The Health Curve

Sleepless in the Modern World: Why Routine Advice Isn’t Enough – with Dr. Sahil Chopra, Harvard and Empower Sleep

• Dr. Jason Arora • Season 1 • Episode 11

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Tried all the usual sleep hacks but still find yourself wide awake at 2 a.m.?

You’re not alone.

In this episode of The Health Curve, Dr. Jason Arora sits down with Harvard-trained sleep physician Dr. Sahil Chopra to dig into the deeper, less obvious reasons we can’t switch off.

From overlooked stress signals and tech traps to the cultural myths shaping our sleep expectations, this conversation goes beyond the basics to challenge conventional wisdom—and offer fresh insights that just might help you finally rest.


SPEAKER_02:

Welcome to the HealthCurve podcast. I'm your host, Jason Aurora. Today's episode is for anyone who's ever followed all the right sleep advice. and still found themselves staring at the ceiling at 3 a.m. You've dimmed the lights, you've put away the screens, you've set the perfect room temperature, and yet real sleep still feels out of reach. The truth is there's often a lot more going on beneath the surface, and that's what we're going to unpack today. I'm joined by Dr. Sahil Chopra, a Harvard-trained sleep medicine doctor and co-founder of Empower Sleep, to go beyond the usual checklist and explore the deeper reasons so many of us are stuck in cycles of poor sleep, despite doing all the right things. We'll dig into the surprise analyzing psychological, biological and social forces that are disrupting our rest and we'll debunk some stubborn sleep myths and we'll share practical tools that may actually work especially for people who've already tried all the basics. We'll also address many of the community questions you've been sending in so thank you so much for these. Let's get into it. Dr Sahil Chopra, thank you so much for joining us. It's really great to have you here. Perhaps to start We've all heard the standard sleep advice by now, especially in recent years. Go to bed at the same time, avoid screens before bed, eat your dinner earlier, no caffeine late in the day, avoid alcohol before bed, sleep in a cool room, all these things. But despite knowing all this, I feel like a lot of people, myself included, still struggle to get good sleep. So first of all, can you just remind us what the established advice is and a little bit about the evidence behind that? And then perhaps we can talk about why so many people are still struggling to get good sleep.

SPEAKER_01:

Yeah, I think you said it more elegantly than I did of all of the sort of tips and tricks that we should be doing, but I'll just shed some light on where those things come from. If we look at sleep, there's sort of two things that regulate sleep. The first is our circadian rhythm. So what you talked about, like having darkness in the evening, sleeping in a dark room, getting ample daylight upon awakening, that's basically modulating sleep through the lever of our circadian rhythm. If circadian rhythms are well entrained, meaning that there's no confusion to our body of like when is the biologic day and when is the biologic night, sleep becomes better. So those things that you mentioned are focusing on circadian rhythm. The other things that you mentioned around not eating too much of a heavy meal, facilitating like a cold bedroom, The meal thing is interesting. If you look at this from an evolutionary standpoint, when we are sleeping, we should not be investing energy into the digestion of food. And if you ever use a consumer-grade wearable device like a Whoop or an Apple, something along those lines, what you'll observe is if you eat late in the day, you tend to have less deep sleep. You tend to have more fragmentation. There tends to be, physiologically speaking, in the gastrointestinal tract, there tends to be more reflux disease that can cause sleep fragmentation. During sleep, lower esophageal sphincter tone is lower too. And peristalsis slows down as well. Gastric emptying slows down.

SPEAKER_02:

For our listeners who don't know, peristalsis is the automatic wave-like movement of the muscles that line your gastrointestinal tract. So it moves food through the digestive system.

SPEAKER_01:

So like Eating too late in the evening times physiologically is not, it doesn't physiologically and evolutionarily make a lot of sense. Like most of us all knows like the abstinence from alcohol. Most people have probably noticed or observed how their sleep just goes down the tank with one night of excessive drinking and it doesn't recover the next day.

SPEAKER_02:

Even one drink for me these days, it affects my sleep negatively. It's really sad, but that's aging, I guess.

SPEAKER_01:

And the last thing that I was going to say is about temperature regulation. During our biologic night, like when it's the body's nighttime versus body's daytime, our body temperature drops. So this whole idea of using a cooling mattress or taking a hot shower is essentially just like it's facilitating our body temperature to get to its nadir point. A hot shower before bed raises skin temperature. And what our physiology tries to do is to drop it. So the higher the delta is, the more depth of sleep one can possibly create. So that's the idea there is to, when our body is hot, we will try to dissipate that heat. And when in the process of dissipating that heat, it will facilitate the temperature drop during sleep. So that's how like mechanistically how that sort of like tighted. And, you know, so all of these things are, things one can do to improve subjective objective sleep quality. But the other things that play a big role is the one we look at sleep is, you know, we have sleep quality, we have sleep timing and sleep duration. Those are sort of like the three pillars of like how to assess someone's sleep from a duration standpoint. And in adults, we know that adults should be sleeping seven to nine hours. That comes from population health statistics. And then from a timing standpoint that again is sort of rooted back in circadian rhythms and we should be sleeping during the body's nighttime we should not be sleeping during the body's daytime and most for most people who are not shift workers that those are hours of darkness so that's kind of like the basic framework of how to think of this and where this becomes a little bit convoluted and complex is when there's like an underlying sleep disorder where someone is doing all these basic things but they have an underlying sleep disorder. They have like conditioned themselves to have like a hyper aroused sympathetic nervous system that are just, they're just in like sympathetic overdrive the entire time. And that will sort of lower one's threshold for arousal during sleep, or they have sleep apnea, or they have restless legs, or they have like something else that they're doing that knowingly or unknowingly is causing some downstream consequences. So basically to summarize, we have, you know, sleep timing, sleep quality, sleep duration, And all of the things that you sort of alluded to sort of fit into this construct. But all we're trying to do is pull the different levers to move each of these sort of things.

SPEAKER_02:

And do genetics play a role in terms of how good people are at sleeping and how much sleep they need? Yeah, so,

SPEAKER_01:

you know, short sleep phenotype. A phenotype means like a manifestation, symptomatology. Some people have like this natural short sleep trait. And what that means is like they can sleep less, but still be able to function like any other normal individual. They can sleep four or five hours on a daily basis. Sleep architecture is relatively normal and preserved. They go through the appropriate sleep state cycles and they wake up in the morning feeling rested. It's almost like a superpower in a way. I really wish I had that. Yeah, I do not have that, but I really

SPEAKER_00:

wish I did.

SPEAKER_01:

Yeah, no, me too, right? And exactly how this works, we're not entirely sure. But we know that these people don't have any like downstream consequences because they're genetically designed that way. And so there's a couple of genes that regulate short sleep. One is this one called like DEC2. There's another one called salt-induced kinase 3, SIK3. And then there's like another glutamate receptor gene. So there's a couple of different ones and they all mechanistically work a little bit differently. Like this DEC2 one, the way this works is it modulates a neurochemical in the brain called orexin. You know how we think of like GABA is a sleep promoting neurotransmitter. Orexin is a wake promoting neurotransmitter. So it like reduces the amount of wakefulness by modulating that neurotransmitter. So like they all work somewhat differently. Some influence the circadian rhythm, some influence alertness. So different genes work differently. But the phenotypic presentation is that of like, hey, I don't need to sleep as much as John Doe does and I can function really well. So how do people know if they have this genetic trait or not? They won't. They like one common story that one might elucidate in a history is there are many people in my family on my dad's side or my mom's side who they just don't need a lot of sleep and they can be very productive and they feel completely like anybody else who gets seven to eight hours of sleep. And there's probably ways to do this genetic testing. I'm sure Mayo Clinic probably has some kind of a lab order. I'm sure MGH probably has some kind of a lab order or a Cleveland Clinic. You can look into this a bit more. But these people won't ever end up in our clinic because they don't have any dysfunction. So it's really hard to find them.

SPEAKER_02:

The way I tend to think about this is obviously there's the genetic component and then there are a few environmental components, right? So there are our habits, which we've talked a lot about so far, things that we can do ourselves around eating and drinking and bathing and all these things before sleep. Screen time, I think we haven't talked about much yet, but screen time is another one, of course, the habits that we can control. But then, you know, we're not robots. There's the social aspect, which impacts, for example, how active we are just before we go to bed, it impacts how late we eat, you know, whether we are going to have that drink or two before bed, all that sort of stuff. And then there's work, like how late into the evening are we working, which impacts things like our sympathetic nervous system, as you said. So getting into the non habitual stuff that are just part of the rhythm of life, do we then start to get into some of these hidden drivers that are less talked about today?

SPEAKER_01:

I think we totally do. And these are, as you sort of alluded to, hidden drivers. You don't know until you try to uncover them. And you don't know until someone gets a good history from a patient. I just saw a patient right now before I jumped on with you. Lady who has, she's in her 60s, late 50s. In her 50s, when transitioning to menopause, developed sleep maintenance issues. She went from like an eight-hour sleeper to... a five to six hour sleeper. And then she also has vitiligo and eczema and she's on topical tacrolimus and another immunomodulator and did some research and discovered that that can possibly cause insomnia. Although the topical drugs don't really make it into systemic circulation as much as we think they should. But as soon as she stopped them, she went from like this acute on chronic insomnia to from going from like five, six hours of sleep to two, three hours of sleep. And upon abstaining from these topical medications, went back to this five to six hour sleep sort of duration. So it's not straightforward. It could be really complicated and medications play a role, hormones play a role, other pathologies that develop can directly or indirectly play a role. And you're totally right. They're hidden until someone has a question or does a sleep study or tries to tease out like, why are you not sleeping well? Tell us a bit more about restless leg syndrome. tingling sensation in my legs but the second i get out of bed or the second i scratch my legs on top of each other that sensation goes away and the reason it's important is one like it can cause pain at nighttime and making it someone has pain it can make sleep onset difficult the second thing is it can cause sleep to be disrupted at nighttime so people who have rls symptoms usually have more symptoms of insomnia more symptoms of depression anxiety there's the it They have a higher cardiovascular morbidity. So restless legs, although it sounds like, oh, it's just some discomfort in my legs, there are treatments available for it. And if left untreated, it will result in other downstream consequences.

SPEAKER_02:

Let's get into some of the psychological factors like anxiety, perfectionism, stress, overthinking. These are more of the emotional and mental aspects. How do they tend to disrupt sleep? A few things.

SPEAKER_01:

Anxiousness is like a sympathetic activation system. And sleep, when we look at our autonomic nervous system, kind of a balance between parasympathetic predominant state to a sympathetic predominant state. And from an evolutionary standpoint, it's good to have this because if I'm being chased down by a tiger, I want to be in like sympathetic overdrive during that time. But when I'm just sitting here and relaxing, I don't want to be in sympathetic overdrive at that time. And if we look at the state of what happens during sleep, to our autonomic nervous system, it's a parasympathetic predominant state. So going back to this example, if someone has a lot of anxiousness, they're in sympathetic overdrive, then that will shift that balance from what should have been a more parasympathetic predominant state to a more sympathetic predominant state. And if one does this chronically over years, decades, sleep will be impaired. And then from like, A depression standpoint, that is a little bit probably more difficult to tease out because what we do know is people who have active depression or major depressive disorder, I'll say, like the extreme of depression, their sleep architecture actually changes. To the point, in such a reproducible way, there are studies that can look at sleep study to estimate, does this person have major depressive disorder? And what happens is REM onset is much faster in people who have major depressive disorder. Sleep duration is much longer in people who have major depressive disorder. There is more REM sleep in these individuals too. So what that means exactly, I don't think we completely know. But these mental health conditions influence our sleep in a variety of different ways. And I think mechanistically, they're all a little bit different.

SPEAKER_02:

Interesting. And just quickly for our listeners, REM is rapid eye movement sleep, which is basically when you dream when you sleep, right?

SPEAKER_01:

That's correct. Yeah. REM sleep is dream sleep and non-REM sleep is non-dream sleep. And non-dream sleep or non-REM sleep is sort of broken down into three stages, stage one, two, and three. And stage one, stage two is sort of like light non-REM sleep. And stage two, stage three is sort of like deep non-REM sleep. Tell us about sleep apnea. So sleep apnea essentially refers to, as the name suggests, some apnea, some cessation in breathing during sleep. And the reason this is important is because if someone has any level of cessation in breathing during sleep, there's two important fundamental consequences of that. One is that their oxygen levels drop during sleep. And the second is they are aroused out of sleep during this opportunity for sleep. So it causes sleep disruption. It causes hypoxia, low O2 levels, and it just is disruptive and it leads to a ton of long-term consequences. And who is that more common in? What are some of the risk factors for sleep apnea? Some of the risk factors for sleep apnea, historically, we used to think of them as like a morbidly obese male who snores. That's your classic phenotypic presentation of someone who has sleep apnea. But now what we're learning is our anatomy plays a big role. The shape of our mouth, Remember, you must remember in medical school, these adenoid faces of someone who's a mouth breather, long forehead, puffiness below the eyes. So having someone who's a mouth breather, chronically congested nasal passages, enlarged tonsils, volumetrically a small upper airway, nasal passages, oral pharynx, nasal pharynx, all of those things play a big role. Someone has too much weight on their neck, like for example, football players. The prevalence of obstructive sleep apnea in football players is more than it is of that of the population. And this is

SPEAKER_02:

American football, of course, not

SPEAKER_01:

football. Sorry, just my British side coming up. Thank you for clarifying. Yes, American football players, like the prevalence is north of 30-40%, but in So like, it's not just obesity, but like even too much muscle on the neck plays a big role in all of these things. What's a normal sleep architecture? What's healthy? From a duration standpoint, it should be about seven to nine hours. From a sleep stage distribution standpoint, about 50% of sleep is light sleep. About 20 to 25% sleep is deep sleep. And 20 to 25% is REM sleep. So that's kind of like a rough idea. And this evolves over age. In younger individuals, like when we were in our 20s, we had much more deep sleep than we did now when we're in our 30s and 40s and 50s. And that pattern continues. The amount of deep sleep we have continues to drop as we get older. But REM across a lifetime is relatively the same. Like most humans across a lifetime should be sleeping about 20 to 25% in REM sleep. Okay,

SPEAKER_02:

I have one other question about the autonomic nervous system and sleep. I know we've talked about the sympathetic or fight or flight state, which is really when your adrenaline is up and that doesn't support good sleep. And then there is the parasympathetic, the rest and digest as it's called. But rest and digest, which is how we've simplified it, digest and poor sleep. Can you take us back to eating late and people feeling restful and wanting to digest their food and feeling relaxed? but that not really chiming with having good deep sleep. So how does the rest and digest state, especially after a big meal, impact sleep quality? And is it right to just put it down to the autonomic nervous system and the parasympathetic state?

SPEAKER_01:

Yeah, that's a great question. And we use this like pretty loosely, rest and digest. But digestion is actually an active process. It's not a passive physiologic process. So what is the What is typically supposed to be happening during sleep is whatever is in the gastrointestinal tract probably is supposed to be the tail end of digestion should be happening rather than the acute process of new food coming into the stomach just prior to bed and then digestion happening. So to me, digestion is what's happening in the small and large bowels rather than what's happening mouth, esophagus, and stomach. But we do know for sure that peristalsis is slower during sleep and gastric motility goes down and people who have reflux disease can be exacerbated during sleep. So it's probably from an evolutionary standpoint, I don't think eating late in bed is conducive to healthy sleep and some of the physiologic biomarkers don't necessarily suggest that too.

SPEAKER_02:

Let's talk about hormonal imbalances and how they impact sleep. Can you tell us about some of the hormones that positively or negatively impact our sleep? It's

SPEAKER_01:

more clear in women because the change in hormones is much more abrupt. And even though all the endopause is a thing, menopause is much more well-defined and studied. And what we do know for sure is sleep changes substantially during this time. It's a mix of When one transitions from a reproductive age to a non-reproductive age, estrogen and progesterone levels drop substantially. There is more vasomotor symptoms, which independently influence and disrupt one's sleep at nighttime. It causes more fragmentation of sleep. The absence of estrogen and progesterone also plays a role in muscle tone. So when there is less muscle tone of the upper airway, as a byproduct of the absence of estrogen and progesterone, the prevalence of sleep apnea and upper airway collapse goes up. It almost doubles. It goes up almost 200% during menopause in women. So the prevalence of sleep apnea doubles. And then women can also have the prevalence of restless leg symptoms also goes up. So there's more emotional fragility during that time for most women as well. So We think estrogen and progesterone play a protective role in protecting the development of obstructive sleep apnea. And we know that indirectly because when there is the absence of this, the prevalence of some of these conditions goes up. But what we don't know or what studies have not shown is if you give someone HRT, do you reverse the likelihood of them not having obstructive sleep apnea or restless legs? And that's something that is not entirely clear, but we do know that these hormones play a direct role in helping one sleep better. And we do know that the absence of them does disrupt sleep. And so that's one thing that's true. And the other thing that's also true is that, at least in men, when there is sleep disruption or obstructive sleep apnea, there is more hypogonadism in those individuals. Like we see patients often, who come to us because their concierge medicine doctor said, hey, you need to be on testosterone replacement therapy. Like, why is your testosterone low? Is there like a sleep condition that is causing it to be that way? So it's a bidirectional relationship.

SPEAKER_02:

Yeah, there are studies that show that less sleep leads to less testosterone production in men, right? Absolutely. And so on that, can you talk a bit about testosterone and sleep? These gonadotropic

SPEAKER_01:

hormones, they typically rise during sleep. After the pituitary gland releases these precursor hormones, they then go to the distal organs, in this case, you know, maybe ovaries or testicles, to then produce that local hormone. So these are the sex hormones, right? Correct, correct. Yeah, both for men and women. And if someone's sleep is impaired, this whole hypothalamic pituitary axis can also be impaired. And so that's sort of the thought process behind this. So if sleep is impaired, downstream consequences of low sex hormones can be a byproduct of that.

SPEAKER_02:

So the brain produces the precursor hormones, and if sleep is impaired, then there is a reduction in the precursor hormones in the first place, right? Yeah, that's what we think. And how about stress hormones, as people call them? So cortisol. And how about thyroid hormones? The

SPEAKER_01:

cortisol story is an interesting one. What we do know is cortisol is highest upon awakening because cortisol has a circadian peak in the trauma over a 24-hour period. And if someone doesn't sleep well, the data suggests that people might have higher cortisol levels. And then people who have higher cortisol levels can also not sleep well the following day. And we know that from individuals who are on high-dose corticosteroids. For example, if I'm seeing someone who has a flare-up of their asthma or COPD and they need to be on prednisone, dose pack, or some kind of a taper, it's not uncommon for them to say, I have much more insomnia with this than I did before. It's a bidirectional relationship. One can influence the other. It's quite convoluted. Okay,

SPEAKER_02:

so... We've talked a little bit about the biology and normal sleep and habits, some of the different lifestyle factors that impact sleep. And I feel like one of the hardest things with good health is just culture. It's the environment in which we live, working culture, social culture, but in particular these days, digital overload screens, but also just connectivity, being on all the time, whether it's your phone or your laptop or something else. Working from home culture now, which means I know it's changing again post-pandemic, but people are on more than they used to be. And so there is this constant connectivity. And then there's also performance culture, which is, you know, in some ways a uniquely American thing, I would say, and the hustle mentality and that sleep is historically deprioritized. Can you tell us a bit more? Just you see so many patients with sleep disorders. What have you found helps work against societal pressures and culture that is not good for sleep? And it's probably an impossible question, but let's talk about it anyway. How can you change culture,

SPEAKER_01:

right? It's such a difficult question to answer, but I'll just share my anecdotal experience here. And I just saw a patient this morning who has taken a highly driven guy now in his late 50s, has taken multiple companies from zero to a few hundred dollar million exits and a couple of public in a you know, very short period of time, like lived a very successful life. And like now he's coming again and he's, he was like taking pride in like Sahil. I used to be able to function by sleeping three hours, traveling across time zones between the U S and Europe and China and just like constantly being on the go. And now he wants to, you know, improve his sleep and how he became aware of this is now he is has made a conscious choice to take care of his health. And what triggered that, I'm not entirely sure, but I think there's like an undertide of a few different things. One is these wearables have provided so much insight into our physiology that we never were aware of for the longest period of time. The amount of information that can be derived from these whoops and auras and apples around HRV, blood pressure dipping, heart rate dipping, sleep architecture, number of, the amount of movement one has during sleep is just, it's eye-opening. And people who are these highly motivated, data-driven people, when you show them the data that your health is not as good as you think it is, then that at least allows them to take the time to focus on it. And so I think awareness into that is really powerful. The second observation has been The Atiyahs and the Hubermans and the walkers of the world are talking more about how sleep is kind of a foundational component of all of these different things. Before taking rapamycin and metformin for your longevity, dude, how's your sleep? Are you exercising? Are you eating healthy, clean foods? Are you getting adequate sunlight? What's your mood? There's these really core basics of physical health, mental health, sleep health. and nutritional health. They're just foundational stuff. You can take all the supplements you want to and do all the stuff on Blueprint, but we got to fix the basic things. And I think these things have definitely helped people draw some awareness to this. That's kind of been my anecdotal experience over the last couple of years. And

SPEAKER_02:

that chimes with mine as well. We'll get back to this conversation in just a moment. But if you're finding this episode helpful, Here's a quick ask. Take a second to follow or subscribe to the Health Curve podcast wherever you're listening. And if someone in your life would benefit from this episode or any of the others you've heard, please send it their way. All right, let's get back to it. So what is an actual sleep disorder? How do we know someone has an actual sleep disorder?

SPEAKER_01:

We actually don't until someone has a detailed conversation. And you can suspect a sleep disorder through a conversation with a patient. But when we think about what's a disorder, a disorder is something that causes some impairment of function. And it is pathologic. It's not normal for someone's physiology to be this way. So then we call that pathology. So sleep pathology or sleep disorder, the way then to then diagnose it is that you have to have some physiologic metric that you are measuring. And in sleep medicine, those physiologic metrics are what we call sleep studies. And these sleep studies can happen at home. They can happen in the lab. But they're basically just a tool to understand someone's physiology during this window of sleep. And what you're looking for is, is this person breathing in a normal way? Is this person moving in a normal way or not moving in a normal way? Or do they have like normal brainwaves during sleep? Do they have a normal drop in their heart rate during sleep? Is it free of any arrhythmias? And so you're, learning a ton of things. And through these sleep studies, you can understand one's sort of brain health. You can understand their sleep health. You can understand their respiratory health. And they're very powerful tools to understand someone's sleep. And there's actually now tools even in these are saliva tests that we order often where you can understand someone's circadian health. Like where is Jason's nighttime? Is Jason a 10 to 6 kind of guy? Is that his circadian rhythm? Or is Jason a 2 a.m. to 8 a.m. or 10 a.m. kind of person? And you can actually measure this to figure out where their biologic night is. So I think it just comes down to measuring what's going on with someone's physiology in a more scientific way. Can you change that? 100%. And traveling across time zones is a really good example of the plasticity that our circadian rhythms have. And from a population health standpoint, like our circadian rhythm will shift about an hour per time zone that we move. So if you move four time zones, you'll probably like a normal person should acclimatize there in about four days. And so, yeah, no, this is totally normally there should be a lot of plasticity there. Genetics play a role in like one might gravitate towards one either advancing early to bed, early to rise in the absence of all social cues and all light cues and someone might genetically predispose towards being a night owl if they are left to themselves. But normally there should be enough plasticity that one should be able to acclimatize to different time zones.

SPEAKER_02:

And it can take some time, right? I know having come back from Japan now two weeks ago, I think we've only just recovered from that. Okay, so we've started talking a little bit about how you measure sleep and how you can say something is a sleep disorder versus not. When you talked about How do you determine whether something is a sleep disorder or not? You said that when we observe someone in their sleep, we can see what's going on. And I guess it can reveal that there is another cause of their sleep disturbance. There might be another medical condition. There might be something else going on, even if it's not a medical condition, if it's psychological, something like that. But sleep is something that's getting affected by it. Can you talk a little bit more about As a sleep doctor, how do you measure and assess sleep? And what does it reveal to you in terms of there is something else going on here, or there is primarily a sleep problem? And is there a difference?

SPEAKER_01:

Yeah, that's a good question. It's really hard to tease out. So let's take a step back. What are the tools to measure sleep? And the framework that I would share is like, okay, you have consumer grade tools, such as the whoops and the auras and the garments of the world. And then you have like medical grade tools, like sleep studies that can be done either at home or in a lab. And the metrics that one looks at is sleep architecture. Do they have that sort of normal, expected, desirable sleep state distribution that we talked about, like 50% light, 20%, 25% deep, 20, 25% REM? Like, is that roughly the the distribution of their sleep stages. And if there is an abnormality there, then it makes sense. To answer your question on how does one tease out what is the root cause, some of the things are obvious, but many are not. And so I'll give an example. If someone has, say, obstructive sleep apnea, where they snore, they have pauses in breathing during sleep, They wake themselves up gasping in the middle of the night. They have drops in oxygenation. That's kind of a slam dunk. It's like, okay, one then assumes that your reduction in sleep health is a result of the sleep apnea that I have identified. So then one says, okay, let's treat the obstructive sleep apnea and then let's see over time. How is your objective sleep health and how do you subjectively feel? That's really easy to do. Other examples could be you do a sleep study and there's just a ton of movement and restless leg syndrome or periodic limb movements. And that is causing disruption of someone's sleep. It's causing a lot of arousals. And that's also very easy to go. This is like cause and effect. Where this becomes really difficult is you do a sleep study and you Patient says, like, I don't sleep well. You do a comprehensive sleep study and then you discover that they have like no deep sleep or their deep sleep is like 5%. REM sleep is normal, but it's just like they're a light sleeper the entire night. And then you're like scratching your head. You're like, what do I wonder? Like, what the heck is going on? Like, why is this person not sleeping well? That becomes really difficult to tease out. And that's when we sort of go down like this rabbit hole of is there some kind of a nutritional or hormonal deficiency? Is there some kind of what's happening in your environment? Tell me about your routine again. I know you told me a little bit, but I want to spend like 30 minutes to tell, like walk me through, like what do you do on a consistent, on a daily basis, like after 6 p.m. And what do you do two hours upon awakening? And let's go over your medication list again. Because it's not clear to me of like why your sleep quality is as lousy as it is. And that's the hardest part to figure out. And I would say, at least for me, like, maybe five to 10% of the time, we're not able to figure it out. It's really, you don't know. And you can try supplements, you can try breathing exercises, eight sleep, vagal nerve stimulation, parasympathetic tone modulation, things that you can go, you can just, that is sort of a can of worms where we don't know how to take care of these people like we know how to take care of like obstructive sleep apnea or restless sleep. And in these situations, using medications is something that should be explored. Different sedatives and different hypnotics to see if, When you give them this medication, does their sleep subjectively and objectively get better? Is like what I think is a good time to experiment with these drugs. And this is all assuming that one has gone through what's called cognitive behavioral therapy for insomnia, which is basically sort of a restructuring of their thoughts and habits around sleep that is driving some of their insomnia type of symptomatology.

SPEAKER_02:

And that specifically would be a sleep disorder, right? Because it is tangibly about how someone experiences approaches their sleep, at least in the mind.

SPEAKER_01:

100%. And insomnia is a sleep disorder because it causes dysfunction. Like some people, you wake up in the middle of the night, you're up for 20 minutes, person is retired, and they then go back to sleep and they wake up and they don't feel unrefreshed. They still wake up feeling relatively fine. And they go out about their day and like, they don't have any daytime dysfunction. Insomnia, means that there is some level of dysfunction that this person is having. Either at nighttime it's causing issues for them or during the daytime it's causing issues for them. So just having a couple of awakenings in the absence of any symptoms may or may not be worth chasing. But having difficulty with sleep onset or difficulty with sleep maintenance and then waking up in the morning unrested and having some level of dysfunction, that's totally worth chasing. That's when we start calling this some level of insomnia. symptomatology. And that's where CBTI, cognitive behavioral therapy for insomnia, plays a role. That's where medications play a role, for sure.

SPEAKER_02:

We spend an average, ideally, of a third of our lives sleeping. And so something I've always thought about in my personal life, especially as I've gotten older and everything requires more maintenance, health requires more maintenance, is to invest in well on sleep, to have good bedding, all that sort of stuff. What should people focus on when it comes to investing in their sleep? Just as a core, you know, non-experimental, these are the basics.

SPEAKER_01:

You know, it's different for everyone, but I think the basics that apply to everybody is, and it's not, I don't even think it's bedding. It's more so of this idea of like, turn your room into a sleep sanctuary, like reserve your bedroom for sleep insects. That's it. Try not to use your bedroom for working, television. One does not want to associate their bedroom to things that are cognitively stimulating or things that are wake promoting. It's kind of like a kitchen, right? When you go to your kitchen, even if you're not hungry, you open up the fridge. We've created these associations. You see some fruit on the counter, you might pick at it, even if one is not hungry because we have created these associations that the kitchen is a place for eating. And if we can intentionally do that for our bedroom, that the bedroom is a place for sleeping, that I think is probably the strongest lever that can be pulled. And once that has been done, then we can talk about other things around make sure you have a comfortable sleeping environment. That is, pick a mattress of your choice that fits your needs based on pain and body habitus and all of these things. And make sure your bedroom is cool and dark. And I think those are like the basics that most people are probably aware of. But I think the one thing that gets unrecognized is trying to be intentional that this bedroom is not a place of like hangout or thinking or television or watching movies or tinkering on your phone because you don't want those associations. They're not conducive to healthy sleep long term.

SPEAKER_02:

One of the purposes of this podcast is to address health misinformation. And so there's a lot out there, a lot of content out there right now on sleep and other things, you know, especially in the context of longevity. Can you help us debunk some of the most common myths you come across with your patients around sleep?

SPEAKER_01:

You know, our patients are pretty well informed. So there's not a ton of myths when it comes to sleep and longevity. I think, you know, there might be something around this idea that I need to have nine hours of sleep. The more, the better. So if we look at the data, the data displays itself in kind of a U-shaped curve where on the Y-axis you have mortality and on the X-axis you have sleep duration. So like too much sleep and too little sleep both have a higher mortality. And too much sleep or too little sleep is also associated with cardiovascular disease. Too much and too little sleep is also associated associated with dementia, diabetes, mental health issues. So it's a very strong relationship. It's not necessarily causal. But I think what sometimes happens is people may think that the more sleep I get, the better I am. And I don't think that's necessarily true. Waking up rested is probably important. Having something that's somewhere between seven to nine hours reported is is probably okay. And I'm intentional about using the term reported because it's not measured. When there's a wearable device in the picture and the wearable says, hey, you're sleeping seven hours and 15 minutes and you're trying to target for nine, well, that's going to be really hard because when we say seven to nine hours, that's like patient reported times. And like what the patient thinks and what anything is measured, there could be a wide discrepancy. So if one is sleeping seven, seven and a half hours and they feel rested, And they're asking me from a longevity standpoint, like, hey, Sahil, can you prescribe me some trazodone so I can extend my sleep? Or I don't know if I would be doing someone a service if I did that.

SPEAKER_02:

I think the irony of sleep is despite the fact that measurement really helps us, it's one of those things where you can tell how well you're sleeping based on how you're feeling. Like the feeling is actually the most important thing and the measurement can almost... validate that feeling, whether positive or negative. Would you agree with that?

SPEAKER_01:

Yeah, no, 100%. And the interesting thing is some people who sleep really well could actually be very bad breathers. So it's not also uncommon for me to see someone who has almost normal appearing textbook sleep architecture, but they have just horrific hypoxic obstructive sleep apnea, like just really low oxygen levels during sleep. And tons of pauses and breathing 30, 40, 50 times an hour, but their sleep architecture is still relatively preserved. And they're just able to sleep through all of this physiologic asphyxiation that is happening during their sleep. And they're just a very good sleeper. But that again is like a very small subset. But generally you're 100% spot on. Like if you feel well, you don't need to nap, you feel like your energy levels are good, you wake up in the morning rested, you can fall asleep easily, Your sleep is relatively consolidated and your wearable is giving you data that is like age appropriate. You're okay. Adding an extra 30 minutes to your sleep is not, I don't believe that it will be a significant lever for your longevity. I think there are other places where one can invest their time instead of like sleep is probably foundationally a good, you're probably in a good place at that time. So I'll throw a couple of other myths at you.

SPEAKER_02:

You can catch up on sleep on the weekend. Is that true?

SPEAKER_01:

Yes, that is true. You can catch up on sleep on a weekday or a weekend, assuming that there is some sleep debt that has been built up. Whether or not that's good for you or not, I think that's a separate conversation, but you can catch up on sleep. And most of us who have gone through residency and fellowship, like through medical training, like we would catch up on sleep on the days that we were off. And then you feel so much better when that happens. And the interesting thing is when you catch up on sleep, your sleep architecture is actually different. as compared to when you're sleep-deprived. So yeah, catching up on sleep is a real thing.

SPEAKER_02:

But it doesn't necessarily reverse all the negative

SPEAKER_01:

effects of lacking sleep, right? I guess that's a loaded question because how long has one been sleep-deprived? Do they have any underlying sleep disorder or not? For example, father of a newborn who has underlying undiagnosed obstructive sleep apnea will... that person will have a much more harder time recovering after having new kids as compared to someone who had healthy sleep to begin with. So one can definitely recover from sleep deprivation. Our physiology is resilient and there's a substantial amount of healing that happens. And we see this in people who have obstructive sleep apnea. It takes time. And I use these examples of sleep apnea or insomnia because most of how we understand sleep medicine today is through... understanding what happens when you treat pathology and what happens if you leave pathology untreated. That's why I keep using these examples, but if someone has bad sleep apnea that has been untreated for decades and then you treat them with CPAP, they will continue to feel better over six months, a year, sometimes even longer.

SPEAKER_02:

Okay, next one. Do older

SPEAKER_01:

adults need less sleep? I'll frame it a little bit differently. As we get older, we're not able to sleep as much. Can that be interpreted that you need, less sleep. I think that could be an interpretation, but it's not that they need less sleep. I think it's more so that they, physiologically speaking, cannot sleep more because, you know, sleep as we age are sleep ages. And like, I cannot sleep the same amount, like when I was 17, 18. And it's, I don't know if I need less sleep. It's just that I just can't sleep as much. Got

SPEAKER_02:

you. Okay. Let's move to some community questions and then key takeaways for people. So on community questions, Can you tell us a little bit about jet lag? How bad is it for you and how can you manage it better?

SPEAKER_01:

Yeah, I think, so jet lag, and again, like, you know, in jet lag, there can be extremes. It could be me going from California to New York and it could be from me going from California to China. And then the question becomes like, how often are you traveling time zones? Like sometimes we have patients who go to China twice a month and by the time they acclimatize there, they're already on their way back. So I think the context is, is like important and if one is going to new york and there's a four-hour delta that's probably not as bad like one will acclimatize assuming they don't have any substantial sleep disorder but if someone is going to china twice a twice a month for a whole year i can guarantee you there is going to be circadian confusion in that person's physiology again like our physiology is very resilient so a few hours of jet lag is probably okay there will be like an acute change in how one regulates glucose, cortisol, all of these things, but will adapt very quickly within a matter of days. But if someone is in perpetual jet lag, that person's going to be in a much worse position. If we look at the literature at this, what we observe is people who have substantial sleep-wake irregularities on a consistent basis, those individuals have more metabolic syndrome, more dysregulation of glucose. Dr. Sachin Panda, he's out of the Salk Institute. He's written a book called The Circadian Code based out of San Diego. And they've done like large population-based studies looking at this idea of social jet lag. Like, hey, when I am staying out late on the weekends and I'm eating later on the weekend, what does that do to my metabolic health? And they've collected some really interesting data showing that in that population, there's more risk for developing other pathology, particularly around metabolic health and obesity and those endpoints. So it's not good, but there's a spectrum of it across how much, like how often.

SPEAKER_02:

So if we think about napping and we think about trying to create this balance between addressing sleep debt and staying consistent and in line with our circadian rhythm, how should we approach napping? I mean, is napping helpful for our regular sleep? or is it disruptive to it?

SPEAKER_01:

It's a double-edged sword, this idea of taking a nap. If someone's sleep is relatively healthy, and healthy being its optimal timing, optimal duration, and optimal sleep quality, right? Like these are the three factors of how we look at sleep. Then one should not really feel the need to take a nap. Sleepiness that requires a nap is a symptom of the possibility of something else being abnormal in their sleep, either by timing, they're sleeping at the wrong times, Or they are biologically a eight hour sleeper, but they are only consuming seven hours of sleep at nighttime. So they have this chronic need of I need to sleep. I need to take a 30 minute, one hour nap every day. Or their quality of sleep is not optimal and they feel sleepy and they need to take a nap. So I think like this idea of napping people, it gets thrown around like it's a healthy, good thing to do. But I think a better way to think of this is, are you taking a nap because you feel sleepy from a nocturnal problem? Or are you taking a nap because you have this opportunity and you have nothing to do? Or are you taking a nap because you slept well at nighttime, but you have a basketball game coming up, and you just want to optimize your performance by taking this 30-minute nap just before a game? So I think the context... matters a lot. But for most people, like the general non-athletic population, people who are quote-unquote napping, that's usually because they're not getting adequate quality timing or duration of sleep at nighttime. How

SPEAKER_02:

about daylight savings time changes? How does that affect our sleep?

SPEAKER_01:

Matt Walker quotes this study. I haven't looked at this in a while, but about on daylight savings day, there's like a higher prevalence of nationally, motor vehicle accidents and more cardiovascular events like heart attacks on that day. So the data suggests that there's a clear signal of like sleeping less can cause substantial downstream consequences. But I haven't gone through like the data in a lot of detail to be able to give like a more educated viewpoint on this. But again, it's just I think these data sets are so heterogeneous that You have probably observed this in yourself. Like if you sleep one hour less, the likelihood of you or myself having a motor vehicle accident is pretty remote. And one can ask themselves the question, hey, did these people already have underlying sleep apnea? And that one hour was like the tipping point. Or did they have underlying cardiovascular disease to begin with? And sleeping less was like that tipping point that pushed them over the edge. So I think associations and causation is like something that as a clinician, we should look at with a little bit more scientific reasoning. But that's what the data shows. And that's what I'll sort of share with

SPEAKER_02:

you. Okay. So another question that we have is around over-the-counter sleep meds or sleep aids. What is generally okay? How much can people use these things safely? And what would you advise? I'll share my opinion

SPEAKER_01:

first. If someone has acute insomnia and they are needing to take supplemental melatonin over-the-counter Unisom, Tylenol PM, Advil PM, NyQuil. It's a very long list of different over-the-counter things that have different medications ranging from diphenhydramine, which is Benadryl, to hydroxyzine. I would ask yourself the question, what is going on that you need this? And ask yourself the question, what am I doing wrong that I need this? What is going on in my life that I need to take this? Because sleeping is not supposed to be hard. We've been doing this for hundreds of thousands of years, and we have evolved, and this is a core necessity. Breathing is not supposed to be hard. Defecating is not supposed to be hard. Urination is not supposed to be hard. These are all supposed to be relatively easy things to do from an evolutionary standpoint. So I think that's a red flag. If you feel that you need to take something, like something is concerning, and talk to your primary care physician about this, especially if you're having to use this chronically. days, weeks, months. But if one needs to take something, sort of like pick your drug. If you want to take a low dose melatonin, you can try that. The problem with melatonin is it falls into the category of supplements, even though it's a hormone. And there's a massive standard deviation in what is on the bottle and what is actually in the pill or in the gummy. And that standard deviation ranges from like negative 70% to over two or 300%. So if something says it's one milligram, It could be as low as like 0.3 milligrams, all the way up to three milligrams in this one milligram tablet. So like it's a very wide standard deviation.

SPEAKER_02:

And these are not regulated, of course, because it's a supplement.

SPEAKER_01:

Yeah. In the States, it's a supplement. Correct. And then if you want to try some of these other medications that are over the counter, Benadryl, hydroxyzine, just pick something that works for you. I don't think one is better than the other. Everyone responds differently, but just don't take it long term.

SPEAKER_02:

So to close, what are the key takeaways you would have for our listeners, recognizing that the purpose of this episode was really about trying to go beyond standard advice, the typical things everyone knows they should do already? What would you tell people to take away from this episode?

SPEAKER_01:

I would say, knowing all the basics, if you don't sleep well, get a wearable device and see what it tells you. Spend a few weeks, months, go to ChatGPT, And again, please use your basic judgment here of using the feedback that you get and just make some changes in your life to see if you can move the needle and improve the trends from these wearable devices. And if you are not able to move the trends and you still feel lousy, go see somebody. There's probably something cooking underneath that needs to be addressed. Ideally, I would say see a sleep specialist instead of going to your primary because a sleep specialist can dig a little bit deeper look at this a little bit more holistically, they will at least order a sleep study for you to do a deeper analysis of like what is happening and then try to let them help you make this better.

SPEAKER_02:

Dr. Sahil Chopra, thank you so much for joining us. We've covered a lot of ground today and we're very appreciative of your advice and your wisdom. Thank you.

SPEAKER_01:

Thank you so much for having me, Jason. I appreciate it.

UNKNOWN:

Thank you.