite if sleep were irrelevant, right? Wouldn't you think that gaining that hour of sunlight in the day in the spring, just the overall anticipation? I mean, there's virtually no one in the Northern Hemisphere that isn't happier in April than they are in November, right? So So it's almost like you have all of that positive stuff working

against you going is the effect it will see. The signal was described yet so in the fucking cake in the face. Yet so in the face off, birds chirping, sunlight streaming temperature warming that one hour of lost sleep will still you put put you back on your Daria rather quickly in terms of all of these facets. So there's one example for cardiovascular disease. Another one. There was a fascinating city where they took a group of otherwise healthy middle aged adults who had no sign off coronary artery disease. And then they tracked them for five years. And then they looked at how much sleep that they were getting. So again, hands up. This is essentially an associational, longitudinal prospect of sardine it. You can't derive causality from it, but what you can certainly say is when they started, they had no signs off calcification of coronary artery.

Those people in that study, at the end of the five years who were getting five hours of sleep or less, had a 2 to 300% increase risk of calcification off the coronary artery, which is the main corridor of life for your heart. If you have a massive coronary, essentially, when you hear that cloak, really, that's essentially what's happening there so that you could have that calcium buildup on the basis off being book. It'd into insufficient sleep. That tells me that it's not that when you are insufficiently slept, you also are someone who has calcified arteries. It is saying that if you are insufficiently sleeping, you are increasing your risk for developing back condition. This is about the development. How hard is

it to control that? For some obvious things that would track with that, for example, shift workers or people of lower socioeconomic status who are working three jobs and all the other things that can work? There

are exclusion. There's some great exclusion criteria in that city. Were they prevent those participants from entering city? They also then added, in other factors that you could imagine would lead to that. So they controlled for those things like exercise be am I next, the conference smoking. They even include history of snoring. So they tried to take sleep apnea out of the equation, and still that relative risk was significantly larger. What do you think is the mechanism. I think the mechanism is probably several fold. I think the first thing that we see when we understood Leap people is that they become much more sympathetically nervous system driven. Now that to some people may sound Oh, that sounds like a good thing. No, you have two branches of your automatic nervous system. I

swear for a moment, I I thought you would say good knowing that the listener would understand that they're sympathetic and parasympathetic but thinking you were you were gonna make it comment about being Maur high strung is better because But no, you actually were making a joke. I live. I think you're so well tuned to

this. I think that's the beauty of my i. Q is so low. I'm such a simpleton that I can always revert to the naive state, and I don't have to make assumptions. That's the beauty of my idiocy. But no sympathetic nervous system being sort of cranked on your symptoms. Nervous system is not a good thing. Your sympathetic nervous system essentially is your fight or flight branch of the nervous system. And what we find is that as soon as you start to understand Leap an individual, that fight or flight branch of the nervous system starts to ratchet up. When that increases, you start to see. Or perhaps the reason why it increases is that you get a greater amount off adrenaline release you get. Ah, hi. Spiking in levels of cortisol, you get a blunting in growth hormone, and I think probably just the quarters all and the growth hormone alone may set you on a path towards cardiovascular disease because we know that those are two factors that lead into that sort of some of that a throat sclerotic

and brings it back to Alzheimer's disease, which is even if you just look at the epidemiologic data. The signals quite large on the benefits of I, G F and growth hormone more than any other disease in protection from nerdy generation. So that maybe even in addition to everything you talked about with respect to clearance, you're simply taking away neurotrophic factors

correct are essential. There's some data on I don't know how well replicated it is. I just Regine wants the work if you look, if you're happily four, so this is in terms of your genes. There are some genes that can predispose you to Alzheimer's disease. On this podcast, there are wonderful descriptions of going into all of the details of these but apple. We for significantly increases your risk for the development of Alzheimer's disease. It appears, but what's interesting is that if you are apo e four, but you are norm attentive, you don't necessarily have an increased risk of Alzheimer's disease. If you are happily four. But you are hypertensive, then your Alzheimer's disease risk is far higher. So,

in other words, that seems to be an interaction. A gene by cardiovascular disease interaction that leads that Gina type to predispose you to Alzheimer's disease. And therefore, you know, if you are under sleeping, you are putting your self on a path towards many new, different factors that we are learning regarding cardiovascular disease. Calcification of the arteries is one of them, but we also just see blood pressure spike. We can take someone who is in a lovely state of, you know, norm intensive profile and has bean and after either one night of total sleep deprivation or one night of short sleep, you know, we can almost start to see it after about reducing sleep by three hours, take someone down down to five hours for just one night.

You immediately see this spike in the fight or flight. Nervous system. Blood pressure goes up. You start to see quarter soul increase. Heart rate starts to increase. A swell. It's almost as though you've just got a beautiful car engine. You've put it in neutral and you put your foot on the gas pedal and you're just revving the living daylights out of that engine in a fight or flight state. Now, if you do that chronically, which is what most people do with insufficient sleep, you know, day after day, week after week, year after year, decade after decade,

It's not surprising that, you know, just revving the daylights out of that engine. At some point, gaskets are going to start blowing. It's not designed to operate in the high revving state or high revving, occasionally just fine. And if you have a beautiful that's a, you know, mescal, a Porsche engine, which lives to go to nine

grand in court. You and I in the GT three.

I had to geek out on cause for a little bit because I'm just so obsessed. I had to get it, remember? But even then, you just can't stay at that rpm that high rpm for very long. You just know it from listening to the engine. You just know that mechanical badness is happening in neutral when you've got your foot on the gas pedal. Well, that's the same way with chronic sleep deprivation, your nervous system. So I think many of the cardiovascular effects. In fact, I think we're writing a paper right now. I think if there is one central common pathway through which we can understand almost all aspects of the dill, it eerie ISS impact of insufficient sleep. It is through the autonomic nervous system and specifically an excessive leaning on the fight or flight branch off the nervous system. Which is to say that your sympathy vagal balance is way off and you are farm or in that fight or flight sort of aversive state. So I think that to me is were that disease pathology starts and perhaps progresses from that point.

And I think only adding to that, which is probably what you described is sufficient alone. But when you look at what I think are pretty well documented, up edited changes in people under sleep deprivation and, more importantly, the inferior fuel partitioning that follows. So the hyper insulin e media, the impaired glucose disposal, the tendency to probably eat more crap. I mean, I'm at my worst when I'm sleep deprived. It is, you know, I just it's so hard to avoid junk food, whereas probably the single greatest tool in my arsenal to eat well is to sleep well. I mean, it's doesn't sound like that's an obvious thing, but it's amazing

when we read the data. I mean, it's it's striking and, you know we can get into that, which is essentially What you've just described is tthe e the energy balance of an organism of a human being and both the regulation off energy once you've taken it in, and also the import of the energy on the selection of the energy, how do you eat and how much d eat? And then, secondly, once you've eaten, what does your body do with that food in terms of basic kind of blood sugar control?

And then the fourth thing is, where do you access it? So, yeah, I'm sure I mean, I'm sure this has been done. I just haven't seen it. But if you look at respiratory quotient of people, sleep deprived versus not, I'm sure, Arc, you must be going up, right? I'm sure they're absolutely going after the wrong fuel partitioning. That's exactly what you see. I'll do what you do well, be that I always forget to do.

Let me explain why that matters. Respiratory quotient Going up implies that under the same level of exertion, you would preferentially go after glycogen for a teepee as opposed to fat. And so not only is that not what most people want because they prefer to burn their fat, then burn their glucose, it signals and metabolic inefficiency which lays

at the heart of all of this stuff on a beautiful example of that is a great study that looked at the efficiency of dieting. When you are under slept and effectively, what they found is that your diet is all for nothing. If you're not sleeping well, because what they found is that when you are under slept to find a sleeping six hours or less, 70% of the weight that you lose will come from lean muscle mass and not fat, in other

words, is perfect when your cortisol is high,

that exact. So that's exactly what you'll see with cortisol. So, in other words, your body becomes immensely stingy at giving up its fat. Your body will ruthlessly hold onto its fat when you are under slept and not give it away and said it will. So when you are under slept in your losing weight, you're losing the thing that you want to keep, which is beautiful muscle definition. And you're holding onto the one thing you're trying to get rid off, which is the blueberry

fat. And it's really everything. It's the cortisol is working against you. Insulin will work against you. You're gonna have more hyper in Slovenia. You will have more catacomb a means working again.

Yet we see that with norepinephrine in particular Oh,

and testosterone will go down. That's gonna work against a deposit e

getting rid of it. Yeah, I should note, by the way, that you know men and, well, I think we'll come on to this later. But you know, men who are sleeping just 5 to 6 hours a night we'll have a level of testosterone, which is that of someone 10 years their senior. So insufficient sleep will age a man by a decade in terms of that critical aspect of wellness and virility. So if you want to sort of be very, you know, bravado about insufficient sleep, be careful. I would also say that, by the way, we found simply associational. But men who are sleeping just five hours a night have significantly smaller testicles than those men who were sleeping seven hours or more.

And I'm sure that in that you would see F S h and L h must be lower, right

that we do. So you know, I'm not trying to make necessarily funny, even though sometimes I'll start talks that way just to sort of get the bravado folks out the way. But you also firstly see that you men who are sleeping six hours or less will have fewer sperm. Those sperm will have more deformities, but this

is no limit for many's even genetic. So even an employee in

the splits correct? Yep. And you can see that in rats, too, if you do those studies and those studies have been done with short sleeping rats. But it also transfers to women that you see that women who are sleeping just 5 to 6 hours a night will have about 20% reduction in F S H, which is called follicular stimulating hormone, which essentially is a critical part off the reproductive, you know, pathway in terms of getting pregnant. Women who are sleeping that little too typically have about a 30% higher rate off abnormal menstrual cycles. So if you put together a couple that is trying to conceive on, that couple is on six hours of sleep. You've got a man who's down on testosterone down on the amount of sperm that they're producing. The motility of the sperm are reduced. And then the woman you're down on, you know you've got erratic menstrual cycles. You've got F S H. That's down to from a reproductive standpoint. This is

devastation, and again, evolutionarily isn't that surprising. It's basically Mother Nature saying, if the conditions are not optimized for you to sleep, it's probably not optimal for us to propagate the species at this moment,

and that is probably something that really happens and what happens

to F G F 21 do we know?

I was about to say, We don't know. I I should say I don't know of any studies that have looked at that.

If you have 21 has such an interesting. It's one of the few places in the brain where you'll see a difference between men and women under a fasted state. So under a fasted state, you don't appear to see the same hit in reproductive fitness of a man. But you do see it in the woman. There's actually an anatomic reason for this that I at this moment I'm forgetting. But it basically has to do with this rise of F G F 21 you'll see basically the inhibition of F S H and the women without it in the men, which again is like it's this question of if food is scarce. We really don't want a mother to try to nurture another

body yet. Maybe that's the biological warning beacon that just says time out on, you know, reproductive capacity. Right now,

I always get asked, Is Akita genic diet in any way good, bad or indifferent towards fertility? And my answer is, I actually have no clue But just on first principles, it would seem that Akita genic diet could have one negative side effect on the woman, which is exactly that. Because the ketogenic diet generally does put up F T F 21 it could be offset by benefits. If you took someone who's metabolically Il who is fixed right again inside, I could offset it. But all things equal, yeah, you know, I certainly wouldn't recommend fasting for a woman who's trying to conceive, but you've had the luxury of spending a lifetime thinking about this. I'm sort of playing catch up over the past couple

of years. By the way, it's one of the things that you do brilliantly, by the way, from what I I listened to on every one of your podcasts. But but what I would say in response to your question, though, about that evolution in question. The reason I suspect it really occurs, however, is the following human beings of the only species that deliberately deprive themselves of sleep for no apparent reason. You almost never see other organisms undergo sleep deprivation. The only time that you see another species do a seemingly restrict it sleep isn't under two conditions. The first is under certain with certain mammals. After they've given birth, they will deprive themselves of sleep to care for their young. The most obvious example there is in killer whales,

whether mother will break from what's called the part, which is the main group. They will go away and they will give birth, and then they will bring that car back to the main part, and during that time they will short sleep. The second is under conditions of starvation that when an animal starts to become starved, they will. There is awake promoting signal where you will actually stay awake longer. And it gives the animal the ability to forage in a larger perimeter because presumably the current perimeter is not containing sufficient food. And I think that that's the reason why some people will say when I undergo, you know, either time restricted feeding, especially when I undergo fasting. The reason that I feel like I don't need to sleep a CE much or, you know and I feel more awake even though I'm sleeping less and it's great. I actually would be very cautious about doing that for long periods of time and doing it sort of repetitive Lee for long periods of time is because there are still you're still suffering the decker mints of insufficient sleep.

But the reason that you feel awake is because there is a biological mechanism in place that says, Oh, my goodness, if you're not getting food, we need to keep you awake for a little longer. We're going to sacrifice this thing called sleep for a little bed so that you can go and find more food. So there's awake promoting mechanism and we know how that works. But the more important point here being made, I think, for me is that because human beings are the only species that deliberately deprive itself of sleep and no other species has really done that, it means that Mother Nature, throughout the course of evolution, has never had to face the challenge of sleep deprivation. So, in other words, Mother Nature has never come up with any safety nets for any of our major biological systems.

Metabolic, reproductive, cardiovascular immune, mental health. None of these things have any safe holding. They don't have any sort of crutches when sleep goes away. Why? Because Mother Nature's never being asked to solve that question. Now I'll give you an example.

I use the same argument, by the way, for sitting in chairs. You know what I want or so many of these things sedentary behavior as it reaches that we just do that. We you could argue if our species could survive another 100 million years, maybe sitting around doing nothing drinking soda would we would we would figure out a way to make that not so harmful, assuming it interfered with, you know, our capacity to reproduce. If it didn't, then maybe evolution wouldn't take any interest

in it. But, I mean, I think it's It's the reason for me at least why on alternative example there in the pro would be, you know, an adipose cell that Mother Nature throughout the course of our life and most species experienced times when there was feast and times when there was famine and to Mother Nature, faced with that challenge of famine, came up with a solution called the fat cell, so that we could store caloric credit and then spend it when we needed to. When we went into famine, Where is the adipose? Self asleep? Where's the fat self asleep, you know. Wouldn't it be lovely if we could store up sleep credit and then spend it? And the answer is, there is no such thing because it's there is never being the challenge in the course of evolution to come up with that solution

because hibernation is not an example right now, information is the obvious it Hi there. Agent basically says It's not giving you credit to sleep less in the summer. It's just taking stock of the fact that there really is nothing for you to eat in the winter.

Correct, and that that's really about energy expenditure on essentially energy preservation and Tor Perrin hibernation of different states toe sleep itself. But that's always, I think, being something I've thought a lot about that example of, you know, the fat cell versus sleep. And it's the reason why people unfortunately think that sleep maybe like the bank, that you can accumulate a debt during the week, and then you can just sleep it off during the weekend. What's

the name again for that phenomenon of the sort of Monday through Friday short sleeper who been sleeps on the weekend what's

called Social Jet social jet. Yeah, where you sort of essentially, It's what I used to term very politically incorrectly asleep bulimia, which was where you would essentially, you know, purged during the week. And then you just binge during the week. It's really been judge kind of abstinence syndrome. The reason it's problematic is not just because sleep doesn't work like that on the studies show that that's very dill ity. Areas to health is because it also is terrible torture on your circadian biology, because what happens is that you start to wake up. You know you'll be going to bed at once sort of one or, you know midnight rather than nine and then waking up but 10 11 on a Saturday and a Sunday And then come Sunday night, you've got to drag your body clock back by three hours, you know, to get into bed and you repeat it the next weekend.

That's essentially like saying to your biology and no different. I'm going to fly back and forth from San Francisco to New York every weekend. Three. Our social jet like difference. That's a hazard ratio impact on your circadian

biology there. And as I'm listening to you say this, I'm making the stronger and stronger case for my move to Austin, which in part is driven by just shortening the trips that I have to take. You know, to be ableto only have to take a one hour time zone delta or, you know, never basically having to take more than a two hour time zone. Delta is your

fuel life span health. Spend for the impact that you can have on this planet planet and this society. During the time that you're here on DDE for the preservation of you in your Children's life, I would strongly

recommend it. I'll share. We do an interesting example of a patient of mine who has an example of what happens when that system, you know, quote unquote breaks those gentlemen, I'll try toe be as vague as possible. So I don't identify him even if he's listening. Not that he would care if I told the story anonymously, basically worked in the finance sector, but at some point was living on the west coast of the United States but basically was exclusively involved in, you know, Eastern European markets. So you can imagine what time he had to be waking up to deal with that after several years and Heat in part, moved from the West Coast to the East Coast to try to make that gap smaller. But he got to the point where he could never sleep past 3 a.m. It was metaphysically impossible, regardless of what time if he went to bed early. If he went to bed late,

he was up a 3 a.m. And it turned out one of my colleagues, Vic Jane, who's a Stanford trained sleep docket, Northwestern and also someone I just can't wait to interview because he's just so insightful and sleep. You know, he basically did something that you and I had talked about earlier, which was reverse use of melatonin and blue light to phase shift him into the correct time zone. And what humbled me about the story was how long it took to move. And it just gives you that sense of could you imagine forcing that on your system once a week? And I mean, it took months to correctly is correct acquittal right now. Admittedly, it had been in place for a couple of years. By the time you know I met him. So you you know you have a little bit more to overcome. But nevertheless, I was blown away at the lengths that Vic had to go to drag him forward by three hours

for that biology to have bean tortured for that long. It's going to take a reset of, you know, nontrivial magnitude and help from exogenous agents like melatonin, like blue light, regular exercise exposures, daylight, you know, even manipulations of body temperature it could take. So there are a whole arsenal of tools in the sleep doc kind of books that we can use to sort of make thes manipulations, either be it for people with insomnia, be people with anxiety, be a people with sort of jet lag or what's called circadian phase delay, which is essentially what he was suffering from,

which was you mentioned Temperature. This was something I didn't know until I learned it through the through this patient's case and through through vics learning, which was about two hours before the wake up. You see this drop in temperature and, like that drop in this guy is occurring at 1 a.m. He's getting that drop up and then And so you What you basically were doing was dragging that thing to, you know, 4 a.m. You had to drag the temperature dropped to 4 a.m. And again, I think it just speaks to the complexity of this situation and is a general rule. When you mess with really complex, hardwired, evolutionarily sound things, you've gotta be careful. You're gonna pay the fiddler

when you fight Biology and sleep is one of the most conserved behaviors across all living organisms that we've observed. When you fight that kind of innate hard grained biology you normally lose on the way that you know that you've lost is disease and sickness either acute or chronic. You know, at some point a lack of sleep will get you. It may be in your late stages of life. You know Margaret Thatcher. Ronald Reagan Examples with Alzheimer's disease could be from a heart attack prematurely. When you're 56 years old, could be a car crash at any moment in time because of a micro sleep, you will be pumped out of the gene pool pretty quickly.

So let's talk about one more thing, which I'll we could talk about cardiovascular disease for much longer. But let's talk about cancer and let's talk about when I talk about these diseases with patients. One of the things I try to do is say, Let's reverse engineer what we think is happening when this disease goes wrong and then back things out. So when it comes to cancer, I say, Look, cancer has a bunch of things that have to go wrong. First, you have to have a genetic insult to it has to be missed by the immune system. Unfortunately, most of the time R T cells can figure out that cancer is non self, et cetera, et cetera, and you kind of walk through all of these things. So let's talk about the immune system for a moment,

because we know that if you're not well, I wanna let you explain that. Yeah, well, like I said, I was gonna I was just about to go off on this topic, but tell me about how sleep impacts the immune system, and not only how that might impact getting common colds, but how it could impact cancer.

So, firstly, what we know is that there are now significant links epidemiologically between sleep and cancer off a variety of forms. Currently, that list includes cancer of the bowel, cancer of the prostate, cancer of the breast. And then

we can step down. You're basically three

of the top. Our Exactly. Yeah, three of the heavy hitters. Next, you can sort of say Okay. What? What about the causal evidence? Well, firstly, I would say before I describe the causal evidence that causal evidence is now so strong that recently the World Health Organization decided to classify any form of nighttime shift work as a probable carcinogen, their words not mine and the proof of evidence that is required by the World Health Organization. To make such a statement usually has to be astronomical. On that data is now, I think, very well put in place. I'll just mention one quick cause on manipulation study done by a colleague down at U.

C. L. A. They took a group of healthy adults, and they limited them to just four hours of sleep for one single night. And then they looked at a set of cells called natural killer cells, and you can think of natural killer cells like the Secret Service agents of the immune system in that they're pretty good at identifying dangerous foreign elements, one of which are malignant cancer cells. They'll inject some things into them and try and destroy them essentially. So what you want is a pretty veer. I'll set of those immune assassins circulating in your body, and what they found is that one night of four hours off sleep reduction led to a 70% drop in natural killer cell activity. That's quite a surprising state of immune deficiency that has happened within one night so you can step and repeat that and imagine what would be the state of your immune system, particularly for those critical anti cancer fighting immune cells. After several weeks, if not months,

of insufficient sleep, that's one aspect, which is what is your vulnerability to developing cancer? Because, you know, many of us are you know, we'll have cancer cells emerging in our body retail, so we need those aspects of our immune system to prevent those cells from becoming the disease that we call cancer. E

mean that such an important point. And I'm probably biased because I trained in immunotherapy lab, but I don't think people necessarily appreciate that we pretty much always have cancer, and our immune system is pretty much always protecting us. It's actually the exception when the cancer develops into something clinically and you know, I've debated, not debated the wrong question. One of my favorite sort of sitting around dinner discussions with with cancer biologists is what is the greater driving force for the obvious age association of cancer. In other words, why does cancer increase non linearly as you age? And I offer to hypotheses? Is it three? Actually, is it an increase in the rate of muted Genesis? Do X to experience on a per unit of time basis? A greater insult to the genome, too,

If you assume that that's the same, is it that overtime, the accumulation and the expression the FINA type of that becomes more problematic and or three is it that our immune system, specifically the adaptive immune system, is weakening and the balance starts tipping in favor of cancer? And, you know, I've asked this question of Nobel Laureates and future Nobel Laureates. Every one of them has said we don't know. They suspect it's all of the above, but they all agree that the weakening of the adaptive immune system is almost assuredly playing a role in why we get cancer. Maura's we age because we know many things air working against us when we do that. And so when I hear you say NK cells, which you know the CD eight cell, the NK cell, the CD four cells these are These are your green Berets and your navy seals of the war against cancer.

If you put a hit on those guys, you you know, you could be taking a 10 year step in the wrong direction, right? Just as you talked about the ganado tenure leap, right? Yeah, testosterone

to me. I would love to add a three b hypothesis the which is that one of the most dramatic changes with age on the most sizable and robust physiological changes in with age that we see is that your sleep gets worse and sleep is probably one of the most powerful regulators of your immune system. You know, if you want a full arsenal and you want every single weapon in there to be sharp and ready to annihilate, sleep is what you need that data. I think it's very clear in terms of the decimation of your immune system with sleep on that. You know, I just gave one example. That, too. And the funny thing is like, you give that example and

it's not even that dramatic like there's no person listening to this who hasn't had a four hour sleep night. That's part and parcel for just being a human being in the civilized world, maybe even in a non civilized world, right? And yet to think about a lifetime of stacking those things and the com pounding effect of what does it mean to get eight hours a night versus 6.2 to 5 hours a night? Imagine that. I'm almost amazed it doesn't kill us quicker because, to your point, we have adapted a great system to cope with excess nutrients, right? We had a great system, and it takes a long time for that to break us down. I think in some ways we're probably so naive and our ability to measure the short term consequences of sleep. I mean, not you, of course, because this is what I'm thinking about that night. But I think as a medical community were really shitty at knowing how to measure short term like what's really happening and sleep deprivation

in, you know, in clinics and healthcare system. There, like

in school like we don't really understand how bad sleep deprivation is on a learning child. We don't We clearly don't understand what it's doing on the road like we don't understand that this will kill you much faster than bad nutrition right, which is literally going to

kill you. But you know, if you look at all cause mortality and short sleep, don't even linear. It's exponential. You know it, really, it's sleep. Will bend that curve of your life span in a downward direction with a dart into the ground when it starts to get short.

I think your argument is so great that it really comes down to the fact that at least we had a system in place to train us for excess nutrients. Now, look, we can argue we didn't have a system to train us to consume refined carbohydrates. We didn't have a system that trained to consume massive amounts of poly unsaturated fats or high high amounts of sucrose, but we still knew how to consume some of these things and there is a dampening effect in nutrition that the, you know, ever present at a parasite can numb and at least for a while, blunt that system. But you're right. If we didn't, if it wasn't really until what, probably 200 years ago, that sleep deprivation could have become common. When do you really think was the tipping point? I know that in the forties we could compare the forties to today, but it would almost seem like the light bulb was a pretty big step in the wrong direction. If I know anything not to blame,

Yeah, but you could go back and you could argue that you know, Edison with the light bulb and hiss his company may have bean the starting point. I think it was probably happening even earlier on the basis of social demands. You know, the industrial era,

I think. Then you

compound things once we switch from an agrarian society to an industrial society. In my mind, that's when stuff

I mean, my histories were home, but that's about 250

years. Yeah, exactly. Yes, I think we've seen that back cover started to

happen, so it's an evolutionary millisecond

correct. Correct. Sounds like a long time, the blink of an eye. The other aspect of you know cancer is not just that you increase your risk for developing cancer because you weaken the immune system components that other to combat against all of those, you know, carcinogenic influences Selya Lee that you've just described. But another study by a colleague at the University of Chicago, David, goes out. He looks at the relationship between sleep loss and cancer and mice, and I'll just give you one example of us that he he did took a group of mice, inoculated them with some cancer cells on the back and then gave that cancer a one month period to grow. At the end of the month, he resected the skin measured the size of the tumor. Half of those mice were allowed to sleep normally. The other half had their sleep restricted,

so they just had their sleep kind of top and tail, not total deprivation, just limiting their sleep in the morning in the evening a little bit. What they found is that at the end of that one month, there was under slept mice when they looked at them the tumor was 200% larger. I mean, it was physically distorting the body. And if you were to see these pictures, you know, you would just think My goodness, you know, I can see it's small, tiny, little sort of dot That is the growth of the cancer in the well slept mice. You know, the others.

It just looked like a hideous, you know, mass on these under slept mice. Secondly, what they found was that that cancer in those under slept mice had actually metastasized, which is just, you know, in some ways a fancy way of saying that it breached the original origin and started to invade other organs bone as well as brain. And when cancer becomes metastatic, you know, that's when we know things can get really dark and grim in terms of life.

Expect there are many mechanisms that you could generators or hypothesize. It could explain that I want curious as to how many they were. So one would, I think, be exactly what we've described. Which is this immune weakening? Yeah, but you could also look at so hyper quarter Salimi is gonna drive him patty glucose outputs as they activate hyper insulin. Did they say

you look a little green, Elect, um, ized the mice and prior to that prior to it. So they control the control of the metabolic resurrects. Yeah, and what they did find in terms of they looked a little bit of the mechanism. They found that macrophage em one sells. Those were actually down, regulated by a lack of sleep on what was up. Regulated was a sort of a rogue version which is called the M two cells, which seemed to have a tomb of promotion components to them

as well. So they really But the adrenal ectomy is brilliant. What clever to take

out the stress response. And they limited that. And if you deal, and that's the fear is how much worse would it be when it really happens in humans? Because you will have that plus this huge tsunami off a cortisol impact hyper courses all impact, which is only going to say so.

So bring this now back to the clinical tragedy here, right, which is again the weakness of our profession. And I say ours. Meaning mine and not yours. You take a patient who's got a diagnosis of cancer. Do you think anxiety is going to go up? Hell, yes, right. Do you think they're sleep is going to deteriorate on no basis other than the fact that they have this diagnosis and there often undergoing horrible treatment, right? It's amazing to me that I can't imagine how many oncologists are thinking through this problem. Right, Which is as careful as we are about crafting what the chemotherapy regimen looks like with the exact if you go to ask. Oh, right. If you go to the largest oncology meeting, I don't know how many papers are being addressed on this topic. Do you

know, I I think there are. They are few and far between

with where do you think about some of the stuff we machin eight over an oncology? Like exactly who gets the sentinel node biopsy versus this? And Well, what if this is any RPR positive breast cancer versus an e r positive pr negative. Like we could we could noodle and machin eight on the most minute

details, which, you know, maybe

they matter. Maybe they don't And yet something like this seems so obvious. And yet, you know, we just seemed ill equipped to deal with it like it's almost like you said.

And it doesn't surprise me either. By the way, it's not your fault as a medical profession, you know, and being part of that profession, you know, what I did was I looked at a retrospective, and I looked at medical curriculums across. You know, the top 21st World countries practicing medicine on what you find is that on average, most doctors get about 1 to 2 hours off education regarding sleep, so 1 to 2 hours regarding 1/3 of the patient's lives that is so anemic in terms of meeting the needs. But the critical part is that 1/3 of their life spent sleeping also makes such a huge difference to their 2/3 of their life awake. That is just to me unacceptable.

And there's a deeper problem, which is in training to be a part of that profession. You enter a culture that is as difficult as the one you described where you know, heads of state are chest pounding about how little they sleep. I mean, I'll just pause for a moment to share another sort of set of stories, so When I started my residency, we were on call every third night. I'm in every third night. You know, I think my record I think the most sleep I ever got on call in five years was five hours. And that happened once. And it wasn't, of course, straight five hours. But I had accumulated five obviously gonna call night. So I think you would average probably 2 to 2.5 hours of sleep every third night.

But that's average. So guess what? Lots of those times or 30 minutes or less. So you're on call every third night. So it's my second month on the job. So the way it works is you. You're basically either on call post caller pre call. Those would be your designation. So I come in on a Monday. I am pre call. So it's my day before Mike all day. So, you know, you come in at five in the morning, you would normally leave by about eight o'clock at night or seven o'clock at night. And as we're finishing our rounds that evening,

someone a surgical resident had failed to show for the e r shift. He got sick. So The chief resident said, You know, Hey, we need somebody to stick around tonight to cover the e. R. So I volunteered because I want to show how tough I am. Like, Of course I can do this. So I stick around. I do the e r shift that night. Of course, in the air, you're absolutely not. You don't get one minute of sleep,

obviously. Now it's Tuesday. Now I'm on call. So I'm awake, Of course, all day, Tuesday and Tuesday night and Wednesday. And I probably slept an hour Tuesday into Wednesday. Now it's Wednesday. I get to go home early, which means 6 p.m. On Wednesday. So I've been up since Monday morning. So this is not like within the realm of the type of sleep deprivation that's gonna kill you. There are lots of people in the comeback to that. Yeah, it almost,

actually. Yeah. Okay, so I'm driving home my point in case so I'm driving home. So I have quite a long drive till I have to get to the freeway. It's about two miles, but it's like stop signs and street lights, and then I have to get to the freeway and then I've got kind of a hike home. At the this point in time, I lived kind of north of the hospital. I noticed something really odd every time I come to a stop later stop sign. I can't keep my foot on the clutch because for some reason, I just I have a habit of, like, keeping my foot on the clutch and keeping it. And first,

as opposed to just sitting in neutral, which whatever. So the point is, I keep stalling, and I'm thinking, I've never done this in my life. Like, why can't I even sit here for 27 seconds and maintain my motor control over this thing? So I met aboutthe last street, maybe maybe two streets away from before. I have to get on the freeway for a 15 minute drive. And in what I can only describe as one of the best, dumbest decisions of my life, I decide I freaking cannot get on this freeway. I'm going to die. So I pull over to the side of this road Eastern Avenue,

and there's this park called Patterson Park. I have no idea what Patterson Park is like today, but at the time I knew nothing about it other than it was grassy. It turned out at the time it was like, you know, an open air drug market and and this is now speaks to the second point. So I had really good judgment, which was Don't get on the freeway. But then I exercise the comically bad judgment, which is I'm going to go take a nap in the park so I get out of my car, probably didn't even lock it, walked into the park, put my pager on my neck of my scrubs, set the alarm for one hour. It's like 6 p.m. Wake up at 2 a.m. In the middle of the park with rat bites on my arms. I mean,

this is like the drug infested, rat infested park. And just think to myself, what in the hell just happened? I had about three of those in residency. The other thing that happened once in residency, same situation every third night call. But I had to take an extra shift in there, and to be clear, I volunteered, right? It wasn't like no one put a gun to my head and said, You have to do this. I volunteered for someone who couldn't take a night of call, so I basically was on the same thing. But now I'm way further into my residency.

You know, this was in my fifth year of training, and I think the accumulation of that was devastating. And so now it's two in the morning on that third night and we're operating on a patient. And the way it works in residency is when you're a senior enough resident. You're the operating surgeon, meaning you're the one doing the case. The attending surgeon is assisting you, and there's a very trivial operation we were doing. The only reason, in fact we did it in the middle of the night is just to get the O. R. Time like it wasn't even an emergent case. It certainly could have waited a day was just removing the gall bladder laparoscopically. So I'm holding the two devices that in the TRO cars, and I'm doing the case and the attending is just retracting for me and I don't know how it happened, but I fell asleep on the patient and face planted directly onto the patient and again, the only Solis.

You imagined the amount of sleep pressure that was necessary to build up for you, too. I mean, and I remembered that

I had had a number of head drops

prior. Exactly. Yeah, everyone's like jamming take up music. But no. Then it's just like falling asleep,

right? Right. And, you know, after God knows how many of those it just turned into bang you full l position face first into the patient again. The only fortunate thing there is in the process. I didn't jerk my hand and tear the common bile duct. Or, you know, an artery that could kill a patient. So what happened? Well, the attending surgeon said, Dude, you're too tired. Let me do the case. You come and hold this like it wasn't even like it was just sort of like this happens and you go stand over there now,

whereas you think about like if that had happened in an airplane, an airplane or in some other profession, where you think that's a four alarm fire that say, What's going on here? How can this happen?

It is on the data that we've got is pretty strong. You know, I've lobbied the the medical association on a number of times a night, just recently wrote a piece in the general called the Lancet, which was called a sleep prescription for medicine on a lay out the case for why both for patient and doctor sleep is, you know, utterly essential but profoundly absent. And firstly, what we know regarding, you know, your surgical experience and that that story there we know that if an attending surgeon has slept only six hours in the previous 24 there is 170% higher likelihood that they will make a major surgical era such as, you know, spicing some kind of major vascular component of the patient. What's also interesting is that when if a resident has worked a 30 hour shift relative to when they've worked just a 16 hour shift, that resident after 30 hours of being awake, when they get back in their car and start to drive home, just as you did,

there is a 178% increased likelihood that they'll get into a car crash end up back in the same emergency room from which they just came. But now, as a patient requiring e R treatment because they got into across. The irony is lost on me, either that the other point is that we know that one in five medical residents will make a serious medical era during their residency caused by insufficient sleep. One in 20 medical residents will kill a patient because of insufficient sleep. Now, when you realize that there's well over 20,000 medical residents active right now and you think about that statistic one out of 20 and you, too, then do the math and lay out the number of bodies in front of you that were preventable deaths preventable by way of this simple thing called insufficient sleep. I think it is an absolute disgrace. You know, doctors working in the E R. If, if they residence, if they've worked a 30 hour shift,

460% I think it is more diagnostic errors, which just stuns me in terms of a number. But what's also interesting is that when you lobby the medical organization and I've tried to do this a while back, and I lay out that compassionate case of medical errors impact on patients impact on doctors themselves. There was incredible pushback and resistance, which was my mind is made up. Don't confuse me with the facts. And

I want to just, you know, have a mea culpa because there are few people that were more vocal, more vocally opposed in our residency than me when this 80 hour work week came in and my view was not that sleep was, you know, good and we needed more of it. I really didn't have a point of view on that. Actually, frankly, hadn't reflected on that because I obviously didn't know any of the data you shared. My view was, the conditions under which we work are horrible, and that's a selection feature. You want people that are willing to opt into that who are willing to take that much pain to do this. And I had this whole thesis, which I have no idea if it turned out to be true or not, that if you lowered the bar,

lowered the pain, you would bring in a broader demographic. Now, regardless of whether that's true or not, it doesn't really matter in the face of this data. In other words, if it is true that back in the day you were just training better physicians because you were attracting people that could persevere more or had whatever you know, make up your thing. It still doesn't change the fact you've gotta come up with a new screen. For that. You gotta come up with

a new filter. Evidence off the delicate, serious impact of even if you attract, even if it's just a selection bias that you're bringing in thes hard nickel folks who can just jam through with wakefulness in ways that you know really are just horrific for everyone involved. You still can't get around the fact that they're not going to be performing medicine at its highest, and we know for a fact that you don't need to. So I think the only piece of evidence that favors that type of, you know, 30 hour, continuous residency type of mentality. The only good argument I've heard is continuity of care that once you go down to a shorter amount of time, you lose continuity of care with the patient that you're cycling doctors between patients. But I have to say, though even that I don't believe, because when I looked at systematically at the other medical practices. There are places that train wonderful physicians that have a maximum of somewhere between 12 to 16 hours, places like New Zealand,

Sweden and France. They all limit their junior doctors to training on nothing Maur than those amount of ours. And if you then look at the ranking off the medical systems in terms of how well they're doing, those guys are way up there at the top. So I find it difficult to see a case for arguing for the ability to train doctors with insufficient sleep.

I'll tell you what I think is going on, because I agree. I mean, I haven't been away from it for so long, but I've spoken to a few people who have kept up with the sort of medical education literature, and it turns out the 80 hour work week has not solved the problems that they had wanted. I don't believe that medical errors have necessarily gone down. You could argue, will eighties not low enough. But I also think of a more subtle part of it is in the countries that you mentioned. I suspect that it is the cultural norm of not just the residents, but the people who trained those residents because they were trained in that sort of more humane way that you bring a different way of thinking about handing off a patient. It means something different because it's just so ingrained in. That's how medicine is practice. And I think what happened in the United States and again, this is wild speculation. I don't follow this literature,

but just based on what I've seen since, I suspect that when you overnight created a new rule which I think took place like July 1st, 2003 new rule right overnight. But none of the people that were leading that had trained under those conditions they didn't necessarily know how to teach under those conditions. They didn't understand, as we said, like, What does it mean to hand off a patient after 16 hours? Because in our day you are responsible for everything. I mean, you wouldn't dream of doing something like that because you just don't know how to communicate what needs to be done to the next person. I mean, so much of it just comes out of that. So I suspect that's a big part of it. And of course, unfortunately, that would suggest that this is going to take time, but it still

has to change time. But I said, I fear that type of mentality is going to die one generation at a time because in part that was, you know, it's a bit of an old boy's network. I think some of it. But you mentioned those things about how do we understand the informational transfer the propagation from one doctor to the next regarding continuity of the patient who remains on. I think that really is an important point part of me that feels as though we've been able to put people on the moon and that was non trivial, but we solved it. I think we can also probably solve continuity of kir and protect both patient and doctor like in terms of their well being and still do it. So I think it's no, no, no, don't do that sort of trivialize the problem. And I think what I want to try and do here is, you know, just raise my hands and say that,

you know, I really appreciate how hard that is. It It's just like early school start times and the work that I'm doing there to try and lobby for kids to start later. That's not a small thing, either, because you've got to solve multiple problems. You've got to solve bust unions, bus transportation. You've got parents who need to be in work at a certain time point on, you know, starting those times later is going to be nontrivial. All of these things are hard problems, and it's not as though I'm either ignorant of those on. I want to really recognize how hard they are. But what I would also love to do is to try and just make sure that we don't lose sight off the end outcome here. The end outcome in terms of education is our Children and making sure that we are not essentially educating our Children.

EMusic, by way of the insufficient sleep on the same is true for our patients and our doctors. Let's keep the target that we have in our cross her at the end of this process in mind. Rather than get perhaps distracted by how difficult the problem is, it is difficult. I am so sympathetic to that. I know it's hard, but there's so much on the line. There is too much on the line for us to be swayed by the difficulty of the problem in terms of the importance of the solution that we must reach.

No, no, no. I don't disagree with anything, you said. I think what I'm trying to do is provide an explanation for why. And it's not an excuse. More of an explanation for why I think the experiment has failed here and it probably speaks to the need for a greater buy in to the gravity of the problem and therefore a greater emphasis on solving what I agree are quite in the grand scheme of things, trivial problems. I mean, splitting the atom was hard putting a man on the moon that was hard eradicating slavery. That was hard. All of these things have been done,

But I think we will look back, you know, with shame, just like you were describing to your family regarding sleep an insufficiency as we look back now with smoking, you know, 50 years ago we will look back in probably 20 years with shame that we were having schools start at 7 30 in the morning. By the way, for schools that started 7 30 in the morning. Buses will start leaving at 5 30 in the morning. That means some kids are having to wake up at 5 15 5 o'clock or even earlier, which in my mind is lunacy. And I think that shame will be present when we consider the impact and the impact we already know from the studies there. When we delay school start times, What we see is that academic grades improve. We see truancy rates decrease. We see behavioral problems and psychiatric problems also decrease. You see the number of people who drop out of school and drop out of certain classes also decrease.

And then finally, shockingly, the life expectancy of students increases on the reason that it increases is because of car crashes. It was a great study in Tatton County in Wyoming. They shifted their school start times from 7 35 in the morning toe 8 55 in the morning, and then they look to seeing just this narrow age range of just 16 to 18 years old. What was the change in car accidents on what they found in that following year? Not just that the kids reported getting one hour of extra sleep. There was a 70% drop in car crashes that following year. Now the advent of A. B s technology and cars, antilock brake systems that dropped accident rates by 20 to 25%. And it was deemed a revolution by some people. Well, here's a biological feature getting enough sleep that will drop accident rates by up to 70%. So when sleep is abundant, mines will flourish. And if all goal, as educators truly is to educate and not risk lives in the process that I fear that we are failing our Children in a quite spectacular manner with this incessant model of early school start times, it's

a little bit more on this. You and I have talked about this in the past, which is, and I think I even posed the question to you this way, which was, you know, all things equal, Matt, if you're trying to pick between three schools for your kids, like, would you weigh start time in the matrix of decision and you your answer was emphatically. Yes. Why is this the case? Why is it that do kids just is there something in their brain is. They're developing that. It's just a question of they need more sleep and therefore you'll pick it up in the morning. Or is there something about they need to sleep to a later time that won't be solved by putting them to bed earlier?

All of the above. So, firstly, you know kids, even when you're 16 17 18 you're still needing 9 to 10 hours of sleep because your brain doesn't finish developing until it's about 25.

What percentage of 18 year olds in the US do we believe are getting that sleep? Or if it's easier to answer the question, what do we believe is the median duration of sleep for about 11% 11% or achieving the required

89% not getting sufficiency?

And do we have a sense of what that averages? I think the numbers you quoted earlier I assume we're for adults or was that for

all comers? No, that was for adults. For teenagers, it's It's down to about seven hours when it should be somewhere between 9 to 10 hours. So the bigger deficit, so then a dialysis deficit is big oven. It is an adult What's also striking, by the way, is if you look at parents and you ask them, Do you think your teenager is getting sufficient sleep? 72% of them will say yes. I think my teenager is getting the sleep that they need, yet only 11% of them are getting the necessary sleep. So in other words, there is a mismatch here between the parental and child sleep equation on what that also leads to then, because parents believe that their kids are getting enough sleep,

there is a parent to child transmission of sleep. Neglect on when I mean by that is, you know, the pulling the covers off of the weekend when these kids are sleeping in for two reasons. First, either sleeping in because, naturally, their biological circadian rhythm moves forward in time, so they they want to go to bed later and wake up later. It's not their choice. They don't get a choice in that biological. It's hard

y. It's over apparent listening. What would you say to them if they're bristling with their kids Sleep schedule? What do we think is the most natural time? Too bad time to rise for Ah 16 17 18 year old,

I think for, you know, 16 17. You know, you're looking at a 10 hour period, probably from, you know, somewhere between 10 to midnight, depending on their krone type two, then sleeping in until, you know, essentially somewhere between 8 32 10 30 the following morning. Now, the reason that that is actually still too early, though, is because that would be what would naturally happen if you were to let them sleep like that every single night off the seven days off the week. But we don't because what we do is during the five days of the school week,

we are getting them up way too early. You can even put them to bed at you know, nine or 10 and say sleep. They can't biologically, so they won't be sleeping as well during the week. So at the weekend, they're trying to sleep off a chronic debt that we've saddled them with during the week due to early school start times. So no wonder they've got such a sleep pressure that is forcing him to try and sleep until, like, one or two in the afternoon. So then we chastise them for saying You're lazy, get out of bed. You're wasting the day, but it's not their fault. Firstly, because their biological rhythms,

the circadian rhythm wants them to be asleep latent into the morning and into the early afternoon on. Secondly, they've got this huge debt of sleep that they're having a rebound from in terms of sleeping, trying to sleep off that debt, that the school systems have given them a swell. So to me, I think we just need to, you know, re formulate our notion of how important sleepers in

that context. And you've already alluded to this. That's a hard one to solve, right, because you're restructuring when apparent, goes to work etcetera so nontrivial what would be a middle ground? That would be a great compromise. In other words, like if if a school started at 9 a.m. I feel like when I was in high school, we started at 9

a.m. Well ironically. Yet what's happened is that back in the sixties, schools were starting around nine o'clock and then evermore as we marched on in terms of our quote unquote development in society in the US, that time has actually gone back and back to earlier and earlier start times, I think because it's been squeezed by the sort of the vice grips off. You know, work schedules were parents are having to work longer hours. They are ultimately commuting for longer, so they have to leave the house ever earlier. So they have to put this kid's in school ever earlier on dhe. I think many of these kids are just sitting there un absorbent, like a water log sponge. They're not going to be taking up information. And in fact, if you look at the data regarding delayed school, start times and you ask, guess overall G p.

A s A T scores, all of them rocket up. They all improve when you delay school start times. But which classes get the biggest benefit in terms of the grade improvement? It tends to be not the classes in the afternoon where they are finally awake because of their circadian rhythm. It's the classes in the morning were before these classes would be starting at, you know, eight o'clock, but now are starting at 9 30 when you push them to 9 30 They're doing much better in those classes. And it reaffirms the case that the hit that is going on in terms off the amnesia impact that early school start times are having is really in those morning hours when the brain is not designed to be awake. And it's certainly not designed to be receiving an education. It's designed to be asleep, preparing itself for its education, which should really start up maybe nine or 10 o'clock in the money. I mean, the United Kingdom right now as we speak at the time of this podcast, there is a bill that's going through that will lobby for a 10 a.m. Start time, which I think is probably that the sweet spot

and the reality of it is because someone will say, Well, great what he want kids to stay in school till six PM and gullible. My guess is you could probably do less with them or, if you did it right in there is he wouldn't need to spend as much time in school. If you could have

cramped tracking, you could efficient, you know, more efficiently learned that information weaved In these studies, you absolutely do learn more efficiently when you have had sufficient sleep. So it's a forcing function. Could you compress it? It's like zipping a file. You know, the amount of information that could be stored is much greater. But what's also interesting? Let's see that that's not the case. And you say, Look to duel of the staggered system with the bust unions and to make it work out with currents and work schedules, it's going to require more money to figure this out. Well, it turns out that some of that could be cost savings at the back end because kids get released later.

There is a time during when kids get kicked out of school if they start early, which is this kind of criminal bewitching hour, which is where the kids are out of school. But the parents are not home yet from work, and when they get together, sometimes for some kids, bad things happen. That's where you see a lot of juvenile crime happen, which is in that sort of twilight hour between, you know, the 3 to 4 PM period when they're out of school to the 6 to 7 p.m. Period. Were the parents of finally there and they get home If you look at the cost of that criminal impact off activity in those hours and then you say if we were to start schools later, kids get out later. We limit the window off criminal opportunity. The cost savings comes back around and pays for itself for delayed school start times. So you just need to open up the aperture of your memory. Think about the problem. And ultimately you can solve these

equations. My daughter hates when I say this, but I keep saying to her that I think this whole summer vacation thing's ridiculous because, you know, it's sort of an artifact of the world when you needed the kids to sort of work in the farm in the summer. But it almost seems like having a shorter day, shorter time in school, more time, another uniform, the situation right, more time to do extracurricular things. More time to sleep. But just go to school 12 months out of the year, like go to school like we work right? Yeah, that seems to be also culturally, a very difficult solution, but conceptually an easier way to approach

this as well. I mean, I love your idea and I do think that the data supports it empirically right now, which is that you may not necessarily need to just simply take the school day and push it forward in time. You may just need to take the start off school and push it forward in time on hold, constantly end of the day. But by way of that sufficient sleep, ultimately you may be able to still gain the same amount of intellectual equity within the minds of those young individuals by way of that sort of later school. Start time on great asleep as a consequence,

and it also just seems like something that is so amenable to testing. I mean, it's very easy to do randomized controlled trial of something.

Lots of that stuff that's going on right now. The data just keeps coming out, and it goes in no other direction. It's so consistent,

it really is. Is there anything that we as parents can do outside of the obvious, which is choosing, You know, if we have the luxury right, a lot of times you don't have the luxury, but if you have the luxury of choosing between schools that have a meaning if you can choose by where you live or if you're putting your kids into private schools or something. The later time let's assume you don't have that luxury, and you got this hand that's dealt to you, which is school starts at 8 10 and you know it gets out of whatever 3 40 What can we do to help the kids get as much sleep as possible, even if it means bucking against what might be their innate circadian rhythm?

I think probably right now the best thing to do is to try and excise technology. And, you know, I'm very

when you say that, you just say that again. That is such I mean, that is such a hot topic right now. But is visit other discussion ahead of my daughter, which is I worried that in 20 years we will look back at the idea of 10 year olds with iPhones. As I worry, we will look at it with even a worse lens than this smoking mother, and that's there's two fold, right. There's the technology piece, which we'll talk about, and then that says nothing about the whole social piece of you know, the influence of social media and stuff like that. But so sticking to the 1st 1 you take the technology away completely. You limit light after

sundown. So there's that component, which is, I think, just the basic impact of light on this is scales to not just Children skills to adults, too, that we are a dark, deprived society in this modern era on, we need darkness at night to allow the release of a hormone called melatonin and that melatonin as it rises it will help time the onset of your sleep. And there are great cities that have bean done where, if you use, let's say, an iPad for an hour before bed. First, you get about a 50% drop in the amount of melatonin that's released, so you lose 50% of the signal off sleep timing. Worse still,

that melatonin peak, even though it's lower to 50% lower, it will arrive three hours later at night, so it's so mistimed by the perverse impact off the screen. So that would be like you and I living here in California. But our melatonin releases much closer to Hawaii in terms of timing. That's one out, one hour of iPad reading. Is that

true? Also Matt. For television, this television him

in the same. It doesn't so television less so. But television has another mental impact, especially if you're watching it in bed. That's not a good idea, because then your brain associates your bedroom as the place of being awake and watching television, not the place of sleep. And that's when you start to form those maladaptive associations. It could be a trigger of insomnia and anxiety, and typically that's one of the recommendations that we have that you only use the bad. If you're struggling with your sleep for sleep and intimacy, that's it. But to come back to the kids, that's the first impact, which is that the light can disturb and disrupt their melatonin. Significantly. We also found in those studies,

by the way, that the one hour of iPod reading before bed reduced the amount of REM sleep time when people woke up the next day, you havethe um, rate. How refreshed by your sleep do you feel significantly lower rates of feeling restored and refreshed by their sleep. What was also interesting is that once you stop that iPad reading it again had this carryover effect. It had this blast radius where they kept sleeping poorly for another 2 to 3 days after that Ipads reading. The second component, though, is a mental component. I think it's the component that maybe as if not stronger than the biological component with melatonin, which is, firstly, that these devices that kids use concourse sleep, procrastination. What I mean by that is and this is just for adults,

too. You could be there with your phone or your iPad and you could be sleeping and you could fall asleep. No problem at all, but because you got it there, you just think, Oh, just check email one more time. Just check Facebook. All right, let me send that tweet out. I forgot the detergent. Let me go into Amazon very quickly, and I just ordered that and and then you look up and it's 40 minutes later, and now you're 40 minutes short on your sleep. Sleep. Procrastination is a problem, but for kids, I think the two bigger issues are waking up in the middle of the night. There was a survey done that demonstrated that well over 80% of teenagers admit to waking up during the night to check their phones and check

social media. Sorry.

Say that again. 8080 during the week will wake up at least once to check their devices. So you've got this dependency that is causing this alertness spike toe, wake you up and that's a habit that wants it builds is quite difficult to break the final thing. I think even if you were to be diligent and put your phone in airplane mode, what those technologies do is cause what's called anticipatory anxiety. So I think many people have had that experience of having it like an early morning flight. And you've got to wake up at 5 30 in the morning and you know it. You set the alarm, but you wake up at 5 28 you are awake like a bolt.

I want I'm glad you brought this up. I have noticed this for my entire life. I sometimes will play the game of Can you wake up at 5 28? I'm blown away at the ability to do that. Now you can't do it if you're really sleep deprived. At least I can't. So I can't go to bed at 2 a.m. Three nights in a row, and I wouldn't believe it if you don't have a mom. What? What is that telling us about? It's almost like I've got a CPU with a crack

in it, like no one actual. No karaoke, that that's

right, because because you condone it to a wrong time, you can miss set the clock at the bed by 10 minutes and hit that time versus true time, right? It's

crazy. And if there's a great experiment that I'll tell you about but that anticipatory anxiety, that airplane example, that's kind of like the extreme version, but, ah, weaker version, but a chronic. And I think Avery maligned, sort of version of It happens with our phones because most people, the first thing that they do when they wake up in the morning is swipe and may just unlock this world of anxiety that comes flooding in through their phone e mails, texts, social media. You essentially are training your brain toe. Anticipate that wave of anxiety every morning, and what we've discovered is that when you embed that anticipatory expectation in the morning, the amount of deep sleep that you get a night is less.

You end up sleeping in a shallow state and you don't get the same amount of deep sleep. And the great earthy anxiety that there is the next morning. The greater the reduction in deep sleep that you have night before. That's why you'll feel like you've had a pretty rough night of sleep when you're waking up for that early morning flight because you've just had, ah, poor quality of sleep. But the timing think so. I think to come back to to make the point here, So I don't forget. I think for kids, the best recommendation right now is technology to try and limited. And I know that's hard because the genie feels like get out the bottle and it's not going back in any time soon. And I don't want to be puritanical. I don't want to be puritanical about alcohol off caffeine about CBD teach. See, I don't want to be puritanical about kids getting the sleep or timing of the sleep that they need or can't get.

But what I would say is that to try and maximize that sleep in the face off early school start times, which is what we're currently facing right now. Taking that technology out the bedroom is probably the single best thing that you can try and dio. The other thing that they recently found was a correlation between the use off or having social media in the bedroom and fear of missing out. Because for kids so often I understand this, you know, because we were both kids, you could remember that folks were going out, you know, in the afternoon you want to be there. He wants to hang out. Is fear of missing hours foam? Oh, well, now foam Oh, place out on social media and it plays out when you disengage from the parents.

It plays out, in other words, in those twilight hours. And so there is good data now showing that fear of missing out is directly related to insufficient sleep at night in teenagers. The way that you can try to help that is to try and limit the devices that give you the ability to have foam O in the first place. So, but in truth, I don't honestly have a good set of solutions right now for this teenage sleep problem. I think it's gonna have to be letting them sleep when biologically, they naturally want to sleep again. You fight that biology. It's not gonna go your way. It's

just not, well, Matt, that that certainly ah will scare any parent senseless with respect to electron ICS. You know, one of the question on that that my daughter actually asking all the time if she's reading a book in bed with Like a night light is that is harmful. A. From the standpoint of light, which is actually the question she's asking and now be would be my question. More broadly, we talked about not watching TV in bed because that's creating kind of a different purpose. Is reading in bed a bad idea and or is the, you know, sort of natural white light that not natural. But you know, the white light you get from a bulb? Where does that rank on the melatonin suppressing scale?

So if you're someone who is struggling with sleep, that you are someone who has sort of insomnia suggests that you are finding it difficult to either fall asleep or you wake up at night and you can't get back asleep so The first is what we call sleep onset insomnia. The other is called sleep Maintenance and somebody You can fall asleep. Fine, but you can't maintain your sleep. The advice there is even reading should be something that you should forgo that you should read in a different room. Wait until you get really sleepy and then go to bed. That's the advice. And because otherwise, as I mentioned, the brain is this incredibly associative device. And if you lie in bed awake, your brain quickly learns that your bed is the place of wakefulness. I hear this from patients a lot where they'll say, Look, I'm sitting on the couch watching television on, I'm falling asleep and then I get into bed and I'm wide awake and I don't know why.

And the answer is because your brain has learned the connection of your bedroom being a trigger for wakefulness, because wakefulness is what you do there. So what you need to do is break that association and get up. After 20 minutes, go to a different room in dim light, read a book else were in dim light, and I'll come back to what type of light in a second and then only when you're sleepy and there's no time limit for this, should you return to bed? The analogy would be this. You would never sit at a dinner table waiting to get hungry. So why do we lie in bed waiting to get sleepy? And you shouldn't way need to, sort of, you know, bring that back. So that's if you're struggling in terms of light.

What I would say is be a bit mindful as to what kind of light it is if it's an led light, it's usually enriched in the blue sort of low frequency of the visible light spectrum. And it's the blue light that is most harmful to melatonin. So light in general, not great for melatonin. It will stamp the brakes on melatonin, and it will stop releasing it. So your brain is fooled into thinking it's still daytime, even though it's actually on the clock face nighttime. But off that light, if there is a better form of light, it's the red and the yellow, the very warm kind of colors, the cold blue light that comes from led. That's the more dill it eeriest light. That's the type of light that is more detrimental.

So I would say that you know, you could get these smart light bulbs now that can change the dynamic frequency range of that light in the visible spectrum. Make it Maur kind of warm and yellow in the evening. Definitely favor that and try to stay away from, you know, light that is led light, even if it's just going back to a classic light bulb, which typically is warmer in color and low in wattage.

That's your best light for reading as the experiment been done when this magnet from the ethical Today, where subjects are given no restriction on when to sleep. How long to sleep. But they're put in a perpetually light environment.

No, but the opposite. Well,

I know of the opposite. Yeah,

this'll, too. No, there's one experiment that has kind of being done, that it's like that. And then there's the other opposite, which is so the one experiment that's not dissimilar to that actually happened inadvertently, unfortunately, which is with premature babies in the neonatal intensive care unit, What they used to do was they would just leave thes fluorescent light bulbs on in the nick you all of the time. And at that point, even though the circadian rhythm isn't especially, you know, robust in infants there, you know, awake, they're asleep or awake.

They're asleep. They still need that signal of light and dark. And what they found is that when they regularized light in the neonatal intensive care unit, in other words, when they gave back darkness at night and gave strong light during the day, firstly, the infant started to sleep better. You saw about a 50% improvement in oxygen saturation in those infants, and they put more weight on within the time period because they were sleeping more regularly. And then finally, they left the neck you somewhere between 2 to 2.5 weeks earlier. So that's the only example I know off were you take condition where you were put under artificial continuous light conditions, and then you do the experiment where you try to mimic more naturally, what a 12 12 hour cycle off light, dark would be. And what you see are just biological changes all for the better.

That's the only experiment that I know of in the positive, which is what you're describing the reverse experiment was done where they essentially took a group of people. They said, you know, what time do you normally go to bed, mister? Nobody goes to bed early. I can't get sleepy until about 11 p.m. On I sleep usually about 6 6.5 hours. They took that group of people off. They went to the Sierras, here in America, this sort of beautiful mountain range with no electricity whatsoever, no access to artificial light. And firstly, what was dramatic was that these individuals started going to bed around nine o'clock in the evening. This wasn't necessarily just because they didn't have anything to do.

They actually rated themselves as feeling sleepier earlier. Why? Because they were getting the signal of darkness at the natural time. Secondly, they went from being, you know, ardent about the fact that they were only 6.5 hour sleepers, and that's all that they needed to then sleeping a little bit more than nine hours. Now I think this point about going to bed at 9 p.m. Is a really important one. Have you ever thought about what the term midnight actually means? It means it means middle of the solar cycle means middle of the night. Where is now with the perversity of the industrialized civilization? Midnight and especially now in the digital revolution means it's maybe the last time. Thio, you know, send a few emails,

whereas if you look at hunter gatherer tribes whose way of life hasn't changed for thousands of years and you ask, how do they sleep as if they are a good indicator? And we think that that's probably a good indicator of how hominids should sleep. They typically go to bed about an hour and 1/2 to 2 hours after sundown. Serb around sort of 8 39 o'clock. They usually get about 7 7.5 hours of sleep a night, and then they have a siesta like nap in the afternoon to make it up to around about a total of nine hours. So I think what has happened with modernity is that we have changed both the amount of sleep that we're getting. We've reduced it. We've changed the timing of sleep, so we're getting less sleep on. We're getting it at a different time, quote unquote, perhaps a wrong time of night, and finally, the nature in which we obtain our sleep has bean changed.

It seems as though we are designed, perhaps to be sleeping by physically, which is a long about at night and then a siesta like nap in the afternoon. A lot of people will ask me about this two faces of sleep thing, but in a very different sense, which was you sleep about four hours. Then you wake up. You kind of have a social life. And then you go back to sleep for another four hours and it's called the two Sleeps or first sleep in second sleep on. There's a great book written on this now that definitely happened sometime in human civilization. It seemed to happen around the Deck Enzian era, but there is nothing in our biology that suggests that we should be sleeping in that way. It seems to have bean a social feature, social

pressure. There is a meal that took place a lad's rail that took place between those two sandwiched between the 24 hour sleeps, right?

Correct. Yeah. Yeah, and people would you know, they would have social activities planned. They would write. They were playing music make love people. You know, it was a really thing, but it was not a biologically defined way of sleeping. It's not not a

natural waves you'd think you'd be. I mean, I guess you could condition yourself to do anything but toe wake up after four hours of sleep, under any circumstances generally quite miserable.

It's rough. It's absolutely terrible. So that happened. But I think to come back to the point, it's just that how we are sleeping in modern society is not just about sleeping less. It's about sleeping less, the timing of our sleep and the structure of our sleep. So I think those are the things that have changed. One

of the questions I get asked a lot, and I don't know the answer. So I'm hoping you do is one that you sort of touched on it. But the efficacy of naps and two, the notion that you should or shouldn't nap if you're having sleep issues, right, so on the 2nd 1 I have a slightly stronger point of view, and I hope it's not incorrect, which is in that situation. That nap is is wrong. You want thehe dentist, an accumulation and you wanted to draw your bedtime back earlier, right? If you're struggling, I would rather you pushed through, not sleeping and then go to bed at nine o'clock. But to the first question,

more broadly speaking, I can't imagine that one cycles through what you described at the outset of our discussion in a 20 minute or or our long nap, right? I mean, what actually, do you have people nap in the lab as well? You must know what does it

look like? So we've done a lot of thesis studies. Were we ask, you know, what are the benefits of napping? And we certainly do find them. We find benefits for learning and memory. We find benefits on immune function. We find benefits for things like cardiovascular health. In terms of metrics of heart rate variability, we see benefits in terms off lowered systolic blood pressure. All of these things we found benefit by way of a nap. Now, when I say nap, you can ask, What do you mean by a nap? And we've played around with that dose as it Well,

we've done so. We tried to do a little bit of a dose response curve with some of these things, too. What we found is that you can go down as lowers about 20 minutes of a nap and still see some mental benefits in terms of things like learning and memory. But typically we do a nap. That is 90 minutes, because that gives the ability of the brain to go through the full 90 minute cycle so that the brain Congar, through all of the stages of non REM sleep stages one through four, and it gets the shot to get two realms sleep. And then we can ask by testing people in brain scanner sort of before and after him with cognitive tests on them with peripheral body tests, we can ask what was the benefit of that nap relative to a group that does exactly the same thing? They lie in bed, but we don't let them fall asleep that they may just kind of passively watch a movie so there, inert for the same amount of time that in bed they get off the wires on the head. We tried to do it as controlled as possible, with the only difference between being sleep between those two groups.

So you do find benefits T to your first point to your second point. You're absolutely right in terms of your sleep prescription for your patients. Their current recommendation is this. If you are finding it difficult to sleep at night and sleep throughout the night, the recommendation is due, not nap during the day. And this helps us when we try to think about the biological mechanisms of how wake and sleep actually work. And you mentioned a chemical called Dennis seen So from the moment that you and I woke up this morning and everyone listening the moment that you woke up this morning, chemical is being building up in your brain called Dennis Scene, the more of it that builds up the sleepier that you will feel. So it's the sleepiness chemical, and after about 16 hours of accumulation, you should have enough weight off healthy sleepiness. You should have enough a dentist scene within the brain tohave you full asleep easily and then stay asleep soundly. And then when you're in sleep, the brain actually will clear away that a dentist seen removing the sleepiness,

and after about eight hours of sleep, you've removed 16 hours off accumulation of a dentist scene so that when you wake up them in the morning, you feel alert. You feel more awake, and that's the reason that you don't feel a sleepy anymore throughout that following day. Now the problem with naps is that if you nap in during the day, particularly if you nap in the late afternoon, essentially, what you're doing there is acting like a pressure valve on a steam cooker that you're building up all of this great, healthy sleepiness, that sleep pressure and then you nap. You just release some of that sleepiness. So now when it comes to your normal bedtime, you don't feel a sleepy Why? Because the nap removed some of that sleepiness, pressure removed some of Theoden hissing,

and you are going to perhaps find it more difficult to fall asleep. And Stacy, perhaps, is the important point. There are some people who can nap if you can nap regularly and all you don't have problems with sleep at night, then naps are just fine. But if you can't nap regularly on especially if you're struggling with sleep at night, the advice is, don't nap. Stay awake. Build that healthy sleepiness build lots of a dentist scene that gives you the best chance to stay asleep and then full under the spell of sleep. Under that weight of sleepiness for as long as possible,

you know might be oversimplifying, but the way I generally describe sleep to patients is sort of a balancing act between a dentist sing cortisol and melatonin, and you've got it like these three things have to make their like an orchestra. You have to have the crescendo of a dentist scene with the D crescendo of cortisol. And then you have to let melatonin take the brakes off this whole thing. And, you know, even when I just think about myself personally, I am convinced that virtually all of my sleep woes are on the court. It's Alexis, and the reason I'm hypothesizing, that is I can't measure a dentist sing. It's very complicated to measure. You need a very special type of mass spec to do that or m rs, but we can measure melatonin and you're in. We can collect urine overnight and measure melatonin levels, so we haven't least some sense of how much we're making.

But because I measured glucose 24 hours a day, and I'm pretty familiar with meal timing and response. In many ways, nighttime glucose for me as a proxy for nighttime cortisol and the association between high nighttime glucose and poor sleep is overwhelming. And I suspect it's that I suspect it's through. This court is all access

there is in some ways and manipulation that will speak about in just probably a little while off a dentist scene. Even though you can't measure it, you can actually manipulate it with something called caffeine and that can demonstrate

to you how, by the way, we're we're in America here. I think there's a human that doesn't know what caffeine is. Your get everybody's ears perked up like you're gonna mention like some new compound you just discovered in the lab yesterday. It's yeah, yeah, yeah,

some this squared. No, no, it's Cathy. But what's interesting regarding cortisol, which really supports your hypothesis right now, the leading underlying mechanism, the leading theory of insomnia, essentially comes back to that fatal flight branch of the nervous system that you are in. This profound parasympathetic state with that nervous system is cranked too far in sort of the high strength direction. And if you essentially have a cannula and new sample quarters all every 30 minutes across 24 hour period, you see this? You know this nice rise during the day, where quarters all is helping you stay awake. It's keeping you alert, doing all of the things that it needs to dio. And then,

as you start to come towards the night time period quarters all should drop and needs to drop for you to be able to initiate sleep. And in fact, it usually hits its sort of almost. It's an idea at the point where most people will say, That's my typical bedtime, and it then goes through this awesome sort of down stroke in terms of concentration. And then a few hours before you wake up, cortisol will start to rise, in other words, to prepare a tree hormone that starts to get you ready for wakefulness. If you look at patients with insomnia, however, what you see is that their cortisol starts to come down nicely in the evening, sort of six or seven or eight. So you know, they could feel just a sleep years a regular person,

but then, right before bed it goes back in the opposite direction, it spikes again and then starts to come down. And then often in the middle of the night, you will see cortisol spike back again when it should be lower still before it starts its rise. Those 2/4 all spy PES, I think, are the natural biological bookmarks for what we call sleep onset insomnia and sleep maintenance. Insomnia. So your quarters all spikes just before bed. You can't fall asleep. Sleep onset insomnia. Cortisol spikes In the middle of the night, you wake up roller decks of anxiety and brain starts to happen. Cortisol spikes. You can't fall back asleep.

That's what we call slink. Maintenance, insomnia. Those are the two principal types of insomnia. I think that's where you can see part of the biological basis. And my guess is that if we were to measure, you know, things like your heart rate variability and we were to decompose them with some mathematical equations that you would know of things like the fast for a transform. You can look at the contribution of the sympathetic versus Paris empathetic when you break down the heart rate variability. My guess is that you're going to see that sympathetic, that fight or flight branch of the nervous system getting jacked just before sleep onset and then once again, spiking in the middle of the night, underlying the cortisol spike which underlies the awakening which underlies the syndrome of Insomnia. Yeah, Who do you

think in that equation? I mean, I don't want to give everyone a lecture on this topic because you've done a great job explaining what sympathetic is right, which is autonomic, but it's sort of different from the glucocorticoids regulated pathway. Do you think that the sympathetic is driving the glucocorticoids or the other way around? And the only reason I ask is in a moment I'm gonna propose the only two things that I've ever really thought I have in the tool kit to treat that. But but the answer to this question might

impact that as well. I honestly don't think we have the evidence toe argue which way round that chain of command unfolds. I just genuinely don't know of the evidence. I think both a tenable hypotheses both could be independent, so they I think they could be no mutually exclusive. So, in truth, I don't think I know the evidence in favour. But what's nice is that the fact that we know that they both happen and can be causal contributors means that we've got at least two treatment targets that we can go over after, which I think will then plane to exactly what you're going to say which,

well, I don't know that they're correct. But to me, when we see that pattern because we do measure nighttime Corta, Saul and we you know we measure the metabolites of it and all of these other complicated essays. When we see that high nighttime court saw, we basically, you know, I mean, we sort of That's a very hard problem to treat from it And, you know, because if you really think about it, we're just dealing with the endocrine system, right? You know, it's a heck of a lot easier to treat thyroid dysfunction and dysfunction of the sex hormones, and I'm not saying that those things are easy,

but they are easier than treating the upper end of the week when when you have low sympathetic function and low glucocorticoids function, that's actually easier to treat them the opposite. The hardest problem I think in clinical medicine from an endocrine perspective is high. Sympathetic output Hi, good quarter, Quite output. And really, it's amenable to behavioral therapy, right? It really comes down to a change in mindset and a change in routine. We were talking about this earlier. It's like the further I can separate bed from email the better, because for me, e mails just hate emails so much. So any time I'm looking at your else agenda field. Yea, I'm just I'm just I have a low level of pissed off fitness whenever I'm looking at email. So the further I can separate my pissed off fitness for, the less my court

of Saul is, can I get

that tea ship bythe? And then the second thing which appears to work anecdotally, is hospital searing at a high enough dose, which generally requires about 400 to 600 milligrams. And and again, for me, the only time I find that that Snus that's really necessary isn't under those jet lag circumstances. You know when you're trying to put yourself in the time zone of London when you're leaving San Francisco and you basically have to make yourself go to bed, and it's only two PM in your brain. But it's late enough there, you know the You know, slamming yourself with 600 hospital Syrian really seems to move the needle both in terms of your glucose response in your cortisol response. What else do you have up your sleeve on that particular problem? Because I honestly I can't think of a more difficult clinical problem and the one you've just described.

I think the glucocorticoids issue is iving is a really tough nut to crack. I think for the sympathetic Dr I do think you're correct that it's behavioral there, I would actually argue meditation on dhe. I looked at this data when I was researching the book. Gosh, this must have been about four years ago now, you know, And I'm I think I'm a bit of a hard nosed, dyed in the wool scientists. So some of the when I was reading the city's on meditation and insomnia, I was wondering if it was a bit wound, know how to take it seriously, but the data was very compelling. In terms off, it really does decrease the amount of time it takes someone to fall asleep the continuity of their sleep is improved. If you look at some of thes APS that do it very well and you know things like head space or calm my guess, although I don't know if they've ever released this data,

is that if you were to look at their usage statistics, you will already see that people are self medicating their insomnia by way of meditating right before bed. And I think you know, both of those acts are starting to now launch, you know, aspects of sleep and sleep health in the portfolio of offerings. Rightly so because they've probably realized that sleep is a huge part off the issue for which people are coming to them to solve on dhe. The clinical data is very supportive of that. So I would say that for driving it, it's almost impossible to fall asleep if you're autonomic nervous. System is pushed in a sympathetic, dominant state in a fight or flight state on dhe. A good example of this is, you know, when you are jet lagged, you could be there.

You you may not have slept on the plane. You can feel that you're tired. You're really tired But for some reason, you know your quarters all is now spiking because your mismatch with your circadian rhythm you can feel your heart rate, and you could just know that your nervous system is cranked and you are tired as tired can be in your eyes and in your mind. But your nervous system, because it's on on that sort of upward swing, will not let you fall asleep. But meditation, I think, is a great way to drive a parasympathetic dominance of the nervous system, which is to take you out of the fight or flight branch on DME or into this quiet sort of more introspective state. I think that's probably the the bastard thing. Now I know it's not from clinical medical perspective as desirable, because it's not a pill that we can take. It's not dosage. It's you just have to put in the work to sit there and meditate. But I think

that's the nature of sleep. I mean, I think C b t I has efficacy, but it requires work. It does, and changing the way you eat requires work. It's not a pill, I mean, exercising something, and I've been asked this is a totally unrelated topic, But people always say, Oh my God, you know, Please write me a prescription for metformin because it's gonna help me lose weight and Bubba Blonde I said, Look, let me be clear. I mean,

I think metformin is a really powerful pill. I don't think it's nearly as powerful as an exceptional diet. In other words, metformin superimposed on the world's worst nutrition versus No Met Foreman on exceptional nutrition. I don't think it's any comparison in the end. Molecules that you take intermittently aren't really nearly as potent as molecular changes that occur over time. Course, behaviorally. I mean, that's I mean, I I wish that weren't true. Truthfully, Yeah, I really

I'm not anti pharmacology by any means. You know, if we had a good sleeping pill, I would embrace it, and I would recommend it. But right now, the sleeping pills on the markets, they firstly don't produce naturalistic sleep. Secondly, they've been associating with a significantly higher risk of death and also significantly higher risk of cancer.

I'm glad you mentioned this because this is a great segue way to this topic and going back to my friend Kirk Parsley and I remember another thing he said, Cause I This is Gigi and going back to 2000 in 2012 my go to travel drug was Ambien. Fortunately, I've never I've never had insomnia, but I empathize greatly with those who do. I've seen enough people with it. But when I need to sleep, I was gonna take Ambien. And I remember getting hints that this wasn't a great drug when I would. When I worked at Mackenzie, I used to have to go from San Francisco to Atlanta every single Monday for a day and because I was ruthless in my pursuit of not wasting time rather than, like, take a Sunday afternoon flight and come back. Tuesday, I took a red eye from San Francisco to Atlanta every single Sunday. And as one of my friends put it, that's the pinkeye.

And ain't the red eye like that's a four hour flight, right? You always get the tailwind, so you get about 3.5 hours of sleep on a plane. I'd get to Atlanta at five, pick up a rental car, drive to the gym, do a two hour workout, shave shower, get to the clients stay there all day, You know, leave at 6 30 Get to the airport by, you know, 8 30 Get the flight back to San Francisco. You're back by whatever your home in minutes there's a 26 our door to door every single time. And I was using Ambien to make sure I slept on that flight. I would I would come up with these grisly discoveries, which is I'd find e mails I sent that I didn't know I'd sent. And thank God none of them were inappropriate. But you hear these stories of people doing really crazy stuff on Ambien,

which is never committed to memory on dhe, you know, it's only when people make the phone call the next morning they say, What were you re going on about last night?

Oh, I One of the scariest things I ever saw was I remember looking at my phone and seeing outgoing calls to people that I didn't remember making. So my friend Kurt Parsley is saying and by the way, that Ambien crap that you take, you know, a couple times a month, he said, You know, that's not sleep right? And I said What do you mean? It's not sleep? I'm out and he just being again? You'll laugh at this because this is exactly the kind of story that you tell so eloquently, he said. You're confusing consciousness and sleep or lack of consciousness and sleep. If I took a baseball bat and hit you on the head, I could render you completely unconscious,

laying on the floor for eight hours. Do you think in any way that mimics the restorative process of sleep? I mean, not even close, right? So, you know, think of Ambien. Maura's a chemical baseball bat to the head than something that's actually promoting what you've just been speaking about for the last little while.

It's such a critical point again. I'm not anti pharmacology, and I know some of the people in the drug industries, the scientists and their goal. Their passion is to create drugs that better humanity, and they are genuine and authentic about that, and I love that about them. But I also will not accept or speak in public about a drug that clearly doesn't seem to be beneficial for a certain process. And unfortunately, if you look at the evidence firstly you find absolutely that those drugs are class of drugs that we call the things like Ambien. Lester. You know all of these things that you've heard their class of drugs that we call the sedative hypnotics and sedation is not sleep. But people mistake the former with the latter, and it's not. It's literally just knocking your cortex out. So I'm not going to argue. When you take those drugs that you're awake,

you're clearly not awake. But to say that your in naturalistic sleep isn't equal fallacy, because if I look at the electrical signature of your sleep, when you are on or off Ambien radically different for a start, you don't get into the same depth of deep sleep that you get. It's not the same electrical quality of deep sleep. The second thing that we found is that there does seem to be, ah, hire association with mortality risk. Now we don't know if it's causal on. My guess is that on the strength of the evidence right now, I r be committing his ethics committees. That sort of allow you to do certain scientific studies may not even allow you to try and do those thirties because the evidence is already so dill. It eerie a CE. The other finding was this strong association with risk off all forms of cancer which perplex me because you would think well, if I'm taking this drug that helps me sleep.

Maur on sleep is so good for the immune system, including things like natural killer cells and combating Z then this drug induced sleep should actually make my cancer risk lower, not higher. And the fact that it is higher, I think tells you that the type of sleep that you're getting is not off this rich, complex, restorative rest ful, biologically appropriate sleep. The other thing I would come on to and these are very difficult cities to get funding for because, you know, see some of the drug companies, they may not necessarily want some of this information out there. It was the only chapter in the book, by the way, that my publisher brought in a legal team to kind of look at when I was kind of making all of these claims. But this is just I'm just conveying the science.

There's nothing controversial about the science, and they ended up feeling legally comfortable with what I wrote. There was this stunning study done by a good friend of mine called Marcus Frank at PAN, and he was looking at basically brain plasticity. How does the brain make connections and strengthen those connections on those strengthening of connections? Is the underlying mechanism that we know leads to the long term formation of memories? It's a very well understood mechanism, this idea of brain plasticity. And there is a model where if you kind of patch the eye of an animal and then you measure the visual cortex, what you see is that once you patch one eye, the brain says, Well, we're not going to waste the real estate off that one eye that's no longer doing visual processing. We're going to shift a lot of that over to the other eyes territory and give it even Maur kind of rich connective fidelity as it were. So you've got this model of what's called mon ocular deprivation plasticity, which is a classic model of how the brain re wise itself for things like learning and memory.

What he found is that he took a group off animals and he gave them naturalistic sleep and did this kind of mon ocular deprivation and sleep, it turns out, basically doubles the strengthening of plasticity. Sleep is wonderful for shifting things and making new connections and really strengthening those neural connections. Sleep is essential for brain plasticity, and it's almost it's people almost double the strength of the connections relative to If you just keep the animal awake, so sleep. It's not just time that helps the brain rewire itself. It's time with sleep that makes the difference. Then he dosed those animals with Ambien. Now, firstly, the animals slept longer because they were dosed with this sedative hypnotic. And you would think that surely that should improve this strengthening of re wiring in the brain. It

did exactly the opposite, I was gonna say, Or it worse.

It would make, not exchange right control from the control if it was quote unquote naturalistic sleep. What he found was actually a 50% unwired ring off the connections that have bean laid down before, when the animal was awake. In other words, not only had sleep failed to strengthen the connections the Ambien laced or the Ambien in juiced sleep was doing the opposite. It was weakening connections within the brains. Now what makes me fearful about that is firstly, if you look at the number of people who are using these medications, you know it took George Lucas. I often say, I think about 40 years with Starr was franchised to amass about four billion in profit. It took Ambien less than 24 months to address that in terms of profit. So you got to imagine the number of prescriptions being written are high, then the fact that the prescription age off thes sleep AIDS is starting to decrease gradually as parents get more concerned about their kids, who may have more anxiety who are having sleep problems, the turning to pills.

And when you bring that experiment back into the context of pediatric prescriptions off sleep medication, you've got a brain that is developing a brain that needs toe wire itself up, strengthen connections, build and mature. It needs to learn it needs to consolidate, and then you're providing a form of sleep through medication that may actually be unwired. Ring that nervous system unwired those memories rough and strengthening them that Frank,

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