Wellbeing For Real Life - Sleep

In this episode of the Wellbeing for Real Life podcast Dr Richard Pile and Dr Aseem Malhotra talk about  sleep.    The conversation includes their own personal experiences of being well slept and sleep deprived, how sleep affects performance, what happens during sleep, the harms of sleep deprivation (including chronic disease) and the benefits of a good night's sleep.  They give their top tips for better sleep including routine,  physical activity, exposure to natural light, limiting screen time,  managing caffeine and alcohol intake, acknowledging how our bodies and circumstances change over time and the importance of addressing mental health concerns.

Richard is a GP specialising in Cardiology and Lifestyle Medicine, and author of "Fit For Purpose: your guide to health, wellbeing and living a meaningful life".  Aseem is a Consultant Cardiologist and passionate campaigner to improve the nation's health.  He is also the author of  books The Pioppi Diet and The 21 Day Immunity Plan.   You can find out more about Richard here and Aseem here.

Fit For Purpose is available from Harper Inspire in paperback, e-book and audiobook format, with Richard reading the audio himself.  Find out more here.  This podcast has been produced the brilliant team at  Monkeynut Audiobooks. 

Transcript

Richard Pile  0:18  
Welcome to the Wellbeing For Real Life podcast.

Have you ever wanted to live life better, but found yourself baffled bewildered and bored by complicated, confusing and condescending advice. This podcast is the antidote. I'm Dr. Richard Pile, GP, lifestyle medicine specialist, and author of Fit for Purpose. Each episode, I'm joined by leading experts, as we explore different areas that affect our everyday lives. This is the wellbeing for real life podcast. 

Welcome to wellbeing for real life. Today we're talking about sleep. I'm Dr. Richard Pile GP with a special interest in cardiovascular and lifestyle medicine. My guest on the show today is Dr Aseem Malhotra. Aseem, rather than have me introduce you, could you just tell us briefly a little bit about yourself. Yeah,

Aseem Malhotra  1:08  
I'm a consultant cardiologist.  I qualified in 2001 from Edinburgh medical school. So I've been practising, you know in medicine now for almost two decades. I have a special interest in lifestyle medicine and prevention. I'm also a visiting professor of evidence based medicine. And my personal mission is to save lives, a million at a time.

Richard Pile  1:29  
Okay, that's a very impressive personal mission.

Aseem Malhotra  1:32  
Yeah well I think you know, it's, it's something that's to aim for, you know, hopefully we'll we'll save a few lives on the way.

Richard Pile  1:39  
Absolutely.  One of the things that we're going to be talking about today is sleep, which obviously is a pretty important thing when it comes to saving lives. I just thought we can if we can start we could each describe, maybe something that we're really happy about with our sleep, and maybe an area where we either struggle or would like to do a bit of improvement.  Would you like to bare your soul and go first?

Aseem Malhotra  1:57  
Yeah, I think, actually, interestingly for me and I'm somebody that certainly tries to, and most of the time will follow my own advice. I think the one area which I probably can improve on is making sure I get good quality sleep. Evidence does tell us as you, as you all know, ideally we should all be getting at least seven to eight hours of good quality sleep per night. It's very important for mental health, physical health, it's you know the time when a lot of the repair mechanisms of the body are going on. So for me, I think that that's one area where I have not been very consistent. And I think most of it for me personally, is often things that are out of my control so external stressors that then influence your sleep. So try and make a habit of, you know the things I'm good at, when it comes to sleep because I've got a very, a very consistent routine, in terms of making sure I go to bed and I've always been someone that likes to go to bed early. So during the working week I like to be in bed by sort of 930, at the latest, you know, read before bed asleep and falling asleep has never been an issue for me but it's sometimes waking up for the night and often, you know, waking up for the night is related to the stresses of the day. I think one thing I've learned, and something that other people can also think about is that if you're in an environment which is relatively stress free (and that can even be you know, being around people that you care about or it can be that you're on holiday) you know that you're sleep, generally from my perspective,  is a lot better.

Richard Pile  3:30  
Yeah, absolutely. And for me, I find that I don't have a problem with the quality of my sleep, when I've had it measured with electronically, I sleep really well, quality wise but I haven't always given myself the quantity. And it sounds like you've, you've got a good routine in  that you often go to bed at sensible time. I've rarely ever gone to bed at sensible o'clock until probably in the last, well in the last three, four or five years where, you know, as part of my developing an interest in lifestyle medicine I had to grudgingly concede that maybe I should be thinking a bit more about this and practising what I preach. And having a wife that insists on going to bed early, has really helped me. I used to be slightly resentful of that and now I find it really helpful. I look forward to my, to my bed times.

Aseem Malhotra  4:12  
Yeah, I you know I find, as well, when I've had periods where, you know, I've been able to maybe go away and spend time with my extended family, very quickly, it's interesting how I notice within the space of a few days I'm suddenly waking up later. I've got to, instead of waking up I'd say half three or 4am I'm sleeping till 6am. And it's just amazing how the only change has been a less stressful and so called, I think happier environment, you know for me I think slightly unique maybe everyone's different, I live on my own. And I think that is probably one of the downsides of living on your own is, for me anyway, is actually that in itself probably has some kind of impact on my sleep, because having people around you, if you've got flatmates or whatever else,  I think it helps build emotional resilience.  You know, I see that with other people, some of my patients for example as well, you know, these are, these are the things that are really important. and moving on from that what's really interesting or what I've learned, you know, just a couple of interesting anecdotes, concerning some very famous sportsmen. One being Roger Federer, as you know the tennis player who's probably one of the greatest tennis players of all time, and the other one is a basketball player in America called the LeBron Jame.  Huge very very famous, successful basketball player. And both of those individuals are very very proactive in telling people or explaining to people, that one of the secrets to their success and longevity as athletes, and sportsmen, is the fact that they are obsessive about getting good quality sleep so Roger Federer, I read somewhere, claims that he actually gets 11 hours of sleep a day and that's the reason he's still playing great tennis, you know, where most tennis players have retired, he's still playing you know fantastic grandslam tennis and LeBron James says he will get at least eight to 10 hours of sleep a day so good hours you know and he's disciplined when he goes to bed, etc during that during the night time but he'll also take two hours out of his day in the afternoon to have a nap. It's fascinating. I think it's something that we haven't focused on enough, and even if we're aware of it a lot of people probably don't know or don't have the tools, or don't have the, education, if you like, to try and improve their sleep, which obviously is you know, your book obviously mentions quite extensively.

Richard Pile  6:44  
Yeah, so those are really great examples of how sleep is performance enhancing. So if we take a step back a bit should we talk a bit about what goes on in our brains when we're asleep, I think that could be quite helpful to give people an understanding of why it is that we're so interested in this, from your perspective.

Aseem Malhotra  7:03  
Yeah, I'm looking forward to hearing about that from you, Richard.

Richard Pile  7:08  
Yeah, so, you know, whilst I don't consider myself an expert on sleep, it's very easy to to learn a lot about the benefits of it. And I think if you think about it we spend about a third of our life, asleep and when we're asleep, we're effectively in a paralysed vulnerable state, so either that's really really important for our restoration, or it's a huge evolutionary mistake and obviously I think it's that the former rather than the latter. And I used to imagine when I was younger and not so bothered that maybe, you know not a lot happened when we were asleep we were just really dormant, but actually there's a lot that goes on for example, our glial cells, which are cells within our brain, shrink, and so the flow of the cerebral spinal fluid through them increases I think by about 60%. And that means that you can clear away a lot of the, of the day's debris. Also sleep is really important for consolidation of learning and memories, and there's good evidence to show that if you are sleep deprived, then you can potentially forget 30 or 40% of what you've learned. Even the day or two or three days before, so that the importance of that is vital and both the rapid eye movement and the non rapid eye movement stages of sleep have really different important parts to play in our restoration. And I think until I realised that it didn't occur to me how much was going on, just as you were lying there, apparently, doing nothing. And so when I was younger I used to take this sort of sleep is for wimps approach, you know, "I'll get all the sleep I need when I'm dead". And I think one of the really interesting things is that from my experience, I only realised the effects of a good night's sleep once I started giving it to myself. And up until that stage I thought I was doing fine, I thought I was functioning really well and then when I did a little experiment after reading why we sleep by Professor Matthew Walker (it's a fantastic book),  I gave myself a proper seven to eight hours sleep every night for a couple of weeks. And I realised that for a long long time, even though I thought I was functioning quite well I was actually chronically sleep deprived, and I suddenly found an extra 10-20% in what I was able to do in terms of my professional life, my personal life, it made a huge difference. Have you noticed in your own life times when you've either been doing really well or not so well.

Unknown Speaker  9:30  
I remember even a few years ago I had a very stressful period in my life just shortly after my mother died. Although I actually thought I was getting quantity wise good sleep. I started having episodes where I was, you know I'm normally, I consider myself very, my brain has been very active. My memories are certainly above average, with things I remember attention to detail, and I've got a mathematical brain. And I found myself, in relation related to what I'm about to tell you,  I'm very, you know I love films, one of my passions is movies so you know I remember names and films and actors and characters and all that kind of stuff and I remember going to the cinema. A trailer came up for a film.   I can't remember which film it was actually at the time.  The face of Eddie Redmayne, the actor came up and I couldn't remember his name and I thought this is bizarre. And I found sporadically I was forgetting, you know, even people, the names of people I've ever worked with and that kind of thing.  Anyway long story short, I ended up speaking to somebody, a friend of mine who's a neurologist, and she actually said to me, Aseem I think this it's likely that you're not getting good quality sleep. And, and there's nothing else going on, and that's what you need to work on so that's interesting because I had a bit of stress going on. Anyway, circumstances changed I end up getting better quality sleep. And, you know, this symptom if you like for me kind of not remembering, you know, recognising faces of people that are well known but automatically to come to me I mean it would it would come to me eventually but it might take half an hour or half an hour and a half hour an hour for me to remember who they were, it resolved itself but it took it took a couple of months. It took a couple of months actually before I suddenly felt like, oh, everything's back to normal again. So I think that was one lesson I learned certainly when it comes to sleep, I think. I think the other thing we all know, Richard, when we've had a good night's sleep, how we feel during the day, you generally feel happier. You're also less likely to feel.. you respond to stress better - anxiety that kind of thing. And when it comes to physical health we know that insulin resistance which is at the root of many chronic diseases, heart disease, type two diabetes, probably alzheimers and cancer as well, to some degree is influenced by making sure we get, you know at least seven to eight hours of good quality sleep a night versus, you getting less than five or six, and those changes can happen, physiologically within just a few days of sleep deprivation. So, yeah, absolutely, it's a really big deal.  Stress eating: if you don't get a good night's sleep, you're more likely to go for those sort of dopamine enhancing comfort foods, trying to lift yourself up.There is data showing that people who don't have a good, seven hours of quality sleep a night , end up consuming more calories during the day, usually from junk food. So it's crucial to everything.

Richard Pile  12:13  
Absolutely.  Do you think that explains my uncontrollable desire for a bacon butty first thing in the morning if I've possibly not had enough sleep and maybe a couple of drinks do you think that could, that could be behind it?

Aseem Malhotra  12:27  
Absolutely.  You know that it's like in the morning when you've had a late night on a Friday or being out or whatever, and you know that you're not going to get much sleep that day you know if you come back at one or two in the morning or you're drinking with friends or whatever else and you wake up at the same time you normally wake up and find our sleep and  automatically you do feel when you wake up that you want to go for that sort of high carbohydrate meal.

Richard Pile  12:48  
Your comments about the insulin resistance I think is really valid.  I've seen patients who were suffering from stress in their lives, developed hypertension, perhaps some pre diabetes, and when you chat to them,  when I chatted to them, actually, in theory they were ticking quite a lot of boxes: they were very physically active, they tried to practice a bit of sort of mental self care, but their jobs are very stressful, their days were very long, they had a lot of stress at home, perhaps.  They were not sleeping very well and I've seen people completely reverse their hypertension and their pre-diabetes, almost through doing nothing other than just getting a better night's sleep, which is incredible, isn't it because the alternative is potentially a lifetime of medication and doctor's appointments, and the inevitable complications of those conditions. And yet, just that simple restorative of getting a good night's sleep free to all of us.

Aseem Malhotra  13:43  
I think the other thing as well and it's something you're reading more and more about in the literature, I'm seeing more and more patients with this issue, especially blokes, is the impact of sleep deprivation on testosterone.  Erectile dysfunction for example is increasingly common in people over the age of 40. I think that statistics are 40 to 50% of men over 40 will experience erectile dysfunction at some point, significant erectile dysfunction. You know, obviously for a guy, testosterone has so many roles to play in the body, it's not just about sex drive, it's about sense of well being, it's about competitive drive.  Sleep deprivation, just a few days of sleep deprivation can even crash someone's libido. So that's another incentive for people who might be suffering from not realising actually that is the key to them getting back to feeling that vitality again, and improving their libido etc & sense of well being is just making sure they focus on that sleep and that may well be the most important factor when it comes to hormones like testosterone.

Richard Pile  14:43  
We've had a good conversation around quite a few of these topics. One of the things that we tried to do in this podcast is to really keep it practical for people. So, should we each give a few of our top tips then for a good night's sleep? I'd like to touch upon one to start with which I think you've already mentioned which is the importance of routine. We know that our body clocks are roughly a 24 hour cycle.  I used to do this thing where I would wake up early in the mornings during the week but I tried to give myself a lie-in at weekends, and I didn't realise that some sleep deprivation during the week trying to compensate for it on a Saturday and a Sunday, didn't really work, I just ended up kind of jet lagged. So my first tip would be I encourage my patients and my colleagues to really try and roughly go to bed and get up at the same time each day of the week if they can give or take, you know, obviously, life can be a little bit different depending on your circumstances at weekends etc but I really recommend that.  I think if people can anchor that with other bits that make the routine quite solid such as morning being also the same when they go for a walk, or get do some other kind of physical activity, then you're combining a regular sleep and weight time with physical activity and also light exposure, so that really just kind of anchors that all together. So, my top tip would be certainly a good routine. How about you?

Aseem Malhotra  16:04  
I completely agree with you and I think the one thing I've added especially these days, it's become a major issue for many people and they don't even realise it, I've got, I won't name them but certain relatives as well who I know are having their sleep quality interfered with because they're addicted to social media.  We know that screentime for example, suddenly closer to bedtime, it's going to have an impact on your sleep quality. It might even interfere when you go to sleep or you might be able to sleep, you might fall  asleep quite easily but then wake up later on. So I recommend to my patients as well, that you really should try and be off screens for at least one to two hours, ideally two to three hours before bedtime. Getting off social media, getting off your phone. Keeping your mobile phone out of the bedroom.  I think it's a really important tip for people and you can notice a big difference once you get into that habit of saying okay I'm not going to be,  the last thing I do before I go to bed is not getting on social media, and looking at Twitter or Instagram or Facebook. It's been shown to have quite a big impact on sleep quality.

Richard Pile  17:10  
And that would be my other joint favourite tip.  I absolutely agree you beat me to that one.  I think it's not just the whole blue-white light, and lowering our levels of melatonin, but it's also that activating our brains as we disappear down those, those rabbit holes of of anxiety and the fear of missing out, etc. So I absolutely endorse that Aseem I think that's fantastic. Another one that I tend to suggest to patients is talking about avoiding drugs that are going to disrupt your sleep. For me too big two are caffeine and alcohol really.  I've got a friend who could drink a double espresso an hour before he goes to bed and sleep like a baby. But he's probably unusual, so I recommend to people who are struggling, that they try to avoid their caffeine after midday. Ideally.  Because the half life of caffeine is six hours so you've still effectively got a quarter in your body at midnight if you've had your cup of midday and obviously if you're sensitive to the action of caffeine, that's an issue and then the other one of course is alcohol which I'm sure that you speak to your patients a lot about as well.  We know that alcohol is a sedative. It's not a restorative drug. One of my friends, wired me up once with a heart rate variability monitor to look at fitness and recovery, and I did a trial on my self.  I wore it for three or four nights and the first night  I just drank no alcohol, no phones, went to bed at a sensible time. The next night, I had a couple of drinks and looked at my phone for just 15 minutes. And the effect on the objectively measurable data overnight that showed how well I had recovered, or in the second night, not recovered, was staggering. It was really really quite sobering,

Aseem Malhotra  18:51  
So the combination of the alcohol and looking at social media was a really...

Richard Pile  18:56  
Deadly

Aseem Malhotra  18:56  
Lethal, basically,  when it comes to sleep.

Richard Pile  18:58  
But I'm a pragmatist, you know, I enjoy a beer. I even enjoy a couple of beer sometimes. and one of the things I tend to recommend to my patients, and to myself, is that if I'm going to enjoy having a drink I'll probably try and do it in the earlier part of the evening, or perhaps if you're going to go out with your friends for the evening maybe don't combine a couple of drinks with getting to bed at one in the morning because clearly you've got a particularly toxic combination.

Aseem Malhotra  19:22  
I think that you know there are some people, you know if your sleep is an issue then it's about focusing on these specific thing so you can go through periods of your life and I tell my patients where you're doing things that are your routine you've slept fine and suddenly the sleep gets interrupted for whatever reason whatever trigger then it's time to then focus on those things that, actually okay what alcohol are you drinking ,when you're drinking and all of it interacts in the sense that if you've got, you know, for example if patients that I see are suddenly having more stress in their lives, even though they may have been fine for years having two cups of coffee a day, I will say: listen - what I want you to do right now is reduce your caffeine intake because when you are stressed, caffeine makes it worse. You may have been fine three months ago but right now you're really stressed and it's making it worse. So just focus on these little things. Actually it's really interesting to come back, you know, in the follow up and say, you know these things really helped, whatever it was because it was it made it easier for me to combat this problem by cutting out caffeine and reducing my alcohol intake. So, absolutely I think we've got to think about it also in a bit more of a nuanced way.

Richard Pile  20:30  
That's a really helpful example Aseem that reflects the fact that life is complex, and changes and the people that we are changes as well as it were.  Our circumstances change. Yeah, and the things that we once took for granted, it might change because of variable things including our age, and everything else that's going on in our lives.

Aseem Malhotra  20:52  
Thinking about the catch-up sleep on the weekend I used to do that as well as a student.  Never was a problem for me.  I felt great.  I could do that during the week and not sleep as much and then a lie-in on the weekend. I'm sure that, you know, there may be some small effects in the body but in your 20s It probably doesn't have that much of an effect, it's not that big a deal but when you get older, you're plus 40,  the body does changes.  It's just part of the unfortunate part of the ageing process but it's something I think we need to be more proactive about as we get older.  Of course, prevention is better than cure, but again if people who are listening think "Oh,  I'm fine and, you know..." Wait till you hit 40 and then you'll see what happens to your body and then you might have been made changes.  Things that you just took for granted before now problems to you.

Richard Pile  21:37  
Lessons that you and I have clearly both had to learn!  The last thing I want to mention Aseem, and I'm sure that you and I both seen this in our clinical practice.  We've talked about sleep hygiene tonight and lifestyle and we can talk about other things like keeping your bedroom cool and dark and making it a place you just go to sleep but one of the reasons that many people talk to me about sleep and I'm sure you've seen this too, is actually because there are other things going on in their life which are causing that sleep to be disrupted.  They're not neglecting themselves as such but typically, mental health problems are a common example of this. Clearly, a person may be suffering from poor sleep because of that and so far we've talked about practical things that you can do to make those adjustments, but as we begin to wind this up, from your perspective, how do you broach those conversations? If you sense there could be an underlying mental health issue, how do you talk about that to patients?  Do you make any particular recommendations for example?

Aseem Malhotra  22:35  
It's all based upon individual patients.  Some of my patients, of course, are going to need extra help. When I say extra help, we're talking about lifestyle, and all these things are crucial to think about as you move forward, but people can get in situations that are so bad that they need medications, I'm talking about antidepressants for example. And if I pick up clinical depression, if they've developed true clinical depression where, as you know, you've got these persistent symptoms for at least two weeks often I will then give them a kickstart and say listen, you've got to situation which is quite bad. You need a medication.  It will start to help you to feel better within two to three weeks.  I still want you to focus on lifestyle stuff, not to just take this as a substitute, but think about that, but it can it can have a massive impact on people, you know, and they can stay on as you know Richard.  You don't need to necessarily stay on them for very long. You can ideally get them off it in three to six months once they've come out of that deep dark hole they found themselves in. So I think it again it's individual-based.  When it comes to other external factors often people, when you explore it, I will ask them as part of my consultation.  For my cardiac patients, you know, I talk about stress and sleep but I will ask them about how their how their personal life, how's the relationship and family life, going, what's going on work. Now I will explore that a little bit and they will often divulge and sometimes some people are very tearful and say something like "okay you've hit a nerve there" and it's something that's been growing for a long time. I mean it's our job as doctors to try and identify those root causes.  Just sometimes having that conversation, and then suddenly opening up to you as a doctor and something they've been hiding or not been able  to talk about with anybody.  That in itself can be very therapeutic for patients, but it also then leads, allows them to think a little bit more about "okay, I've got to this situation because of this, this and this, you know, something with work. Is there something I can do to change the external circumstances?" Obviously it's not easy to capture all of that or give people all the best solutions within one consultation or conversation but you can at least start that process.

Richard Pile  24:35  
Absolutely, really, really important I think and I would just recommend to anyone listening to this, if you think that your mental health could be a factor in affecting your sleep, do talk to someone about it, whether it's your friends your family or your doctor.  It's really important to have that conversation.

Aseem Malhotra  24:52  
I think, Richard, on that as well, I think we need to say if this has been going on for a long time, with many people you can get to a state of where actually despite you trying with your best efforts all these different things that we talk about, your sleep is still in a bad way.

This often can indicate that things are more significantly wrong in terms of the biochemistry.  You've got to a point where your serotonin is depleted, you're clinically depressed, and you will need help.  All the advice we give you at that point may do nothing at that point to help you.  You may well need medications and I think people should not be afraid to reach out and speak to their GP or healthcare practitioner about it, because that can make a big difference to getting you out of that hole.

Richard Pile  25:38  
That's a really helpful note on which to finish.  Aseem,  I've really enjoyed this conversation. Thank you very much for your time today. I hope the listeners have also enjoyed it. I'm sure we'll be speaking again soon. But today, thank you for your time.  We'll speak soon.

Aseem Malhotra  25:51  
Thank you Richard, my pleasure. 

Richard Pile  25:52  
Take care. You've been listening to Wellbeing For Real Life with me, Dr Richard Pile. If you've enjoyed this episode, please give it a nice review and tell other people about it. If you'd like to learn more, my book Fit For Purpose is out now, published by Harper inspire and available in paperback ebook and audiobook. You can also follow me on Twitter, YouTube, and my website WellbeingForReal.life. This podcast was recorded at MonkeyNut audiobooks. Until next time, take care of yourself.