What Is Driving Your Poor Sleep And How Can You Fix It?

Mark Hyman, MD

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Dr. Cindy Guyer: The clocks in the brain and the clocks in the body that are ideally going to be working in sync with each other, they're influenced by light, by movement and by food. So when we line all those things up during the day, it's going to help us get the rest that we need at night. Dr. Mark Hyman: Welcome to The Doctor's Farmacy, I'm Dr. Mark Hyman, that's pharmacy with an F, a place for conversations that matter. And if you struggle with sleep, you better listen up because this conversation is for you and it's with my friend and colleague, Dr. Cindy Guyer. Cindy is an extraordinary woman who I've known for decades now, hired originally at Canyon Ranch to be a doctor there. She became the medical director and has been there for 23 years, leading the way there in functional medicine and has recently joined the Ultra Wellness Center. We're just so happy to have her. She's triple board certified in internal medicine, integrative medicine and lifestyle medicine. She's on the faculty of the Center for Mind Body Medicine, teaches all over the country and the world and is one of the best doctors I know. And I am just so excited, one, that she's joining Ultra Wellness Center and two, that we're having her here on the Doctor's Farmacy podcast. Welcome, Cindy. Dr. Cindy Guyer: Thank you, Mark. It's my honor and pleasure to be here. Dr. Mark Hyman: All right, so we're in a special episode of The Doctor's Farmacy called House Call where we dive deep into clinical topics and talk about how functional medicine takes a little bit of a different approach to thinking about diagnosing and treating problems than traditional care and why traditional care often misses the boat for things that are mostly driven by lifestyle and environment and are not acute illnesses. You get hit by a truck, you go to the emergency room. You have pneumonia, you need an antibiotic. But most of the stuff we're dealing with is lifestyle or environmental driven and really we struggle to take care of these things. We push all these pills on people and often it misses the underlying cause. And it's often not what you think. Dr. Mark Hyman: So today we're going to talk about sleep concerns, particularly for women, because if you haven't noticed, men and women are different. And actually there was an NIH director, the first woman, Bernadine Healy, she was a cardiologist and she was like, "You know, we really haven't done much research on women. We just do all our studies on 70 kilogram white males from Iowa and maybe we should think about studying women." And she initiated the Women's Health Initiative, which was a billion dollar study and just really started the whole conversation, which you think would've been started a long time ago. So let's talk about what are the challenges that you see in your clinical practice around women and sleep? And what are the main reasons that you're finding, and some of them are expected. And then let's go into how they would be traditionally approached by conventional medicine and then we'll dive into functional medicine. Dr. Cindy Guyer: Sure. So I think the first thing is that some common sleep conditions, like insomnia and restless legs, they disproportionately affect women and they can have a connection to lifestyle. Sleep apnea, interestingly enough, gets underdiagnosed for women. And there's a lot of reasons, which you can dive into it, but some of that has to do with stereotypes on the part of clinicians, that thinking about sleep apnea being a man's condition. Dr. Mark Hyman: A big, heavy guy, right? 300 pounds. Dr. Cindy Guyer: But lean women can get sleep apnea too and it may show up very differently. There's also the idea that when we look at times of hormonal fluctuation for women, whether that's before their periods or during pregnancy or the post partum or the menopause transition, that can also cause an uptick in disruptive sleep. So hormone balance and regulating hormones can play a huge role in improving sleep quality. Dr. Cindy Guyer: And finally, disproportionately in the past, caregiving demands have fallen on the shoulders of women. And I think that really became manifested or evident during the COVID-19 pandemic when you saw a bigger proportion of women than men experiencing an uptick in insomnia, anxiety and depression. So they're all interconnected. Dr. Mark Hyman: Yeah. So women take on the burden of the families. They often, especially during the peri-menopausal years, become the sandwich generation between raising their kids and taking care of their elder parents and you're kind of in the middle of that, toward the tail end of it. So you kind of went through that. And it puts a lot of stress on women. And also, I think there's something unusual causes of sleep that get missed by traditional medicine. So if you were a woman and you went to the doctor like, "I'm having insomnia," what are they going to tell you? Dr. Cindy Guyer: They'll probably tell you to take a sleeping pill. Dr. Mark Hyman: A little Ambien. A little Valium, right? Or maybe they'll give you an antidepressant, right? Dr. Cindy Guyer: Right. Dr. Mark Hyman: And of course those come with side effects. They're addictive, they impair cognition, they have all kinds of long term effects. The benzo, like Valium and Lorazepam or Adavan, they may lead to increased cognitive problems like dementia when you get older. Ambien, we've heard all those stories about people wandering around doing stuff they shouldn't do in the middle of the night. It's unfortunate that there are other things, too, that traditional medicine misses that are in sleep. You talked about the big ones, which are the stress and the sleep apnea and the hormonal issues. But there's really more that we know about sleep disruption. And the difference with functional medicine is that we tend to take a detective approach, we don't just stop at the diagnosis. Insomnia is a symptom, it's not a disease. Dr. Cindy Guyer: Right. Dr. Mark Hyman: Right? And so we go I know why you can't sleep, you have insomnia. No, that's just the name of it, silly, that's not the cause. And so we kind of have a different approach. And over the years, there are things we've really uncovered in functional medicine that play a role in sleep that are mostly ignored. You shared a little bit about it earlier when we were chatting but what are the kinds of other things that we see underlying the root causes of insomnia? Dr. Cindy Guyer: So if we think about insomnia, about 80% of people who develop chronic insomnia, there's an initial inciting event but it leads to ... A stressful event, for example. Dr. Mark Hyman: Like a death or a divorce. Dr. Cindy Guyer: Right. Or a transition with a job, and I think the pandemic has contributed to it as well. But then what happens is there's this up regulation of the HPA access and this chronic- Dr. Mark Hyman: What's that? Dr. Cindy Guyer: Overproduction of cortisol and hypothalamic pituitary adrenal axis. Dr. Mark Hyman: So it's the brain's command center that tells the body what to do? Dr. Cindy Guyer: Absolutely. So it's that connection between what our brain is registering as a threat and how that impacts our need to respond to that threat by pumping out these hormones that then, in turn, keep us ready to deal with a threat that may not be there anymore. Dr. Mark Hyman: So basically if you're in fight or flight your job isn't to go take a nap? Dr. Cindy Guyer: It is not. Stay alert and wait for the next thing that's going to threaten you. Dr. Mark Hyman: So that activated sympathetic nervous system is huge. In our culture it just does that. The phone is like a dopamine pump. A dopamine pump that keeps your blood pressure up. I mean, when people are dying in the intensive care unit, the drug we give them to keep their heart going is dopamine. And that's what- Dr. Cindy Guyer: That's a great analogy. Dr. Mark Hyman: And so it's like at the very end of life, if epinephrin failed, everything else, you give dopamine because it's so powerful at keeping you awake and alive. And so everything in our life is the sugar, the phones, we're just constantly in a dopamine barrage. Dr. Cindy Guyer: It's funny you said that because I've had people tell me, "I wake up at 1:30 every night." And I say how do you know it's 1:30? Because I look at my phone and it says 1:30. And that, again, perpetuates the cycle because then you're thinking it's 1:30. Oh crap, I'm awake, I should be asleep. And then it just becomes ... Dr. Mark Hyman: Yeah. The best thing I ever did for my sleep issues, because I struggle with them as well, is putting my phone and my watch off. Taking everything out and not knowing what time it is. Just letting my body do it's thing. Dr. Cindy Guyer: I think that's brilliant, Mark. And even sleep trackers, for some people, it can be a double edged sword because you're thinking, okay, what's my tracker show me? How well did I sleep last night? So it's that learned pattern. Dr. Mark Hyman: Okay, so we have that chronic stress, what else is driving this insomnia pandemic, which is huge? How man, 70-90 million people are struggling with insomnia? Dr. Cindy Guyer: Right. So I do think that there's a need to address underlying contributors to anxiety and depression, independent of their impact on sleep. So talking about what's going on, bringing in some kind of breath based practice, whether that's yoga or Thai Chi or meditation, just to ratchet everything down, that's another important component of it. And thirdly, you've already touched on a little bit about the dopamine with the phone, but it's also the dysregulation in our circadian rhythms. We think about how, there's been a lot of research about how important it is to avoid light exposure at night, for example. But everything we do during the day and when we do it, is ultimately going to influence our ability to go to sleep when we want to and get the rest that we want to. So in other words, when we're eating all day long and snacking late at night and watching TV at night, that's signaling our- Dr. Mark Hyman: And on our computers. Dr. Cindy Guyer: Yes, and on our computers. That's telling our bodies and brain that it's day, it's day, it's day. So we want to actually re-establish a consistent circadian rhythm. Meal timing so we're eating earlier in the day and then building in a fasting interval before we go to bed. Dr. Mark Hyman: Don't eat three hours before you go to bed? Dr. Cindy Guyer: No. Interestingly enough, as you know, there's a connection as well with digestive function that eating late at night not only disrupts your sleep, but it's contributing to higher reflux, which can also interrupt sleep. So everything's interconnected. Dr. Mark Hyman: Happened last night, actually. I went hiking and it's summer and it's so beautiful and it stays late light so we didn't get down from the mountain until 8:00 at night and I'm like let's go eat, I'm hungry. But then by the time we ate it was like 9:00. And last night, I tossed and turned for a couple of hours before I went to bed, which I usually don't do. Dr. Cindy Guyer: Isn't that interesting? Dr. Mark Hyman: So there's the circadian rhythm disruption. And this morning I went out and sat on my deck and the sunshine was out. So getting light in the morning is so important. Dr. Cindy Guyer: Absolutely. Dr. Mark Hyman: We don't do that. We're all on our phones or computers right away and we need the natural light the reset our brain. Dr. Cindy Guyer: It makes a big difference. Dr. Mark Hyman: Because light is medicine, right? Dr. Cindy Guyer: It is. It is. Dr. Mark Hyman: And also it could be bad medicine if it's the wrong light at the wrong time, right? Dr. Cindy Guyer: Exactly. Dr. Mark Hyman: There's this great book called Lights Out that I read years ago, Cindy, that was really talking about the advent of the light bulb driving chronic disease because of the disruption in our rhythms and so on. Dr. Cindy Guyer: It's interesting. They even looked at LED street lights disrupting the circadian rhythms of animals and insects too. So it's not just humans that are being impacted by this. Dr. Mark Hyman: And there's some other weird stuff that affects sleep that we don't think about. Like what else? Dr. Cindy Guyer: One of the conditions is restless leg syndrome. And that's hard to diagnose. It's more of what we call a clinical diagnosis. People describe this creepy, crawly sensation in their legs or this irresistible urge to rub their feet together. And typically, it's treated with dopamine medications. It's connected to relatively low dopamine levels in the brain. Dopamine, yes, revs you up, but dopamine also seems to play a role with movement. So it's treated with some of the same medications they use to treat Parkinson's disease. But it turns out that that can be more prevalent in people who have autoimmune conditions, in which case we want to address the underlying autoimmune conditions. Dr. Cindy Guyer: There are some nutrient deficiencies that are going to make the symptom of restless legs more significant. Low iron, low vitamin D, low folic acid, low magnesium. So we really want to look at somebody's nutritional status. Dr. Mark Hyman: And by the way, 80% of the population is deficient in vitamin D. 50% in magnesium. 20% in iron. A lot of people are deficient in the B vitamins and they don't even know it. And you go to your doctor, they're not checking those things. And there's even weirder things than nutritional stuff, right? Dr. Cindy Guyer: Mm-hmm (affirmative). So if we identify a nutrient deficiency, for example, the next step is why? What's the why that somebody's nutrients might be low? And there we come back, like so many other things, to the function of the gut. And interestingly enough, there is a higher correlation in people who have small intestinal bacterial overgrowth also having restless leg syndrome. Maybe because it's contributing to ongoing inflammation, maybe because it's also contributing to difficulty absorbing those nutrients from your food. So we're even going to go a step further and say is there an underlying issue with digestive function absorption and assimilation of nutrients that are- Dr. Mark Hyman: So if your gut's a mess it can also cause insomnia? Dr. Cindy Guyer: Absolutely. Dr. Mark Hyman: And then heavy metals are another big one that we don't really hear about. Dr. Cindy Guyer: Right. Lead, mercury, things that are under the radar for many, many people and, unfortunately, can be a problem. Dr. Mark Hyman: Yeah. And I had that. We talked about it on the show but I had mercury poisoning 30 years ago almost and it totally screwed up my sleep. Dr. Cindy Guyer: What happened with your sleep? Dr. Mark Hyman: I just couldn't sleep. I just really couldn't fall asleep, couldn't stay asleep, never felt rested, had chronic fatigue syndrome. Until I got the mercury out, got my feelings out, chelation, everything, I couldn't sleep. And it really took a long time to reset that. Dr. Mark Hyman: Okay so we've got all these different things that traditional medicine are ignoring, the hormonal fluctuations, the gut issues, the heavy metals, nutrient deficiencies. Doctors know about sleep apnea but they often miss it in thin women because that's not the archetype of someone who actually ... [inaudible 00:14:03] with huge belly and thick throat and size 17 neck. So there's all these issues and yet, this continues to be such a struggle for so many people. And the traditional treatments are really just stop gap, they don't really address the cause. Dr. Mark Hyman: So in functional medicine, the way we think about things is to look at some of these other factors. So in your practice, how do you start to dig down? What are the diagnostic things you look at differently? We talked about all these different factors but how do you identify what's the problem in this or that particular person? Dr. Cindy Guyer: Well, I think it's the time to take a history and really understand all of the other interconnectedness that could be going on. For example, somebody with sleep concerns might also have digestive concerns and then we might be thinking about assessing their digestive function. Looking at a nutritional assessment. But I think there's a time and a place and there's tremendous value in screening somebody with a portable sleep study because that gives you a tremendous amount of information. And we're using it, yes to diagnose sleep apnea, but also to say how often do you wake up during the night? How much percentage of time are you spending in REM sleep and deep sleep? Are you tossing and turning all night long? So it can give us a tremendous overview in terms of somebody's sleep throughout the night. And from that we can also decide what else do we need to explore? Dr. Mark Hyman: And then we do some testing, right? You can look at nutrition levels, you can look at these vitamin D and magnesium and folate and iron studies. You can look at, obviously the sleep apnea test. And there's home tests now you can do that are really great. We look at heavy metals, right? And the hormones. You can really get a sense of what's going on with hormones for people, if their estrogen or progesterone is all out of balance, it just happens in menopause, you see a lot of sleep issues. Heavy metals, I said, we can test. So there's a lot of ways we can diagnose using functional medicine testing that you don't really get with traditional doctors that can help get underneath things. Dr. Mark Hyman: So tell me about this patient you had because it speaks to a lot of the issues that we're talking about and it gives you a little unusual approach to insomnia is something you wouldn't really get from a traditional doctor. Dr. Cindy Guyer: Right. So this is somebody that ... And one of the things I want to plant the seed for is sometimes we start with what we think is the most likely issue and we gradually uncover more potential contributing issues and peel the layers of the onion. And this was a woman that I had known for years, she was pretty healthy in terms of her lifestyle. She exercised, she wasn't overweight, she ate a healthy diet, she didn't drink any alcohol, she was treated with antidepressants, she was on a serotonin reuptake inhibitor and Wellbutrin for her depression. And she was also on hormone replacement therapy. She was post menopausal in her 60s. And she started complaining of fatigue and difficulty concentrating and just felt scattered and by Sundays she would have the need to take a three hour nap. So that's unusual. Dr. Cindy Guyer: So we did some of the usual testing for causes of fatigue. We tested her thyroid, it was okay. We looked at her iron levels or sugar levels, they were okay. So I decided to screen her with a sleep study. And it turned out, you would not have looked at her and said, "Oh yes, she is the poster child for sleep apnea." She turned out to have one of the most striking positional components to sleep apnea I've ever seen. When she was on her side her sleep was normal, but when she was on her back, she had respiratory events that count as either a slowing of air flow or a stopping of air flow more than 60 times an hour. Dr. Mark Hyman: So she stopped breathing 60 times an hour? Dr. Cindy Guyer: Yes. Dr. Mark Hyman: Once a minute. Dr. Cindy Guyer: That's a lot. No wonder she was exhausted, right? So when you see a positional component like that, I have people who don't want to do a sleep study because they don't want to ... I'd never wear that stupid mask. But for her, we said okay, let's start with retraining you to learn to sleep on your side. And she tried that. There's some commercially available positional devices, there are all kinds of strategies you can do. Dr. Mark Hyman: There's very, very sophisticated technology called the tennis ball strategy where you sew a tennis ball into a T-shirt on the back so if you roll over on your back, it makes you flip over to your side. Dr. Cindy Guyer: Or the fanny pack with the pillow stuffed in it, yes. There's all kinds of strategies you can do. And of course it's big business, right? You can buy a slumber bump or a bumper belt. Dr. Mark Hyman: I didn't know they had all this. I just go with the tennis ball track. Dr. Cindy Guyer: Even more sophisticated, there's now a biofeedback device that's a strap around that vibrates when you roll on your back. So it's autogenic nighttime training to get you. So that's what she used, interestingly enough. And it helped a little but she was still tired. So as we're peeling the layers of the onion, she had some digestive symptoms, a lot of bloating, a lot of discomfort and we had done a full sleep study, she had restless legs and periodic limb movements. She turned out to have a very abnormal breadth test for small intestinal bacterial overgrowth. Dr. Mark Hyman: That means bugs growing in your small intestine where they usually shouldn't grow. Dr. Cindy Guyer: Where they don't belong, right. Dr. Mark Hyman: Which can cause inflammation. Dr. Cindy Guyer: Absolutely. And low iron. Her iron wasn't terribly low but one of the sidebars here, I think the other thing we do in functional and integrative medicine is understand the difference between a normal blood test, I should put "normal blood test" and an optimal blood test. Ferritin is a classic example of that. Ferritin looks at your total tissue iron. Dr. Mark Hyman: How much iron is in your iron bank in your body. Dr. Cindy Guyer: In your iron bank, your iron stores, right. And normal can be anywhere from 15-250. Dr. Mark Hyman: It's a big range. Dr. Cindy Guyer: It's a big range. And what we know the threshold is for somebody who's got restless leg symptoms, is you actually don't want to be normal, you want to be over 100 because there's some evidence, even comparing it head to head with those dopamine drugs we mentioned earlier, getting somebody's ferritin over 100 was as effective as the dopamine medications. Dr. Mark Hyman: That's amazing. Dr. Cindy Guyer: That's amazing, right? As simple as correcting a nutrient deficiency, not to the normal range, but the optimal range, for that condition. Dr. Mark Hyman: If HEM iron is the best absorbed kind of iron but that usually comes from meat. And if people are vegan, the plant forms of iron aren't as well absorbed, you often see iron deficiency in these patients, especially women who are menstruating. And I think that ... I learned, actually, in traditional medicine that ferritin was connected to sleep. Dr. Cindy Guyer: Interesting. Dr. Mark Hyman: I learned that in a lecture on insomnia I went to by some drug companies. I was like well, that's interesting. But I think it's something that's often overlooked and it's an easy blood test to check your ferritin, which most doctors won't look at. Dr. Cindy Guyer: And Mark, I think from the internal medicine standpoint, too, it's equally important to say don't just correct the iron, figure out the why. You don't want to miss blood loss somewhere. Dr. Mark Hyman: Yeah, has she got colon cancer? Or a stomach ulcer or is she just menstruating heavily? Does she have bladder cancer? Something, right? So I think that's really important. You're right. Just don't look at the symptom, look at the cause. Because low iron is a symptom, it's not a cause. Low iron may cause insomnia but what causes low iron? So that's what functional medicine does is it keeps going upstream and you said something a couple of times, I just wanted to come back to it, which is peeling the onion. Dr. Mark Hyman: So one of the principles of functional medicine, from [inaudible 00:21:25], who is a cool old guy, professor, Arianite, super smart, one of the most thoughtful men in medicine, people in medicine period. And he said we have tack rules that help us determine how to figure things out. One is if you're standing on a tack, it takes a lot of aspirin to make you feel better, right? Take out the tack. So if the bacterial overgrowth is causing the restless leg syndrome, you can take a lot of these traditional medications but it's going to take a lot of medication to make it go away. Or if you fix the bacterial overgrowth, that'll help. But then also, if you're standing on two tacks, taking one of them out doesn't make you 50% better. So she had bacterial overgrowth and she had iron and she had the positional thing. So it's usually three or four or five things. And the problem with medicine is we are so focused on the one thing, you know? Dr. Cindy Guyer: There was one other piece related to her story that I think is also important to call out. Addressing all of those things, her sleep quality was still not what she wanted it to be. So we had a conversation and she relayed the fact that when she was growing up, things were pretty unsettled in her home of origin. There were a lot of late night parties, a lot of noise and bedtime became a time where she didn't really feel safe and quiet and comfortable. So we also talked about referring her to a life management behavioral therapist to really talk about what it meant to be safe and regaining that sense of being okay being in bed. And I think that goes hidden, as well, that a previous history of trauma or not feeling safe can also show up with insomnia and difficulty sleeping. Dr. Mark Hyman: Yeah. And I think that's a big thing for a lot of people. There's a questionnaire you can do online called the ACE questionnaire, it's adverse childhood events, and you get a score. And if you get a high score, it means you had a crappy childhood and you probably have some level of trauma. And different people respond differently to the trauma but PTSD is so prevalent and our nervous systems are so jacked up in general so it's sort of like acute on chronic. We've got our acute stresses on this chronic level of PTSD. And it leads to so many physical, psychological, emotional stresses for people. And there's a lot of ways to access that. You shared about how you used cognitive behavioral therapy or yoga or meditation or breath work or emotional freedom techniques, there's all kinds of techniques out there. But now people are exploring psychedelic assisted therapy and EMA [inaudible 00:24:04] therapy, it's legal in Oregon now. And there's some interesting research going on at Johns Hopkins and NYU and others really looking at how do we help people with these chronic long term traumatic events experience this? Dr. Mark Hyman: And I think, listening to you, it's interesting to hear, dealing with something as simple as insomnia can be quite complicated. You have to look at inflammation in the body. You have to look at where's it coming from? Is it the gut? Is it heavy metals? Is it hormonal changes? Is it nutrient deficiencies? Maybe it's food sensitivities or allergies. Maybe it's low thyroid. There's things that we just don't often think about. And what's so satisfying with functional medicine is we're able to actually dig into these things and look and see the why. Functional medicine is the medicine of why not what. Not what disease do you have, which is helpful but it's not the end of the story. We go why do you have that disease. And that's the challenge of traditional medicine. It's like you make the diagnosis and you stop thinking. Okay, you've got depression, here's antidepressants. You've got insomnia, take this sleeping pill. Or you've got rheumatoid arthritis, take this arthritis pill. Not why you have insomnia or depression or rheumatoid arthritis or migraines, but why. And this was so powerful. Dr. Mark Hyman: And then there's some basic sleep practices. We've covered some of this but I think it would be good to go over it and I think it's important to emphasize that everything matters, sleep, exercise, stress. Obviously your diet plays a huge role, nutrient status. And that's what we do in functional medicine, we dig down into it. So talk about some of the other factors around sleep hygiene that we haven't touched on in terms of diet and lifestyle and food and exercise. Dr. Cindy Guyer: Sure. I think first and foremost, we have to recognize that sleep, you and I trained in an era where sleep deprivation, or how little sleep you could get by on was a badge of honor. So we need to shift that internal dialogue that we all have that if I'm sleeping, I'm wasting my time and I'm not getting my stuff done. So first, honor the importance of sleep for your overall health and wellbeing. And even your ability to stick to your intentions around choosing healthy foods and sticking to your exercise plan. Dr. Cindy Guyer: Then create a sanctuary that's really conducive for rest and relaxation. Dark, quiet, cool, ideally electronics out of the bedroom, or turned off if you can. Getting rid of all of the light exposures, even your chargers. Dr. Mark Hyman: Yeah, those lights. Those red and green lights on different devices. That drives me crazy. Dr. Cindy Guyer: I had a patient who told me she traveled around with black electrical tape whenever she went to a hotel and she would put it over all the little lights. Dr. Mark Hyman: I travel with eyeshades because you never know where you're going to be. Dr. Cindy Guyer: So those two, quiet, calming. And I think this idea that you go, go, go, go, hop in bed and turn it off like a switch, that doesn't work either. So building in a transition to rest and relaxation. If you can do an hour, that's great. And getting off the devices, not watching TV, maybe reading a book or journaling or doing something, taking a bath, stretching in the tub. There's all kinds of wonderful ways to ease into resting relaxation. Dr. Mark Hyman: I like the hot Epsom salt bath and lavender drops. Because the lavender lowers your cortisol, the magnesium relaxes you and the sulfur in the Epsom salt helps you detox. Dr. Cindy Guyer: That's my favorite as well and then you go to your cool bedroom and you do your legs up the wall restorative yoga position and bingo, you've got your transition to rest and relaxation. Dr. Mark Hyman: So powerful. And alcohol, obviously, is a big thing for people. Dr. Cindy Guyer: Yeah, that's a tough one. So the rough analogy is this. It's funny, when they asked partners of people with insomnia how many of them were suggesting that they have a drink to go to sleep, it was about a third of them. So people think alcohol's going to help you sleep and it might make you fall asleep. But then as it clears out of your system there's an arousal that can exacerbate hypoglycemia, it makes you wake up, it's going to make sleep apnea worse. If you're a woman in midlife, oh boy, it's a bladder irritant, it's a hot flash trigger. So it's really affecting sleep in a lot of ways. The rough equivalent is there's about an hour sedation followed by an hour of arousal. Dr. Cindy Guyer: So if you had a glass of wine at 6:00 and you go to bed at 10:00, it's probably not going to impact your sleep as much as if you have two glasses at 8:00 or like your late dinner last night, if you had a glass or two of wine- Dr. Mark Hyman: I had a beer. Dr. Cindy Guyer: Yes. That is another impact on your sleep. Dr. Mark Hyman: I just noticed it, actually. I had an aura ring for a while and I was tracking my sleep and I noticed, whenever I drank, my sleep pattern was so disrupted. Quality of sleep, the depth of sleep, the amount of REM sleep, deep sleep, snoring, all that. Dr. Cindy Guyer: It's really interesting. Dr. Mark Hyman: And then caffeine also is another big one, right? Dr. Cindy Guyer: Absolutely. And we're all different in terms of our caffeine metabolism ability. Some people are really fast metabolizers, I happen to be one of those. But if you're a slow metabolizer, half of your cup of coffee from noon could still be in your system at 9:00 at night. And most of the time we're not thinking back to that noon cup of coffee. With food, it's really about quality, quantity and timing of food. It's all three. Yet another area that's impacted with the health of the gut microbiome is sleep. And data is suggesting that people who eat a wide variety of colorful fruits and vegetables tend to have better sleep quality, whereas a highly processed standard American diet is associated with more sleep disruptions and less deep sleep. So quality matters. We already touched a little bit on the timing of eating. So eating your calories earlier in the day also helps re-regulate those circadian rhythms. So the clocks in the brain and the clocks in the body that are ideally going to be working in sync with each other, they're influenced by light, by movement and by food. So when we line all those things up during the day, it's going to help us get the rest that we need at night. Dr. Mark Hyman: So important this is such good information. I want to close by something we probably should've done at the beginning which is why is not sleeping so bad for you and why is sleeping so good for you? Dr. Cindy Guyer: Probably should do that, yes. So sleep is when we're repairing the powers of both the mind and the body. Sleep is when we reduce inflammation, repair tissues. The discovery of the glymphatic system in 2012, 2013 as this passive channel that runs alongside our arteries and veins in the brain that fills with fluid when we're in deep sleep and allows a washing out of debris we may have accumulated during the day. Dr. Mark Hyman: So all those bad thoughts get washed out? Dr. Cindy Guyer: Not the bad thoughts, no. But the amyloid plaque. That sticky plaque that we secrete in response to inflammation or injury, if it accumulates, of course it can damage surrounding neurons and is associated with neurodegenerative disease and Alzheimer's disease. Dr. Mark Hyman: So in English that means if you don't sleep you're likely to get demented. Dr. Cindy Guyer: Definitely playing a role. And this concept of bi directionality. We know that sleep disruption, circadian rhythm disruption, sleep apnea is present in two thirds of people with insulin resistance pre-diabetes, diabetes. And it is a chicken and the egg thing. It is driving the bus. We used to think you get the sleep apnea because you have insulin resistance and gain weight. But if you have disrupted sleep, your insulins are higher, or cortisols are higher, your glucose is higher, you're looking for highly processed quick energy dense foods and less able to resist them. Dr. Mark Hyman: Wow. So not sleeping is a risk factor for obesity? Dr. Cindy Guyer: Absolutely. Dr. Mark Hyman: And heart disease and cancer and dementia. Dr. Cindy Guyer: And flares of autoimmune conditions and chronic pain. And fibromyalgia. And anxiety and depression. It really affects everything. Dr. Mark Hyman: Oh my God, if I don't sleep I'm depressed and anxious. Dr. Cindy Guyer: But the more you worry about it the harder it gets to sleep. Dr. Mark Hyman: Yeah, it's true. When you get a good night's sleep it's like the world just looks rosy. And when you don't, it looks depressing, gray. Dr. Cindy Guyer: And that's an important thing, too. If you pay attention to how you feel, so you mentioned the aura ring, people ask me how good are these trackers for telling you about your sleep? They don't diagnose a sleep condition but sometimes you can gain some insights. For you, you gave a great example of this. You found, look at this. When I've had alcohol my sleep is not as good. Dr. Mark Hyman: My [inaudible 00:32:38], everything. Dr. Cindy Guyer: And then you pay attention, well how did I feel the day after? Yeah, I was more tired, yeah, I was more irritable. I was looking for different foods. So I think the more you build that internal awareness of that connection between your sleep and how you feel the next day, that's a win. That's really how you learn to prioritize it. Dr. Mark Hyman: Yeah. Just take home here is that sleep is the most underappreciated fourth pillar of lifestyle medicine. Dr. Cindy Guyer: I agree. Dr. Mark Hyman: It's diet, exercise, stress reduction and sleep. And it really is important and I think I feel like a lot of my health issues in part were due to my lack of sleep. And I think as doctors, we were just so trained to overcome our natural instinct to sleep. When you have to stay up all night, alert, seeing patients, you either pound the coffee or you just will your way through it. I remember working the ER in weird shifts, like 11:00 to 2:00 in the morning and I'd be driving home holding my eyes open like this, forcing myself to not fall asleep. And that just messes with you in a big way. Dr. Cindy Guyer: I remember the box of donuts at the nurse's station because you needed the quick energy to stay awake. And then the bottle of Maalox right next to it because your stomach just felt awful. And you'd wolf the donuts, swig the Maalox and go do your work. Dr. Mark Hyman: Sounds like a great lifestyle. Dr. Cindy Guyer: Isn't it great? You have to unlearn all that. Dr. Mark Hyman: Well, Cindy, so much fun having you on The Doctor's Farmacy podcast and a special episode of House Call. We are so thrilled that you're joining Ultra Wellness Center. For those of you listening, if you loved this conversation and you're struggling with sleep, we are here at the Ultra Wellness Center to help you and now we're doing a lot of virtual consults. Unfortunately we have a long waiting list but we're working on that and figuring out ways to help get you in. We would love to hear from you, please share comments about how you've overcome your sleep challenges. Subscribe wherever you get your podcasts, share this with your friends and family, it might help them too. And we'll see you next week on The Doctor's Farmacy. Speaker 1: Hi everyone. I hope you enjoyed this week's episode. 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