Dr. David Taylor (Host): Greetings. This is the On Call podcast at Riverwood Healthcare Center. Riverwood is a multi-specialty clinic in Aitkin, Minnesota. It also has clinics in McGregor and in Garrison, Minnesota. And today, my guest is returning. It is Dr. Tim Arnold. And we talked about exercise in our first podcast, and I think today we're going to spend some time talking about sleep as the next part of the pyramid that we can maybe recap here at the beginning of this podcast. How are you today, Tim?

Dr. Tim Arnold: Yeah, I'm doing well. It's a good day.

Host: Good. Hey, you know what? Just kind of bringing up something from the last podcast, since we recorded that, I heard about a rower who's 90 years old who has the VO2 max of a 40-something-year-old. Do you know anything about this?

Dr. Tim Arnold: I don't know about that specific one. There's a whole group of folks that have been studied out of like Norway and Sweden that were ex-Olympic cross-country skiers, you know, in their 90s have VO2 maxes in their 40s and 50s in terms of the actual number. So yeah, they exist.

Host: Yeah. If people want to look this up, I did end up looking it up, there's a Washington Post article and some other articles about this guy. I guess he took up rowing. So, he doesn't have the base, like the Nordic skiers in Norway or Sweden. He took up endurance athletics in his 70s, early 70s. He was retired. He took a rowing class with his grandson or something like that. And I think the reason I wanted to bring it up is one of the comments we made last time, is it's never too late to start. And the investment in his health obviously paid some serious dividends for him to be in the shape that he's in at 90, at least from a cardiovascular standpoint. I don't know many more details, but I thought that was a really good illustration of how it's never too late to start.

Dr. Tim Arnold: Yeah. And the other thing I wanted to comment on our last podcast, as long as we're kind of going backwards just a little bit here, was, you know, we talked about all these things that strength, flexibility, cardiovascular, all those kind of things, and I want the listeners to know that, yeah, we're physicians talking about these things, but we certainly aren't perfect at these things either. I think people would get quite the kick out of seeing me do yoga. It would be quite the comedy routine because I'm terrible at it. So, just to kind of let the viewers know that, you know, we all have our weaknesses and we all just need to try and we need to work on it and see where we can get. But some of us need some help and I need help when it comes to flexibility.

Host: Yeah, I think that's a great point and just knowing that, again, how you perform relative to others doesn't necessarily matter. It's getting out there and doing it.

Dr. Tim Arnold: So, let's talk just real briefly. Last time, we had chatted about longevity and healthspan, and I kind of brought up this concept of this pyramid and let's just kind of briefly review that, and then we should kind of go into our next topic. So in my mind, I sort of think of pyramid or a triangle. And at the very base of that is exercise, which is what we talked about last time, and it occupies the vast majority of that triangle because of its importance and it's also the base as we talked about our last podcast. It is really the fundamental thing that will drive our longevity and our well being.

Next on the pyramid up, one step is going to be sleep, which we're going to talk about today. And then, next up is going to be nutrition. And then, something we call hormesis, which is basically the concept of asking the body to do something it's not used to doing. And we can talk about that more at another podcast. And then, at the very, very top are the things that we ingest, molecules, medicines, vitamins, that kind of thing. So, that's my fundamental way of sort of thinking about healthspan and longevity.

So, let's jump right into sleep. And I had said just a minute or so ago that none of us do all these things perfectly. And again, my yoga is quite comical. Sleep is also for me one of probably my Achilles heel a little bit. That's the thing that I really struggle with. And I think it actually started in residency. You and I went to the same program. We did 110-hour weeks and we did some of these 60-hour weekends where we didn't sleep for two and a half days. And I think it kind of got broken for me at that time. And so, I struggle with it now. And I'm guessing your sleep probably isn't perfect either, given the fact you're an ED physician and you're up for 24 hours straight at least once a week.

Host: Yeah, I would say that of those first three in the pyramid, my exercise is my strongest and always has been, luckily. My nutrition is probably next, especially better now that I'm married. And then, my sleep is the one that I've also looked upon as a weakness in the past, which is not good thinking. But I have looked at it and said, "Hey, I work in the emergency room. I can stay up all night if I need to and then, I can just bounce back. And I don't really need to sleep." You know, the old, "I'll sleep when I'm dead" comment that I'll hear people say. And I feel like that is a lot of bravado and very foolish. I wish I had thought that it was bravado and foolish 20 years ago, but at least I'm there now.

Dr. Tim Arnold: So, we're going to talk more about that coming up. But let's first start with the definition of sleep, because I think that is something that I think a lot of my patients get confused or maybe don't necessarily quite understand. And I still am coming to a full understanding of this. And the way that I kind of explain it to my patients is sleep is not the absence of consciousness. The absence of consciousness is being in a coma. A great example would be, Dave, I could hit you over the head with a baseball bat right now and you'd be on the floor and you wouldn't be awake, but you wouldn't be sleeping.

Host: Right.

Dr. Tim Arnold: Your brain would be unconscious or offline. Same thing happens when you're seeing someone in the emergency department and you need to put them in a medically-induced coma and put a breathing tube in their throat and breathe for them. It's the same basic concept. At that point in time, that patient or that person isn't sleeping. So, the other way that I explain this to patients is I tell them, and I don't think this is really much of an exaggeration, that our brain is actually more active and busier when we're sleeping than when we are awake. And that's a bit of an overstatement, but it is for sure not an overstatement to say that it is much more orchestrated and coordinated and a very wide range of amazing things that's happening in the brain when we're sleeping. So, it's incredibly busy.

Host: I think to add on to that, in preparation for this, I was listening to a lecture and somebody was referencing a study about what must have been PET scanning, something along those lines that they were imaging the brain functionally. And this is where you'll help illuminate my deficiencies in this, but the brain actually was almost globally active during certain parts of sleep. And during wakefulness, it almost never is that globally active.

Dr. Tim Arnold: Right. So, we have essentially four stages of sleep. There used to be five, it's kind of been recategorized.

Host: Four stages and REM, or then you're including that in one of the stages?

Dr. Tim Arnold: Yep, exactly. So technically, there's REM sleep, which is something called rapid eye movement sleep. That's when we dream. And then, there's technically three stages of non-REM sleep. It used to be four. They've kind of consolidated that a little bit. So, it depends on whose definition you're looking at.

So, the way that I think about sleep and what's going on in the brain is I try to envision a real-life scenario. And the best example I've heard was if you can imagine a football stadium and it's filled with 50,000 people, and let's just assume that that's your brain, each one of those persons represents a neuron in your brain, our brain has millions of them, but this just kind of gives you an idea. So if you think about that football stadium filled with people, everyone is cheering and screaming in their own way and doing something all on their own. And that's basically when we're during the day. Each neuron is kind of doing its own thing, firing when it needs to.

Now, imagine during sleep, if you took all of those neurons and you started to orchestrate them, we all kind of know what the wave is. When a group of people in the stadium stand up and sit back down again, and that wave progresses across and around the stadium and everyone's doing it in concert. Now, imagine that and maybe they're not just doing the wave, they're getting up and doing a certain dance and maybe they're all singing a certain tune or they're playing a certain instrument and the group of the people across the stadium are responding to what's happening on the other side. So, it's all orchestrated and it's all this amazing symphony of activity across all of these millions of neurons, all happening and dependent on each other and responding to each other versus all just doing their own separate thing.

That's kind of the best way for me to sort of visualize what the brain is really actually doing when we're sleeping. It's this highly orchestrated, highly choreographed, very, very intricate, amazing set of activity that's going on throughout the brain.

Host: Yeah, I think that's a good analogy for that.

Dr. Tim Arnold: Yeah. And so, the other thing to think about that's really important is what happens in these various different stages of sleep. When we look at the electrical activity in the brain, we break it up like we said into four stages, this thing called REM sleep. And then, there's these three other non-REM or used to be four categories of non-REM sleep. And I don't want to get into the technical details of that, because I don't think it's relevant here, but I think it's really important to know that each one of those stages does some amazing things.

And just to give you some examples and it helps to highlight why sleep is so, so important, one of the amazing parts of sleep is that it takes all of our memories from the day that's in short-term memory, and it consolidates it and puts it into long-term memory. I sort of think of that like a desktop. You have papers on your desktop that's short term and you file it in your filing cabinet for long term. And the brain is really busy at night taking those short-term memories and sticking them into long-term memory.

And then, what's even more interesting is that it does this amazing job of figuring out where to put those memories and how to tie them to other relevant memories or maybe even non-relevant memories. So for example, we've probably all had an experience where we smelled a certain food or certain smell and it brought back a memory from 20 years ago, something that maybe grandma cooked on the stove when you were a kid or something like that. It's because those memories were tied together in that long-term storage. And then in addition to that, you had an emotion tied to that. You remember what you felt like, you remember how important it was to you to be in that comforting smell of your grandma's kitchen maybe. And so, the brain puts all of these things together in this amazing, unique way. And it starts to tie together emotions and smells and thoughts and feelings, and it puts it all together. It'll also do that for things that you don't think are going to be tied together. And that's where creativity starts to come into place. We've all probably heard of musicians who say, you know, in the middle of the night, they woke up and had this burst of creativity because they couldn't make this song work. And then, eventually, boom, in the middle of the night, they could. And that has to do with that creativity and that putting together of all these different disparate memories and thoughts and emotions together.

Host: Yeah. I feel like I've heard accounts of comedians, which, you know, similarly creative, coming up with things in the middle of the night and having a notepad or some way to record their ideas if they happen to wake up like that.

Dr. Tim Arnold: Right. Yeah, exactly. So, that's kind of sort of what happens on the brain. There's a whole lot there. We could talk about that for hours and hours, but I think it's also important to talk about just a couple of other things. One is what happens in the body when we sleep, not just the brain. So, there's really a lot of data looking at what happens to the immune system, for example, and that gets to this whole longevity and lifespan business.

Host: As we go into this and then put some of those things that happened with the body together with sleep, would it be helpful to give our listeners an idea of a typical sleep progression, like what happens when you start to fall asleep at night and how your body progresses through stages of sleep? Because that's something I don't know of. I mean, everybody I think knows of REM. And then, there's a lot of people I think know about the "90 minutes." But how do you tie that together? What exactly does that mean? And then, maybe if I remember right, your body is actually paralyzed during-- is it REM?

Dr. Tim Arnold: Correct, REM. Yeah.

Host: So for example, maybe if you laid out the framework of sleep progression, then we could integrate then what's happening in the body too, if that seems like a good time to you to do that.

Dr. Tim Arnold: So, sleep progression is pretty complicated. We'd have to kind of get into fairly technical deep weeds on that. I think let's start with a 90-minute cycle. I think that may be a little bit better place to go. So in the night, we typically have these 90-minute cycles that our brain goes through. And we typically go through all of those different stages of sleep during that timeframe. Generally speaking, in the first half of the night, we have much more of the deeper sleep. So, the stage 3 and what used to be called stage 4 non-REM sleep. And it's those really deep stages of sleep that some of the most restorative things happen in the brain, some of the cleaning mechanisms in the brain occur, and that kind of thing. And then, at the latter half of that 90-minute cycle, we'll end up with some REM in there.

Now, REM isn't the only place we dream, but pretty much primary, all of it is in REM, and that's the rapid eye movement is what that stands for. And we've probably all watched somebody sleep or a dog or a cat where their eyes are fluttering underneath their eyelids and they may be jerking a little bit. And that's the time in which we're dreaming. Generally speaking, we're fairly paralyzed during that timeframe except for our diaphragm, and then a few of these kind of jerking, we call them myoclonic kind of episodes, but that's the dream part of sleep. There are some really important emotional integration and regulation that happens during that dream sleep. That's why dreams are sometimes so funny and emotional and scary and happy and all kinds of other emotions get tied up in our REM sleep. As we go through the night, as we get into that six to eight-hour timeframe, the proportion of that 90-minute cycle, the proportion of stage 1, 2, 3 non-REM and REM, the proportions start to switch and start to change. First half of the night, we have more of the deep non-REM sleep. Latter half of the night, we have much more of the REM sleep and a little bit less proportionally of the non-REM deep sleep, which will get to be important when we start to talk about insomnia. Because when we cut off our sleep and we're only sleeping four or five hours a night, let's just say it's four hours, we're not just losing half of our sleep, we're losing a much greater proportion of the REM sleep. So, we might be losing 70-80% of our REM sleep that we need for that night. I think that's probably a good way to talk about those progressions maybe.

Host: Yeah. I think that's kind of what I was looking for by asking you that question.

Dr. Tim Arnold: The other little amazing fact I want to just talk about with sleep, because I want to just throw this in here, I want people to understand that all of the animal kingdom sleeps. And when you start to think about what that means, that means that that is a highly conserved thing that all animals with some sort of higher brain function have to do. So, that includes worms and flies and spiders, reptiles, snakes, turtles. We all know our cats and dogs dream or sleep, should I say. It is found across all species in the animal kingdom. And so, that tells you right there, this is a really, really important thing for our body to be healthy. Otherwise, it just wouldn't have stuck with all those species throughout evolution or the timeframe, or even if you think of it from a creation standpoint, it's there for a really important reason.

Host: Yeah. That's a nice little aside that illustrates its importance.

Dr. Tim Arnold: We spend a third of our life paralyzed and hallucinating, and we're really vulnerable. Take yourself back a thousand years or 2000 years ago. We're really, really vulnerable. We're not getting food. We're vulnerable to predation or enemies or attack. We're not making shelter. We're not doing the things that we need to do to stay alive.

Host: Well, that's what's amazing that it's conserved through evolution because you would think it might be otherwise. So obviously, if it has stayed preserved through all that time when we were much more at risk when we were sleeping, it speaks to its importance.

Dr. Tim Arnold: Right. So, the next thing of importance that I just want to talk about really quickly, go back to again, is just the immune system. The immune system is the thing that helps protect our body, and we think of it as infections like the flu or COVID or maybe pneumonia, but it's so much more than that, it's actually cancer. So, we all have cancer cells that are kind of continually popping up, and our immune system is taking care of those. Anything we need to do to protect ourselves, the immune system does. And it is really, really clear that the immune system is highly affected by sleep and the ability of those white cells to do what they need to do is very much regulated by sleep.

The next big system that's really important is kind of the hormone system. Our metabolism, we talked about this with the last podcast with exercise and energy, is extremely important for longevity. We have to have this engine that runs clean and efficient. And it is really, really clear that our metabolism changes within 24 hours of missing a night of sleep. So if you didn't sleep last night because you were on call on the ED last night, Dave, I know that your cortisol level is not right, I know your insulin sensitivity is not as good as it is after a night's sleep. So, the metabolism and this energy processing really, really starts to get off the rail quite quickly when you don't get good sleep.

Host: Yeah. Do you have any sense of how quickly you can get things back on track after a night of poor sleep?

Dr. Tim Arnold: Yeah, that's a great question. So, there have been a lot of studies looking at can you sort of bank your sleep? You know, this concept of I'm going to sleep a bunch on the weekend and then I'm not going to sleep much during the week, or "I had a terrible night's sleep. Therefore, I'm going to sleep tomorrow. And then, how am I going to function the day after that?" And the data is really clear that you don't recover immediately. Even if you have a really good night's sleep the next night, your ability to make new memories the following day and retain the ones that you tried to make during the day that you slept or you didn't sleep at all is impaired. It takes a number of days to get back to the functioning that you would have had if you were sleeping consistently every single night.

Host: Yeah. I think because I work six to seven, actually seven to eight shifts a month, and most of those nights are not sleeping a full eight hours, which is roughly what I feel like I typically need, I have noticed now maybe more than I paid attention to before that it is literally two or three days to get back a sense of equilibrium. And unfortunately, like working in the emergency room last night, well, now I will work again on Thursday. And that illustrates how shift work can be a problem. But I've definitely noticed over the past couple of years that it's two to three days. And after two to three days, I'll be back on kind of my normal rhythm and I'll feel much better, and it's a remarkable thing to realize that's how long it takes.

Dr. Tim Arnold: I think the data would tell us that it's actually longer than that. You weren't fully recovered at day three.

Host: Yeah, that's very possible. But at least, I'll start to feel that way. And if the data suggests it's even longer, that's unfortunate. But I definitely don't feel it those first few days either. Despite typically having like tonight, historically over the past few years, I will sleep very well tonight, but it won't be enough.

Dr. Tim Arnold: And we will know that, again, if we study the ability for you to form memories, even tomorrow, so you'll sleep tonight and tomorrow, your ability to form memories is going to be diminished. And like I said, even your hormones, like your cortisol and your insulin sensitivity and all those things are still not tomorrow going to be normal.

Host: You're saying it's a good thing we're recording this podcast, because I'm not going to remember it.

Dr. Tim Arnold: Right.

Host: Okay.

Dr. Tim Arnold: Yeah. So, let's talk about insomnia next. So, we need to talk about the flip side of sleep, and that is the absence of sleep. So, let's define it first. There are a bunch of different definitions out there in literature about what exactly insomnia is, but it's easier for me to say in the beginning what it is not. And I have patients all the time come in and tell me, "I'm not getting enough sleep. I'm tired all the time." And when we really drill down into it, it's because they have a lack of sleep opportunity. It's not that they have a lack of sleep. It's just that they have a lack of opportunity to really actually get good quality sleep. And I think in the U.S., that's a massive problem. Some of it is self-injurious. We spend time scrolling or watching Netflix or whatever it might be. But a lot of it's just we're just so busy and we live in a 24/7 society. So, that is a huge problem. So, it's not a lack of sleep opportunity. Insomnia is when you have plenty of opportunity to sleep, but you still can't sleep. And then, it is also not "I've had three or four bad nights." That's not insomnia. Insomnia, there's again a bunch of definitions, but it's bad nights over a long period of time. So, we typically think of three months. There's a rule of three. There's a bunch of different ways to define this. But the long and the short of it is reoccurrent difficulty with sleeping over a long period of time. And then, there are three different kinds of insomnia. There is the kind where you can't fall asleep. But once you're asleep, you do just fine. And then, the second type is you can fall asleep just fine, but you can't stay asleep. We call that sleep maintenance insomnia. And the first one is sleep onset insomnia. And then, the very last one is this perception of insomnia where you actually sleep really well, but you feel like you don't. That's kind of a little bit of a rare beast there, but sometimes there's a mix of those three.

When patients come in and tell me that they have difficulty with insomnia, one of the first things we have to do is just to figure out again, are they getting enough time to sleep? And then, the second thing I need to figure out is are there any other medical issues that are keeping them from sleeping? And there are some very specific things that we can think of, like a thyroid problem or, for example, I have patients who've had organ transplants and some of the anti-rejection medications they take are legendary for keeping people awake. So, there are some medical reasons why people can't sleep that we have to kind of sort out sometimes.

And then, the next big one for me is going to be caffeine and other chemicals. Caffeine is huge particularly in our adolescents and our kids, just really, really getting worried about caffeine and screen time on computers. So, I want to delve a little bit into caffeine, because I think it's really important for the listeners to understand how caffeine works and what it does and why it's kind of a problem today. We have a chemical in our brain that builds up during the day called adenosine. And that chemical is the thing that tells our brain to go to sleep, and caffeine blocks that effect. And so, it doesn't matter how much adenosine you have in your brain, if you take some caffeine, it's going to block that effect and you're not going to feel as sleepy.

The problem with caffeine is that we metabolize caffeine roughly about six hours, we metabolize half of the caffeine we take in. And all of these energy drinks, Celsius and whatever, right? You know, pick your version. And they all have 150 to 250 milligrams of caffeine in it, which is just astronomical. So, let's just take 200 milligrams of caffeine. And let's say you do that at noon and you're an average person and you metabolize half that caffeine in six hours. So, what that means is you start off with 200 milligrams at noon. At 6:00 PM, you still have a hundred milligrams of caffeine in your system. That means at midnight, so 12 hours after you drank this Celsius or 200-milligram caffeine drink, you now have 50 milligrams of caffeine in your system. A decent cup of coffee is about 60. So, because you drank that thing at noon, you now have a cup of coffee in your brain at midnight.

Now, I have a lot of patients then tell me, "Well, I can drink coffee right before I go to bed and I'm just fine, I fall right asleep." well, that very well may be the case because your brain is so used to it, and you've got so much adenosine pressure all the time that it doesn't really matter. But what we know is that the architecture of sleep that we talked about in the beginning of all this, these stages of sleep that do this amazing thing, all these incredibly orchestrated electrical signals going on in the brain, we know that that just gets devastated with caffeine, even if you're sleeping. And so, what ends up happening then is you wake up the next day and you don't feel very rested because you slept maybe six or eight hours, but the quality of the sleep was terrible. And so, guess what are you going to do the next day?

Host: More coffee.

Dr. Tim Arnold: You're going to drink more caffeine.

Host: Or yeah, whichever your form of caffeine. Right.

Dr. Tim Arnold: And you might drink it into the afternoon. And now, it's two or 3:00 in the afternoon, and you're drinking caffeine because you're having a hard time staying awake at work. And it's 3:00 in the afternoon, you drink a big cup and it's 80 or a hundred milligrams of caffeine, and now do the math again. Three o'clock in the morning, you'll still have 50 milligrams of caffeine in your brain while you're trying to sleep. And it just becomes this really vicious cycle.

Host: Right.

Dr. Tim Arnold: So, we really, really, really need to avoid the caffeine. And there's been this explosion of caffeine in our society. Just about everything you can buy at the local quick gas station, if you look on the bottle, it's got caffeine in it. Oh my gosh, it's everywhere. And it's really causing problems.

Alcohol is the other one I just want to mention. So, a lot of people tell me, "Well, I fall asleep really well when I have alcohol." Yeah, because it's a sedative. But what it does is it destroys REM sleep, absolutely destroys the REM sleep. And so, again, the quality of the sleep is terrible. And the next day you feel terrible. And the next day, "Oh my gosh, I'm tired and I'm going to drink some caffeine. And now, at midnight or 8:00, I'm going to drink some alcohol and go back to sleep." And you, again, just get into this mix of just terrible sleep quality.

Host: Do you have a timeframe you like to tell people when they should quit drinking alcohol before they try to go to sleep?

Dr. Tim Arnold: Well, anything after 6:00 PM for sure is going to affect that sleep that night.

Host: Yeah.

Dr. Tim Arnold: And particularly if it's more than one true drink, which I think most mixed drinks for most people end up being more than one shot worth.

Host: Have you heard the 3-2-1 rule? Have you come across that at all? No eating three hours before bedtime for you, whatever your bedtime happens to be. No drinking, and by drinking they mean alcohol, two hours before bedtime, which would be not quite what you'd recommend based on what you just said. And no screens one hour before bedtime. I've heard this rule now a few different times and I was curious if you'd come across it.

Dr. Tim Arnold: I don't think I've come across that rule. I would probably do a 3-3-1 rule, which actually brings us up to really the next kind of step here. And that is what are the other things that we do to precipitate insomnia? Chemicals being one, number two being the environment that we're in. We were designed to live in an environment where the lights went down. We were designed to be in an environment where things started to settle down in the evening, and we sat around and maybe had conversations with our friends and our loved ones and things started to settle down.

Sleep is a lot like making dinner. You have to put the recipe together. You have to combine all the ingredients. You have to set the table. You have to put the silverware out. Maybe you want to light the candles. I mean, all those things have to happen in order for us to sleep well. You have to set the table and set the environment for our brain to be able to go to sleep. And this environment of TVs and computers and scrolling and social media, which are designed to instill rage. I mean, that's what social media is designed to do is to get a reaction out of you and to trigger your amygdala, your fight or flight, your anger side of your brain, all of that hijacks our ability to go to sleep. And that's kind of that last one hour, turn off all the social media, all the screens, all the TV, all that kind of stuff.

So, the next thing in my mind that we need to do with setting that table is to make sure that you have a dark room. It also needs to be a cool room. We need to drop our body temperature a degree to degree and a half in order to really sleep well. One of the tricks is to actually take a quick warm shower. And the reason is you bring all the blood to your surface of your skin. And when you get out of the shower, you've got all this blood on the surface of your skin and you radiate off a lot of heat and you drop that core temperature down a degree, degree and a half pretty quickly and it helps you get to sleep.

You need to have a regular start and stop time. So, try to go to bed at the same time. But for sure, get up at the same time every day if you possibly can. And then, first thing in the morning, get bright light in your eyes. That also helps regulate our circadian rhythms, our rhythms when our body knows when to go to sleep, when to be awake, when to learn, all that kind of stuff.

Exercise, I'm going to go back to our pyramid again. Exercise is really important. That can really, really help the sleep get better affect the quality of our sleep.

Host: Do you tell patients anything with regards to the timing of exercise in relation to sleep?

Dr. Tim Arnold: Yeah. I think there is moderate amount of data out there. I think the best, from what I recall, is morning or afternoon times. If you're trying to exercise right before bed, you do have a pretty good sympathetic response. I'm trying to put this in layman's terms here. So, get our energy up, get our blood pressure up, get our ability to work hard up. We've got this system in our body that turns on these hormones and these chemicals that tell our body to work hard. Well, that's what happens in exercise. That's not really setting the table for sleep. So, we don't want to do that right before sleep. And I think it's a couple of hours. I would probably put that in that two to three-hour rule again.

The other thing I wanted to mention was if you're having troubles with insomnia and you're lying in bed at night and like mine, your brain starts spinning and you start thinking about all the things that you maybe should have done or you didn't do right or whatever it might be, don't lay in bed for over half an hour without sleeping. I want to really encourage people to get up, get out of bed and go do something that's not energizing or exciting. I want you to go do something relatively sedate, like read a book or not a scary book. But read a book or maybe do a puzzle or go sit with the cat or the dog or something like that. The reason is we don't want the brain to get used to laying in bed and thinking, just like we don't want the brain to get used to laying in bed and watching TV or laying in bed and reading a book. So, I don't want you to watch TV and laying in bed. I really don't want you to watch or read a book laying in bed. Even on a regular basis, I really encourage people to get the TVs out of the bedroom. Books should not be read in bed. And if you're not sleeping, get out of bed and go do that in another room and then come back. We want to tell your brain the bed is for sleeping. That's what it's for.

Host: That's good advice, and I think it's so easy for people to sit in the bed with their phone, which is the big problem that we talked about, but even things like a book, you think that's a way to wind down. But you could do that in a chair nearby, and then go into that room to signal that it's time to sleep.

Dr. Tim Arnold: I really encourage people not to look at the phone first thing in the morning when they get out of bed as well. So, what happens there, when we look at the phone, we do get these little hits of this chemical in our brain called dopamine. It's kind of this sort of reward kind of chemical. It's the best way to sort of think of it. And every time we scroll social media or we do whatever, look at the news, whatever it might be, we get these little hits in our brain. It's the reason why we keep coming back to it. And what we don't want the brain to say is, "Oh, I'm lying in bed. When I wake up, I want to get this little hit of dopamine. So, I'm going to look at my phone." I want your brain when it wakes up to say, "Oh, I'm awake. Maybe it's time to go back to sleep again." And that gets to that sleep maintenance business where you can't stay asleep at night. So, get the phone out of the bedroom, or at least don't look at it when you get up first thing in the morning. Do something else for a while, then go look at your phone.

Host: Yeah, that makes sense. Liquids in the evening, do you advise restricting that so people don't have to get up and pee? As a sleep disruptor, is that not something you find people having a big problem with? Obviously, if you have prostate issues and you're up four, five, six times a night, that's a different story, or if you have a urinary tract infection and, you know, or your blood sugar is really high. But do you have any thoughts regarding that?

Dr. Tim Arnold: I'm so glad you asked that question, because it left off a whole big something, a big piece of something that I want to talk about. So when you kind of bring up urinating at night or needing to get up and should you restrict your liquids or not, the very first thing that comes to my mind is not whether or not you drank too much liquids before you went to bed, but do you have obstructive sleep apnea, which I know is a weird thing for me to think about. But a large percent of my patients that tell me I have to get up to go to the bathroom two or three times a night, they're either a man with a prostate issue or they're someone with obstructive sleep apnea.

And let's define obstructive sleep apnea for a second, obstructive sleep apnea means that you stop breathing at night or your airway gets closed off and you don't breathe adequately at night. That's what obstructive sleep apnea is. And often times what happens is your brain comes right up underneath the surface of just waking up, just at the edge of waking up, and your brain also says, "Oh, my bladder's full. I better wake up and go to the bathroom." Had you not come right up to the surface with that sleep apnea, your brain wouldn't have woken you up. You would not have needed to get up to go to the bathroom. And so, it is a real big key for me to think about, "Ooh, I bet this person has sleep apnea." Look at their mouth, ask them other questions about sleep apnea, and a vast majority of them end up with sleep apnea. One of the risk factors for sleep apnea, of course, is our weight, and two-thirds of us are overweight. And so, we just see this huge, huge amount of sleep apnea. We could spend an hour just talking about that. That's another whole big topic.

Host: Right. That might be worth its own podcast. That's for people out there who are not familiar with sleep apnea, which I think it's prevalent enough. Most people know somebody who uses CPAP or has sleep apnea, or knows something of it. Basically, you're going to talk with your provider, you'll probably get a sleep study. And then ultimately, CPAP is the treatment, which I understand it's not all loud machines and hoses and big, uncomfortable face masks anymore. Is that accurate?

Dr. Tim Arnold: Yeah, correct. Most of the machines, you can't hear them run, and there are all kinds of face appliances, nose, mouth, all kinds of different options there. And of course, there's a new surgical option as well that's available that, again, we could spend quite a bit of time talking about.

Host: Yeah. Maybe we will touch that, especially if we get some questions. I will say that on my Canada fishing trips, it turned out over the years enough guys had CPAP machines they brought up with them, or they snored, either one, that you really had to fight to fall asleep right away, or there was going to be troubles getting to sleep with the rest of the guys fishing. What do you recommend regarding melatonin if people say they want to take it nightly? What are your recommendations?

Dr. Tim Arnold: There's a couple of issues. Issue number one is the amount of melatonin found in products that you buy over the counter is widely, widely variable. And so, it's really hard to know exactly what you're getting. The second thing that I think a patient should know is that melatonin is really the signal in our brain that starts the race. It starts the process of sleep. It isn't the thing that maintains sleep. I'm fudging a little bit on that statement. A true sleep scientist would probably argue with me on that. But the bottom line is melatonin is really just there to start the process.

I think it's reasonable to give it a try for a very short period of time, knowing that you're taking a reasonable amount. We could probably talk about that for quite a long time, but I'll make sure that if you buy a product that it's been tested for its purity and you know exactly what you're getting. And really long term, it is not something that I would recommend long-term other than for very specific certain circumstances.

We should also talk about just regular sleeping pills, because that's a very common thing for patients to ask me, "Hey, can you just give me a sleeping pill so I can sleep?" Well, no. Maybe for short-term under some unusual circumstances, yes. But as I had outlined earlier, when we sleep, our brain is incredibly active, just incredibly, incredibly active. And what that sleeping pill is going to do is it's going to suppress that activity. It is slowing all that activity down. So, you're not getting good quality sleep. You may be asleep, but the quality of your sleep is terrible. And we know that patients that take long-term sleeping pills end up with higher rates of cancer and malignancy and those kinds of things. So, it's just not a good long-term solution. There are better ways to go about this. Do all the things that we talked about. The very last thing that I would recommend would be something called cognitive behavioral therapy for insomnia, which is CBTI.

Host: Oh, yeah.

Dr. Tim Arnold: That's also a really, really important way to help with sleep. In the long term, you're going to be in a much better spot.

Host: Yeah, that's good to bring that up. I think that's one that maybe a lot of people don't know anything about. And I think a good takeaway regarding sleep aids is avoid them if possible, medication, sleep aids.

Dr. Tim Arnold: Avoid them, avoid them, avoid them, unless there's some really good medical reason for it.

Host: Right. I think this is a pretty good overview of sleep. And it is funny because when I was initially thinking we could do sleep and nutrition together, I don't know what I was really, because I think intuitively you think, "Well, I know what sleep is and we just need to talk about timeframes," but there really are the devils in the details with sleep, and it's so important. We could have talked longer and gotten deeper into several of these side items that we brought up. And here we are already at almost 45 minutes.

Dr. Tim Arnold: And you think nutrition, that is kind of going to be the granddaddy of them all, because everyone's got their own strong opinions on nutrition.

Host: Right. We could do part one and part two on that.

Dr. Tim Arnold: Yeah, we could.

Host: Okay. Thank you, everyone, for listening. Please let us know if you have any questions and we'll see you at the next podcast.