← Extend Podcast with Darshan Shah, MD
Extend Podcast with Darshan Shah, MD
162. Dr. Meredith Broderick: What An Undiagnosed Sleep Disorder Is Quietly Doing To Your Brain And Body
01:14:52
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- [00:03]
A
Welcome to xtend with me Dr. Darshan Shah. A podcast dedicated to cutting edge science research tools and protocols designed to help you extend your health span. Having become one of the youngest doctors in the country at the age of 21 and trained and board certified at the Mayo Clinic, I've accumulated three decades of practice as a board certified surgeon and longevity expert. Over that time I've discovered that a mere 20% of health knowledge yields 80% of the results. When it comes to your health span, we are living in a new era where we are creating a new healthcare system no longer focused on disease management but achieving optimal health and vitality. Join me as I interview world renowned experts offering you a step by step guide to proactively avoid disease and most importantly, extend your health span There's a version of exhaustion that many people are having trouble fixing. It's when you're getting your hours of sleep, but you're wide awake at 3 o' clock in the morning and your mind is running. Your body's alert, you're and there's no amount of breathwork or melatonin that gets you back to sleep. For millions of people in midlife, this becomes a norm. And what many doctors miss and most patients never get told is that insomnia isn't a diagnosis, it's actually just a symptom. And treating a symptom without finding the underlying cause is exactly why so many people end up with long term prescriptions that never really fix anything. Sleep specialists actually work from a differential diagnosis about why you're getting the insomnia is the same root cause framework that drives the rest of functional medicine. And it's that distinction that changes everything about how the problem gets solved. Dr. Meredith Broderick is one of four practitioners in the world who holds a board certification in all three specialties around sleep neurology, sleep medicine and behavioral sleep medicine. She's also a practicing neurologist in the Seattle area who's watched vascular disease accumulate in patients whose sleep problems had never been taken seriously. And that's what pushed her hard towards a more functional and prevention strategy. Her boutique practice, Sound Sleep Guru is built on a single conviction that chronic insomnia is solvable without a pill if you're treating the right problem. In this conversation, we're going deep on the waking up in the middle of the night and other causes and reasons people get insomnia and what's actually happening in the brain when this happens, why the reflex to grab a sleep aid is the worst thing you can do and what the evidence actually says about how to rewire your sleep for good. This isn't a conversation about just standard sleep hygiene tips. It's about totally changing the way you think about sleep and insomnia entirely. Hey, everyone, before we dive into today's episode, I want to talk about something that you hear me talk a lot about. Your biomarkers. And I want to tell you how I'm approaching this situation right now with all of the patients that are calling me from listening to this podcast. So what happens is every day, patients are writing to me saying they feel exhausted, they can't lose weight, they're having brain fog, and they see their doctor and the doctor tells them all their blood work is normal. But the problem is this doctor usually is only checking about 10 to 15 biomarkers that only tell you if you have a disease developing. Meanwhile, your body has 160 different systems that are running. Then all of these have blood tests that we can test on how effective they're working for you every single day. So if someone is not close to one of my clinics, one of my next health clinics, then I tell them, go to their local laboratory and get on Function Health. Function Health gives you access to 160 different biomarkers, the same kind of comprehensive testing that we do at all of our next health clinics. And if you tried to get this on your own through your regular doctor, it can cost you thousands of dollars. Hormones, inflammation, toxins, nutrient levels, they're all tracked over time in this one platform called Function Health. They could even help you get an MRI scan or a CT scan if you want one. So what I love most about this company is that they don't have a crazy incentive to do this. Function doesn't push supplements. They don't have pharmaceuticals they're trying to get you to take. You're just getting the data and you're getting insights from the data. And you can bring this data to a clinic like ours, and we then have the information that we need to tell you how. How to improve your health. Membership is now only $365 a year. Literally, it's just a dollar a day. And right now, if you're one of my listeners, you can get a $25 credit towards the membership. You just go to the link in the bio or go to functionhealth.com Dr. Shaw and use the code DrShaw25 for a $25 credit towards your membership. I'm so glad you came to see see me here at the next podcast. Thank you for coming. Sleep is Such an important topic.
- [04:48]
B
It is. Thank you for having me.
- [04:50]
A
So I would love to start off. You know, you're a physician, you're a neurologist. And I always love to hear the journey of physicians as they move from like, traditional Western care medicine to what brought you here to help people improve their lives through sleep, for example, but also just in general, just through lifestyle. So tell us a little bit about where you train and how you got here.
- [05:12]
B
Sure. I trained at Case Western in neurology as my primary specialty. And I think like most doctors, when you are in residency, you have an existential crisis because all of a sudden now I'm seeing all these people having strokes, and in a lot of cases there isn't a way to reverse that. And after a while it feels a little bit like a moral injury because you realize you have to do something earlier, and that's really devastating. And I was very frustrated by that. And that's when I came across sleep medicine. And it also interested me because I had such a difficult time with a sleep deprivation in medical training. And those things together, along with a suggestion from a mentor, led me to go visit the Stanford Sleep Clinic, which is one of the world's most famous sleep clinics. And I just knew when I met the people there and saw the work that they were doing, that that was my mission.
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A
Oh, that's so awesome. And did you also then spend some time at Stanford in sleep training?
- [06:12]
B
Yeah, I did. So I. I visited for two weeks and then I applied for the fellowship and I spent a year there. And about midway through the year, I noticed that insomnia is such a big problem and traditional sleep medicine refers that out to behavioral sleep medicine. And so I thought to myself, well, I need to understand this problem and be able to treat it too. And so Rachel Mamber, who's one of the world's most well known insomnia exper, I went to her and just begged her, can you please train me in this field while I'm here? And she's like, it's not necessary. You don't need to do it. You can still learn it. You don't need to get boarded in it. But I convinced her and I was able to do like a mini fellowship when I was there and then take the board. And I thought it was so important to be able to treat both from a behavioral standpoint, because sleep is a behavioral state and to also use my medical knowledge and combine them. And as you know, in corporate medicine, it's very hard to do behavioral treatment because it's very time consuming. So that's what made me break out of traditional Western medicine onto my own practice.
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A
Yeah, it's such a recurrent theme in just doctors getting out of the traditional medical world and doing something different and new. It was kind of like my story. Like, I was like, how am I going to bring together functional medicine, lifestyle medicine, you know, preventative, longevity? Like, there's no model in healthcare that does that. In fact, healthcare loves to be. Well, disease care loves to be siloed. Right. And so those silos create specialties, which is great, like, for that model, but it's really not great for when you're trying to prevent disease in the first place. Because, like you said, like, disease is very multifactorial. Sleep is. It could be anatomical issues. Right. Like sleep apnea and dental issues. It can be behavioral issues. It can be issues with just your routines and your habits. And there's so much around sleep that you need to bring it together under one roof.
- [08:08]
B
Yes, absolutely.
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A
And that's kind of what you do at your practice now, too, right?
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B
It is. I say it's holistic because I really want to look at the whole person. And it's interesting because in the last five to 10 years, there's been a lot of interest in sleep optimization. And so there's the disease treating sleep disorders, and then there's also sleep health. And so being able to look from both angles and be able to treat things in a really comprehensive manner and to coordinate with surgeons and dentists and also various kinds of sleep specialists. Because sleep medicine itself is a multidisciplinary field.
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A
Yeah, it definitely is. And so your practice in Bellevue, what are most of your patients coming to see you for?
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B
So I see the whole range of age groups. I see babies, I see children, and I see adults as well. I would say they mainly fall into three categories. So children with sleep problems. And then I also see a lot of people with sleep apnea or sleep disorder breathing. And then insomnia would probably be the third.
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A
Wow. Okay. And so the way I look at insomnia versus sleep apnea, there's kind of two different buckets a little bit, and both of them are related, but they also need their own kind of way of thinking about how do we fix this issue. Right. And so I see a lot of patients with both problems. Insomnia, sleep apnea and insomnia is also divided up into different reasons or different patterns of insomnia as well. Right. And the one part of this that I don't talk a lot about just because I have mainly an adult focused practice and I want to dive into that really deeply. But I'd love for you to give the audience a little bit about kids with sleep issues because this is becoming a bigger and bigger problem I'm seeing and a lot of parents are talking about this. Can you give us a few minutes on that? Just to like, just so we have some background there and if maybe some of the audience has a kid that's not sleeping well, they can maybe guide them in the right direction.
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B
Sure. There are two really interesting parts of the story with kids. One is the behavioral side because the way we sleep is learned. So one of my teachers, he always said that the need for sleep is biological, but the way we sleep is learned. And so there's a really interesting kind of cultural, psychological, behavioral aspect of it. And so we see this on social media, like, do you sleep train? Are you going to do the Ferber method? Where do you sleep? You know, there's a lot around that. And if you are a parent, you know, there's a lot of anxiety when you first have a child. The newborn period, the waking up in the middle of the night. And people can develop a lot of issues and lack of confidence around that. But then the sleep apnea is an issue as well because we think over time there was this amazing book, Breath, I don't know if you've read it, where they talk about how the actual craniofacial anatomy has changed over time with modern agriculture, with these non nutritive sucking. So using pacifiers and bottles and nursing and processed food and purees so that we're not sort of growing our airway to its optimal potential. And so all kids these days are needing orthodontics and having crowding and mouth breathing and allergies and there's pollute, there's pollution. So it's both the behavioral and then also this airway issue.
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A
Yeah. And when a parent notices that their child is not sleeping well, how would they know if there's an airway issue actually going on? Like what are the signs of that?
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B
Yeah, kids are very different than adults. They aren't gonna typically show up with excessive daytime sleepiness or loud snoring as we think of it. But they may have audible breathing, they may have behavioral issues, things that look like adhd. So one thing I always tell people is, you know, get your child checked for a sleep disorder before you put your kid on meds for adhd.
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A
Yeah, yeah. So true. So many kids are on medications for adhd, right? Now, and it could just be a sleep issue, so.
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B
Absolutely.
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A
How does a parent get their child checked for a sleep disorder?
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B
Yeah, the first step would be to find someone like me, someone who's board certified in sleep medicine. And there are pediatricians that go into sleep medicine, but all sleep medicine physicians are trained in pediatric sleep medicine. That's good to know.
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A
Yes. Yeah. So. So just find a sleep medicine doctor, someone who's board certified sleep medicine to evaluate their child.
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B
Correct.
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A
Got it. All right, I want to dive into adults now. Okay. So we talked a little bit prior to the podcast about sleep centers. Right. And you know, traditionally, I would say up to even five years, if you had a sleep problem, you'd go to a sleep center, you spend the night there, you get hooked up to a million different wires. I mean, I don't even know how people sleep in that state, but that's how you would get what's called a sleep study, which is basically looking at your eeg, which is your brain electrical activity, your heart rate, your oxygen levels, and putting together a full picture about what's going on. Right. And so maybe you could talk to us a little bit about how this model is changing and why it initially
- [12:51]
B
started change because of insurance. They started to require screening with home sleep testing before they would cover an in lab testing. And a lot of us sleep doctors didn't like that because the home tests, especially the older kinds, the type 3, where you have a nasal cannula and a chest belt, they have a pretty low sensitivity in certain endotypes, especially in women, especially people who are not overweight. And. But that changed a lot. And then I think during the pandemic, that also had a big shift. It's also just very cumbersome and I think economically from a business standpoint, difficult to run a sleep lab because it's, it is, it's a lot. It's, you know, it's like 10 hours of staffing and then having to have bedrooms and all that stuff.
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A
Yeah, ten hours of staffing. People working all night long not getting sleep themselves.
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B
I know. Yeah.
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A
Those poor sleep technologists. Right, right. So how have the wearable kind of like at home tests changed? And can you give us like the names of a couple of really good ones if people are looking to do it at home test?
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B
Yeah. The one that I use is called watchpat1. And I love that test because there's a lot of logistical issues with home testing. As a physician, you're trying to get these tests back from people, get them to people and find a convenient time for them to take them. And so the watchpad study uses something called peripheral arterial tone. So it basically has a little finger cuff.
- [14:12]
A
And.
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B
And whenever we have an obstructive breathing event, there's a vasoconstriction in the finger and it can detect that. And that's a more sensitive way in some people to detect sleep disordered breathing than using a flow base. Also with flow based or type 3 tests where there's this nasal cannula, it's really easy for it to move out of the nose while the person is sleeping and to just get a whole night that's not useful. And so the watch pad also, I think you're more likely to get good data from just one night.
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A
And is it just one night of testing that you need to get a sleep study or should people do multiple nights?
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B
If you're screening for sleep apnea and you do one night and you see sleep apnea and you have good data, that's enough.
- [14:57]
A
Yeah. And so sleep apnea, I want to talk a little bit more about that because I think in my practice I see probably 10 to 15% of people with sleep apnea. It is probably even more because a lot of people just sleep, you know, slip through the cracks with sleep apnea because they don't think they have the symptoms. Right. And then, and I say that because I'll ask the symptoms, I'll ask the stop. The stop bang test, right, which is on anyone who's out there that's considering screening themselves for sleep apnea with a questionnaire can look online for stop bang. And that's a quick test that you can do, which is a questionnaire that tells you your risk for sleep apnea. But I think a lot of people, they fill out that questionnaire and there's like, yeah, I don't really have that. And it's very subjective. And then they go home and they put on like a whoop band or oura ring. And then they come back a few weeks later and they show me their data and they're waking up multiple times throughout the night or their oxygen saturation level is pretty low overnight. And then we recheck with the formal sleep test. And it turns out the stop bang questionnaire was incorrect about their risk of sleep apnea. So I'm just curious, like, do you see that in your practice?
- [16:04]
B
I do all the time because I'll get people referred for cbti. And for instance, I just saw a woman and she had paroxysmal atrial fibrillation And I told her, were you ever screened for sleep apnea? And she said, no, because she's this tiny little otherwise healthy woman. And it never occurred to her cardiologist didn't screen her. I tested her and her ahi was like 30, which, as you know, is severe. And so, yes, it happens all the time, especially in people that don't have the obvious symptoms, which is women. Women are going to more likely have insomnia, fatigue, morning headaches and get told they're depressed.
- [16:39]
A
So, yeah, you're absolutely right. I mean, it almost feels like almost everyone should get screened for sleep apnea. If you're not, something's off. Right. Hypertension is another big one. If you have high blood pressure. You mentioned paroxysmal atrial fibrillation. So this is, you know, basically any type of arrhythmia. Right. Obviously, the obvious things are feeling tired during the day, falling asleep while you're talking to other people, or like, weird situations where most people don't fall asleep. Right. Like during lunch or needing lots of naps during the day. What are some of the other symptoms of sleep apnea that sometimes get missed?
- [17:16]
B
Yeah, so one reason I'll get a lot of referrals is from dentists. So people who are breathing through their mouth, they can develop dental issues. A lot of times they're destroying their teeth because they're grinding so hard or they have TMJ issues. So that's a big one, too. Depression, any kind of mood disorder, we wanna screen. Even things like low testosterone or hypothyroidism, we would wanna screen. I honestly think at some age, like 50, everyone should be screened as part of just like.
- [17:45]
A
Thank you for saying that. Right, exactly. I totally agree with you. I think there's so much more screening we need to do on people, especially at earlier ages, like 50 or even 40, just get tested for it. It's so easy now.
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B
Yeah. And it's. There's no. I mean, it's an inconvenient night. That's pretty much it.
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A
Yeah. There's no downside now. Right. So I fully agree that everyone just get tested for sleep apnea. You know, I just feel like there's so many times you find something that you would never normally know. Right, right.
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B
And I. Yeah, go ahead.
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A
I was gonna ask you, do you think that the whole industry will eventually get there or maybe wearable devices would just screen everybody?
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B
I am starting to see, because the Samsung and the Apple watch are identifying. They can't diagnose, but they can identify people with Suspected moderate to severe. And so I am starting to see that where people are coming and saying they got flagged. And that's. That's amazing. But, you know, I think sometimes people know they have it too, and they. They won't get tested because they're. They're. They're avoiding it. They're avoiding the perception that CPAP is the only option and they don't want it. Which, you know, CPAP is not as bad as people think. Sometimes people are surprised by that. It's not as bad. And then some people are also surprised. There's dental options, there's orthodontic options, there's surgical options, and now we have zepbound tirzepatide. So we have a lot. A lot more, you know, a lot more treatment options.
- [19:07]
A
Yeah. It's so important to know that, like you said, a lot of people don't even want to know they have sleep apnea because they only think cpap, which is that device that you wear in your mouth all night long that looks like you're Darth Vader, you know, is the only option. And look like that is a great option for a lot of people, has helped so many people. But the reality is, in 2026, we have, like you said, many options. And I want to go into some of these with you, and don't be scared to find out, because, like, putting your head in the sand is a big problem. Right. Because the biggest issue with sleep apnea is not just the tiredness that you feel during the day, is that this will lead to cardiovascular disease, Alzheimer's disease, even cancer, is relationship to sleep apnea.
- [19:47]
B
Right, Right.
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A
Yeah. So there's a lot of bad, bad things that happen with sleep apnea that compounds over time.
- [19:54]
B
Yeah. I mean, when thinking back to seeing people have strokes, I mean, when that happens to people, they would do anything to reverse that. And so you kind of have to think of that ahead of time. This is an insurance policy to get this checked out and get it treated.
- [20:09]
A
Yeah. It's just like leaving high blood pressure untreated for years and decades. Right. It's gonna definitely lead to bad things down the line. You would never do that. Sleep apnea falls in the same category to me. So I love this kind of, like, bubbling up of sleep apnea in the list of things we need to be proactively checking for.
- [20:26]
B
Absolutely, yes.
- [20:27]
A
Can I ask you. Now, let's talk a little bit about the different options for sleep apnea. And I want to start the conversation with what you mentioned earlier briefly, which is mouth breathing. Right. And so the word, the book, breath, like, they have a few chapters dedicated to mouth breathing. Break that down for us. Right.
- [20:43]
B
If you cannot breathe through your nose, it tells us where the tongue is. And sleep apnea is mainly an airway obstruction behind the tongue. So our natural resting position, if you're just sitting there breathing through your nose, your tongue should be lightly suctioned to the roof of your mouth. And even that little bit of surface tension keeps your tongue from collapsing. So if you're not able to breathe through your nose, even though that's not where the obstruction is, it just. And then once you fall asleep and you're laying down, it means that the tongue is a lot more available to obstruct the airway.
- [21:16]
A
I never knew that. So if you're just sitting there and you're breathing through your nose, if your tongue is not plastered to the roof of your mouth, it's probably falling down in the back of your throat at nighttime.
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B
Right. And also, there's a neuromuscular part of that where your tongue develops a low tone. So it's not sort of doesn't have the strength to sit in the roof of the mouth. And, you know, a lot of times that goes along with kids that might have had a tongue tie or had speech issues. And so nasal breathing is very important. Even it's very tightly connected to sleep apnea, even though that's not where the obstruction necessarily is.
- [21:50]
A
Yeah, it's so true. And so it's funny, I was just at south by Southwest, and I met this person who is an influencer, you know, and he was talking to me at dinner, and he said to me, oh, I got a nose job. It's the best, best thing I ever did. I'm like, oh, yeah, you're kind of vain. He's like, no, no, no. It's not because of how I look. It's because I am sleeping so much better now than I ever had in my entire life. And so this obstruction that also happens a lot of times with people in their nose. You know, I used to do a lot of nasal surgery is because their turbinates are in the wrong place or too big. They have a deviated septum. And you don't have to get punched in the nose, have a deviated septum. This is, like, something that happens. People are born with deviated septums. So a test that I like to do for everybody is just put a finger on one nostril and close it and see if you can breathe comfortably through the other nostril and do the same for the other side. And if there's any obstruction there, you should probably see an ear, nose, and throat doctor to see if relief of that obstruction could help. Right. And I think that's an important part of, like, the algorithm of solving for sleep apnea that a lot of people don't talk about.
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B
Absolutely. 100%.
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A
Yeah. So do you work with a lot of Ents on the nose and the facial structure as well?
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B
Yes. I mean, I have my kind of right hand ENT in Bellevue, and we work together a lot. And look at all of those things even. I mean, everything from just nasal breathing. And let me say, I think nasal surgery is one of the highest satisfactions. And I always tell people, go to someone who understands sleep. Go to someone who's entitled to sometimes even facial plastics, because I have had people who've had a nose job that they could breathe. Their breathing is worse after you've probably seen that too, you've maybe even had to correct that. So, yeah, ENT is like the right hand. The right hand man in sleep medicine.
- [23:38]
A
Exactly. I think so. You know, when you're working with sleep apnea, you want to start, like, from the nose down. Right. And so see if there's any nasal obstruction. Another way to really kind of assess this, too, is get these nasal strips that hold your turbinates open. Right. As well. If those help you, then there's a definite anatomical issue that you should get evaluated for. Right?
- [23:59]
B
Yeah. So I think it's called the caudal's maneuver, where if you go like that and you can breathe better, it's telling you there's. Or if you breathe in and you see the sidewalls of your nose collapse, it's called the collapse of the internal nasal valve. And there is a procedure called Ehler batten grafts or something called an EHR lift procedure, where they can put a little stent in there and it helps. And then we also want to look for things like allergies. And, you know, there are other things that can cause nasal obstruction, just like you said, septal deviation and turbinate.
- [24:26]
A
Do you believe in the book Breathe? You know, he talks about how people that nasally breathe and don't orally breathe, they end up with even having, like, deficits in their cognition and end up with all sorts of other issues.
- [24:37]
B
Do you believe that insofar as it's connected to breathing during sleep and it disrupts the sleep? I do believe that. And I also. The thing that I thought was a strength I mean, that book was written by a journalist, so you always have to remember that. Also this craniofacial growth is. Sometimes people have nasal obstructions simply because their nasal bones, they could have a wider nose. So we always say that the roof of the mouth is the floor of the nose. So there's also these really cool orthodontic treatments that are really just emerging. And I actually went through it, something called a MARPI procedure where they use a bone borne palate expander and you crank it and it expands your maxilla and that helps your nasal breathing and also gives more room for your tongue to sit into the roof of your mouth. And I actually got off of CPAP. I used to wear CPAP for about 10 years and I was able to get off of mine and I was very skeptical that I was going to be able to, but. Yeah.
- [25:33]
A
Wow. So wait, what's the name of this procedure again?
- [25:36]
B
It's called marpi M A R P E. It's called Mini Screw Assisted Rapid Palate Expansion.
- [25:42]
A
So we used to do this when I used to do cleft palate surgeries.
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B
Oh really?
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A
In kids? Yes. On kids?
- [25:47]
B
Yeah, yeah.
- [25:48]
A
Expand their palate with a device that we'd put on top and they would just turn. The parents would turn the screws every other day and expand their palates. Is this similar?
- [25:57]
B
It's similar. It's just that in adults, because the mid palatal suture is fused now they use this really cool cone beam CT and this mapping and they, an oral surgeon will place titanium screws to anchor it to the bone. And that way you're not putting on the pressure on the teeth because if you put all the pressure on the teeth, you know, that's good. And then in men, because the suture is often fused more with more, you know, it's harder to open. Then sometimes we'll do a SARPI where an oral surgeon will make cuts in the mid pallid suture just to kind of help it open. There's also other techniques. There's something called the mind procedure, the dome procedure, the ease procedure, that different surgeons have developed their specific technique. But they all sort of open up the palate. Exactly.
- [26:43]
A
Give it more room. And I think the core idea here is our palate, which is a roof of the mouth over the last few generations, has collapsed because our food has gotten softer and softer. This is what the book Breathe talks about.
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B
Right.
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A
And you know, he actually did something really cool, which was go to Paris and go to the, the tombs and they found a bunch of Skulls. And they saw these big, wide jaws on people. And it's because we're eating softer and softer food, are we're not using our masseter muscles and our facial muscles enough. And basically as just like a. It's just like our entire population, our palates are so much smaller and our jaws are kind of collapsed a little bit. And this creates the anatomy of the tongue obstructing our airway. Is that right?
- [27:25]
B
Absolutely, yes. A hundred percent.
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A
Yeah. And so, you know, I think another thing to really think about is what kind of food are you eating? Are you eating vegetables and high fiber vegetables that really cause your jaw to exercise a little bit as you're eating three times a day?
- [27:41]
B
Right, right. And myofunctional therapists who are the physical therapist of the orofacial musculature, they will say, we want the pacifier out by six months, and we want to start giving food, we want to start training, we want to look for tongue ties. Because a lot of people don't see the tongue tie, I think, as being as medically important it is as it is. But I always tell people, if you just have torticollis, which is common in babies, where the neck muscle is tight, and you don't correct that, there's a whole motor delay on one side of the body, the visual field doesn't develop correctly. So if the tongue is tethered, that has a whole cascade of things in the airway and that can go unrecognized. I do see adults sometimes that have a really severe tongue tie and it just never got treated.
- [28:28]
A
Yeah, yeah. And it's so important because when you're a baby, in those first few years, you're developing based on what your anatomy has developed too. Right. And so if you don't release a tongue tie, then your body's gonna compensate and one of the compensations is obviously gonna lead to sleep apnea in the future, so.
- [28:46]
B
Exactly.
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A
And other problems too. I'm sure there's craniofacial defects that occur if you don't correct a tongue tie as well.
- [28:52]
B
Yeah, yeah.
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A
Okay. So you also mentioned you work a lot with dentists. So how do dentists get involved with sleep?
- [28:59]
B
Yeah. So a really common referral I'll see is a restorative dentist that's gonna do tens of thousands of restorations in someone's mouth. And they say the reason all your teeth are cracked is because you have looks like you grinding, and that's probably because of sleep apnea. I want you to get tested and evaluated before we fix that, because otherwise you're gonna destroy the restorative work. I do. So that's a really common thing.
- [29:25]
A
Interesting.
- [29:25]
B
We also have what's called a mesial migration of our teeth as we age. So you might hear a lot of like 30 year old saying they're getting invisalign again because they didn't have retention from their orthodontics as teenagers. So now all their teeth are starting to crowd. That was one of the reasons I went for the marpi is I was noticing that myself.
- [29:43]
A
Okay. And so, so this happens like automatically as you get older, your teeth start crowding in on themselves.
- [29:48]
B
Yeah. So you people should theoretically wear retainers at night to prevent that from happening, because that's why, you know, your mid face kind of shrinks. And that's one of the, you know, aesthetic changes in the face as well as we age. So that's a really common one. And then like dry mouth can cause a lot of things like cavities or gum disease. And so that's another reason why dentists or dentists will just be doing a procedure and see that the person cannot breathe or they're obstructing during the procedure.
- [30:18]
A
Yeah.
- [30:18]
B
And refer them as well.
- [30:20]
A
Ah, so interesting. So, you know, I think back on my days of doing some cosmetic work for people, and you know, people obviously hate it when their face starts looking older. And what we found in cosmetic surgery is that it's really so much deeper than just the skin. Right. So, you know, all the treatments in cosmetic surgery are like these fillers that go right underneath your skin or Botox. Right. And really the real problem is down to the bone. And so it makes total sense that this collapse of the lower face is what causes the skin to not have good anchor. And then that's what leads to the. The entire facial musculature and skin actually sagging.
- [30:57]
B
Yes.
- [30:58]
A
And so probably another potential use of wearing like a retainer at night is to prevent facial aging.
- [31:04]
B
It is to keep the teeth from that mesial migration.
- [31:07]
A
Yeah, it's so interesting. Okay, so there are a couple other surgeries that like my time in surgery I grew up with was a UPP surgery. And then I never did the surgery, but a friend that had it done, which was kind of like a pacemaker. Can you talk a little bit about those? And any other kind of like new innovative surgical treatments that are out there now for sleep apnea and why would you use those?
- [31:29]
B
Okay. Yeah, the upp. So it's a uvulopalatal pharyngoplasty so if you look in the back of your throat, there's a little V shaped structure that hangs down. And I think of this as a very old school procedure. I don't really recommend it anymore because what they would do is just go in. It's inclusive of taking out your tonsils, if you still have them. And then they just cut the uvula out. And the idea was if we make more space, then we have a bigger airway. This will help sleep apnea. And so what typically happens is it helps for a little bit, but as the scar forms, it contracts down. And then also you remove the sensation of the airway. So the brain is not able to control the airway as well. So after the procedure is done, after a few years, people will come back and say it's not working anymore. Then you try to put them on cpap and it's harder for them to tolerate because you've lost that sensation. So they do have modified versions of it, something called a up flap where they sew the uvula up, but it's not really. It's not as helpful as it maybe logically seems. And then the hypoglossal nerve stimulator, which there are different versions of it now where one is, where there's a little implant here in the chin. And then now. And the original one was an implant in the chest though, like a pacemaker, and they tunnel a wire to the hypoglossal nerve, which is the nerve that controls the tongue. So an ENT surgeon does this, and then what the patient does is they turn it on with a magnet at night and it stimulates the tongue on one side so that during the breathing cycle when. When there's an obstruction, the tongue is activated so it can't collapse in the airway. And there's different versions of it now where I think they're going to be coming out with bilateral stimulation. And it's mainly for people who've tried CPAP and have failed and have moderate to severe sleep apnea. And there's certain comorbidities that would exclude you.
- [33:26]
A
Yeah, yeah. I have a friend that had it done and it took a long time to calibrate it actually to his sleep. And then every once in a while, like during the calibration process, it would actually wake him up in the middle of the night. So it actually did the opposite. But then he eventually got it calibrated and it started working. But then, you know, the same friend got on tirzepatite and it was a game Changer.
- [33:46]
B
Oh, yeah.
- [33:47]
A
So tell me your experience with Tirzepatide now.
- [33:49]
B
I think it's one of the greatest advancements that I've seen in my career. It's really exciting. I mean, as you know, it has to be used correctly. But it's interesting because the weight loss is part of it, part of why it helps sleep apnea. But there are probably other mechanisms as well. And I'm really excited. When the Surmount OSA trial came out, I was incredibly excited about being able to treat not just the breathing problem, but the metabolic problem as well.
- [34:17]
A
Yeah.
- [34:18]
B
So sometimes we have a twofer. We do cpap, we try to lose the weight, and then once the weight is off, maybe you don't need a CPAP anymore.
- [34:24]
A
Yeah. And then your hemoglobin A1C is corrected too.
- [34:26]
B
Exactly. Yes.
- [34:28]
A
And maybe you lose a few pounds. You know, obviously, with any, any one of these GLP1 medications, you have to do them correctly, make sure you don't lose muscle mass, make sure you're kind of changing your relationship with food while you're on it too, because your food noise will be reduced. But I do, I do completely agree with you that, like, now for me, if someone has sleep apnea plus metabolic disease or plus has weight, they need to lose or visceral fat. Like, it just seems like the first thing I want to go to because we can, like you said, kill two birds with one stone or even three, you know.
- [34:58]
B
Yes, absolutely.
- [35:00]
A
Do you think there's a role of GLP1s in people that are not overweight and metabolically healthy in sleep apnea? That's a tough question.
- [35:08]
B
I would say it depends what you mean by not overweight, because there are these people that, you know, maybe aren't as metabolically healthy as they could be and maybe they are a little. Their ideal body weight is like a tofi. Yes.
- [35:23]
A
Yeah. Yeah. Thin on the outside, but fat on the inside.
- [35:26]
B
You read my mind.
- [35:27]
A
Right, exactly. Yeah. Skinny fat. Yeah. If you're skinny fat, there's definitely a role for GLP ones for sure. Yeah. But what if you're metabolically healthy? Because I'm asking this because I want to drill down. You probably don't. No one knows the answer to this. Are there effects beyond metabolic health and weight loss on sleep apnea, particularly, like maybe a central effect, and a person
- [35:50]
B
like that, I'd be really interested to know what their anatomy is and if they structurally have a very narrow airway, I'm going to be more interested in that.
- [35:59]
A
Yeah.
- [36:00]
B
So it kind of depends on the case. But you know, obviously there is this idea of like microdosing and you know, I wouldn't be closed off to it, but I might be interested in looking at something more, more structural, especially if the person did have those features. We were talking about Nasal obstruction.
- [36:17]
A
Yep.
- [36:17]
B
Crowded airway, tonsil hypertrophy, those things.
- [36:21]
A
Absolutely, absolutely. Wow. This is like a master class in sleep apnea for everyone listening. Literally, like heard it from the sleep doctor about everything to think about about sleep apnea. Did we miss anything? Is there any big categories of items that we didn't talk about there?
- [36:36]
B
Those are the main ones. Jaw surgery. So having a full maximo mandibular advancement surgery. I would add that that can be a really important one as well, especially with this, you know, craniofacial growth pattern we've talked about.
- [36:48]
A
Yeah, absolutely. So oral maxillofacial surgeons, ENT surgeons, if your jaws severely receded, you can do kind of a bigger surgery to pull your jaw forward or move your maxilla into the right position as well. So these are larger surgeries. And yes, for some people, they absolutely need those type of procedures. But this is why it's so important for people in your specialty to really guide them through this process because there's so many options and without an adequate evaluation and someone who really has all the options in their tool belt, sometimes you go down the wrong path. And you know, I hate to say this, but if all you have is a hammer, sometimes you're a nail. If you're seeing the wrong sleep doctor for your sleep apnea, 100%, right?
- [37:30]
B
100%, yes.
- [37:31]
A
Yeah. I see a lot of people going to ear, nose and throat doctors. And you know, I'm not saying that they're doing anything wrong, but they're all well intentioned. However, the first kind of jump they make is to upp. It still happens a lot right now. And I agree with you. I think it's a massive surgery. It's brutal. There's a lot of consequences to it. I don't think that should be the only option presented to people now for sleep apnea.
- [37:51]
B
100%.
- [37:52]
A
Yeah. Okay, let's go into the other big topic.
- [37:55]
B
Okay.
- [37:55]
A
Which is I think your passion is insomnia. So maybe we could start this conversation with a little bit of a definition of what is insomnia.
- [38:05]
B
Yes. The one distinction I think that's really important to make is what is insomnia? Symptoms so similar to my belly hurts, I have chest pain. It's a generic symptom versus what we Sleep medicine doctors would call chronic insomnia, which is a formal sleep disorder. So insomnia symptoms can be any type of insomnia, and one out of three people has insomnia symptoms at any given moment. So it's very common. But if we actually wanna look at people who have chronic insomnia, which is trouble falling asleep, staying asleep more than three times a week for over three months, we're talking about a very specific type of sleep disorder that at any given time, maybe about 10% of the population is dealing with.
- [38:44]
A
Okay, so say that again. Three times a week for more than three months.
- [38:49]
B
For more than three months. And it can be falling asleep or staying asleep, or both.
- [38:53]
A
And why are those numbers selected? Is that to kind of exclude the people that are maybe just going through something, temporary travel or stress or those kind of things?
- [39:02]
B
Exactly.
- [39:03]
A
Got it, got it. And so this is when really we need to start putting into place interventions. Because the buildup over time of chronic insomnia can lead to, once again, all the same things we talked about with sleep apnea, which is chronic diseases developing cardiovascular disease, Alzheimer's, neurodegenerative diseases, people don't sleep, they don't have an opportunity to, number one, clear their brain out, which happens at nighttime, of toxins through the glymphatic system, and also to reset metabolic factors, decrease hypertension. All of this happens during sleep. There's so much repair and restoration happens during sleep.
- [39:40]
B
Exactly right.
- [39:42]
A
So, okay, so when you see someone with this diagnosis that you make of chronic insomnia, which is, you know, three months they've been going, they can't sleep three times a week, how do you start breaking it down into where is the actual problem?
- [39:55]
B
Right. It can be challenging because as we talked about earlier, sometimes in women it can look like chronic insomnia when it's really a sleep apnea problem. But there is a very classic characteristic aspect of chronic insomnia, something we call conditioned arousal. So the way you can think of it is this is Rachel Mamber, one of my teachers. She wrote about this in a book she wrote. It's kind of like if you go to a bad restaurant, if you go to a restaurant and every time you eat there, you get sick afterwards, then eventually, just thinking of the restaurant, you go, ugh, I don't like that restaurant. So that this is why the sort of long term nature of it over three months is important, is what happens is people have such a bad experience with sleep that eventually just the thought of sleep makes them anxious. So people will say, Very characteristic things. I fall asleep on the couch. I'm very tired, but the moment I go into my bedroom, I feel wide awake. Or, you know, they feel scared to go to sleep. And so this is a very classic thing that people say who are living with chronic insomnia is there's this conditioned arousal.
- [40:59]
A
Yeah, yeah. It's almost like they are fearful to try to sleep because they know they're gonna have a horrible night just tossing and turning in bed. So it's like they're stuck almost Right. In this situation where they don't want to go to bed, but they know they have to.
- [41:14]
B
Exactly.
- [41:14]
A
And I know there's a lot of listeners out there feeling this right now.
- [41:17]
B
Yes.
- [41:18]
A
And what did you call this?
- [41:19]
B
Conditioned arousal.
- [41:20]
A
Conditioned arousal. And it seems like this is most effectively manage with behavioral therapy, Is that correct?
- [41:29]
B
Yes, exactly. Something called cognitive behavioral therapy for insomnia.
- [41:33]
A
Right. And so I still find that most people have never heard of this. So I would love for you to dive in and give us specifics on what it is, how it's used, et cetera.
- [41:42]
B
Yeah. CBT I is. It's not psychotherapy by any stretch, so we're not psychoanalyzing you. But it has five components to it that are. They're addressed in a certain sequence, usually through a series of visits, like four to six visits, either every week or every other week. And when people come to see you for insomnia, they're desperate. They want to sleep more. But the first step in CBTI is not going to get you to sleep more. It's to try to get you to be awake in bed less. So what we're trying to do is extinguish that conditioned arousal so that you don't have a bad experience at the restaurant anymore. And so we do that by restricting the time in bed and by having people get out of bed when they're having trouble sleeping. And that's the crux of cbti, is selling that to someone that it's going to work. And so there are a lot of books and programs and digital therapies, but sometimes people really need to work with someone who can help them see that and apply that and have the confidence to do something that is very illogical.
- [42:47]
A
Yeah.
- [42:48]
B
So there's restricted. So we call it sleep restriction therapy. It's not a good name, but it's really restricted time in bed. And then there's the stimulus control piece, which is really based on if you know Pavlov's dog. Pavlov's Dog. You ring a Bell, you feed it. When the dog hears the bell, it expects to eat. So now we're trying to get you to expect to sleep instead of have insomnia by removing that environmental cue of being awake in bed. And then as we go on through it, there's also sleep hygiene, so protective preventative sleep behaviors. And we also have cognitive therapy, which, which is helping look at people's thoughts around sleep and sort of their obsession with it and worry and catastrophizing and reshaping those. And then the fifth part is relaxation. So getting people to be able to sort of calm down, the hyperarousal and that hypervigilance state that is also part of insomnia.
- [43:38]
A
Yeah. You know, and I'm so glad you explained it that way, because it really is fully managing and helping people get into good routines and habits around their sleep. So it's not just, you know, I think a lot of people that when I first say cognitive behavioral therapy, they think they're gonna have some psychotherapy around sleep. But I'm so glad you said it's not that it's fully just changing their mindset on sleep, but also putting in place those sleep hygiene cues that really help people get to sleep faster, that everyone should be doing anyway. But a lot of people just don't know it.
- [44:10]
B
Right, Exactly. And also I think there's a perception that CBTI is sleep hygiene.
- [44:15]
A
Yeah.
- [44:16]
B
And that's. And so a lot of people say, my primary care doctor already gave me sleep hygiene. It didn't work. And I want people to know this is different.
- [44:24]
A
Yeah.
- [44:24]
B
The main problem we have is there are only about less than 300 people board certified in behavioral sleep medicine in the world.
- [44:31]
A
Right.
- [44:32]
B
That's a big problem.
- [44:33]
A
Yeah, it really is. And so how can, first of all, how does behavioral therapy work around sleep? Is it like you talk to someone every night or is it a once a week thing? How long do you talk to people? Do you talk to them during the day? Like, how does this practically work in someone's life?
- [44:49]
B
Yes, usually. So in my practice, it's an initial consultation. It's done by telehealth. People tend to prefer that it's usually an hour. And then we would do weekly or bi weekly visits for anywhere from four to six sessions. If the person is already maybe onto this already, they're doing a home program, they might need only two or three sessions. If the person is on a lot of medications they need, they're wanting to get off of them, it can take longer, but yeah, it's I tell people it's kind of like seeing a therapist, but for sleep.
- [45:19]
A
Yeah, yeah. And I want people to know that this is incredibly powerful and it works. A lot of, a lot of the times it really does work. The times I've referred people for cognitive therapy, most of them say, yep, that solved my problem, that's what I needed. I wish I knew about this years ago.
- [45:34]
B
Absolutely, yes. I hear the same thing. People, I think, I think that's the other thing is people don't realize there is a solution that really works. And honestly, if people will execute it and that's. People always say like, can you guarantee that it'll work for me? Because it's very time consuming. They're worried about committing. And I just say, well, if you do it, it works. So that's the crux is can you believe it, can you trust it and will you execute it?
- [45:58]
A
Yeah. I hope we go to a world one day that every time you put someone on prescription medication, there's also a way to get off of it eventually. And I feel that it would be incredibly beneficial just for us as a society that if you get put on a sleep medication, which can help you for the time being. Right. I get it. But that's then required for you to see someone for cognitive behavioral therapy. Right. Because I feel like people just get on a sleep medication, they think it's like, that's it, I'm just going to be taking this for the rest of my life. And it works. So people get addicted to them. Right. And it becomes a huge problem and it's like a, you know, you're chasing your tail. It becomes a self fulfilling prophecy that you end up becoming addicted to these because you don't really have a pathway off of it. It's just assume that you're going to stay on it forever.
- [46:41]
B
Yes, exactly. Or you're just going to come back and try another one when it stops working. Because we know it's going to stop working.
- [46:46]
A
Yeah. So if anyone out there is on a sleep medicine and they haven't done cognitive behavioral therapy, they should look into it and try to find someone that can do it with them.
- [46:54]
B
Yes.
- [46:55]
A
Do you see people out of state or is it mainly in the Washington area for the telehealth piece of this?
- [47:00]
B
I am licensed in California too, so occasionally I do get a few folks from California.
- [47:05]
A
And where can people find like someone that does this in their state?
- [47:09]
B
If you go to the Society of Behavioral Sleep Medicine, they have a directory. Not everyone is boarded, but some of the folks have Done courses, and that's great. It's a good starting place. And then I think the Penn Sleep center also has a directory, so they might have a little different, but it's worldwide, so you can go on there and find a practitioner.
- [47:30]
A
Awesome. With cognitive behavioral therapy, do you find people, they have a high success rate, but they sometimes have to come back and do it again?
- [47:38]
B
Yes, sometimes they have to come back and do it again. And when I see people for an initial visit, I always tell them there has to be a right time too. I'm sure you deal with that with behavioral treatments as well. So if someone tells me, well, I'm going to Europe and then I'm going on a guys trip, and then I'm. I'm like, well, now's not the right time. I think sometimes people also just need time to, to be ready to do it, to feel like they have the willingness to commit to it. And so sometimes people will schedule a consult and then I'll see them on my schedule three months later and they're ready to go.
- [48:07]
A
Yeah, yeah, yeah. A lot of times people want to come to my clinic and talk to me about changing their whole life and getting metabolically healthy and, you know, fixing their exercise routine. And then I talk to them about all the stuff we're going to do and they're like, oh, yeah, but I'm going on vacation for two weeks next Monday. And I'm like, well, this is not the right time to do this. This is not going to work. So you have to make space for it in your life. Right. You need to have six dedicated weeks, probably in a row that you're going to be sleeping at home for the most part. And you can have some time to dedicate to this because that's how you're going to see success. You can't fit it into a crazy, busy life.
- [48:41]
B
Exactly. No, I 100% agree.
- [48:44]
A
A lot of my patients are CEOs and, you know, executives, businesses, and they're running big departments. And the number one complaint I have is that they wake up at three in the morning with their mind racing and they can't get back to sleep. What do you say to those people?
- [49:00]
B
Well, one of the things I like to explain to people is that your brain is very busy. When you're asleep, it's really working. And a lot of times the thoughts that the brain is processing would be very irrational or what we would consider creative. And part of what you're experiencing with the mind racing is you're just discovering your brain in that process, I think the meaning that you make of the mind racing is very important. So sometimes people assume something's wrong with me, I have anxiety, I'm panicked. But if you really ask them about their daytime life, it's not really part of their daytime. And so you could just be waking up, discovering your brain working. The other thing is for people like CEOs that are very busy is we now have this attention economy where we don't have a moment to sit alone with our thoughts. And that default mode network is what neurologists or neuroscientists call it. It also has a very important function where we need to be alone with our thoughts. Our brain is actually doing a lot of work. We call it daydreaming, but it's really filing things and organizing things. And we just don't have that time anymore. I mean, we're looking at our phones when we're standing in line. Right. And so that's another important part is to just take out time in your day to be alone with your thoughts. So I'll tell, I'll tell my patients, like, just schedule some time, some downtime, go for a walk, don't look at your phone, don't listen to anything. Just let your mind kind of ruminate. It needs to do it.
- [50:26]
A
So I shouldn't schedule a call every 30 minutes starting at 8 and ending at 5?
- [50:31]
B
No. Or I mean, hopefully not one of those people that's like working all the way up to your bedtime, which some people do. Right. And it's like, of course your brain is, you know.
- [50:42]
A
Yeah, the every 30 minute Zoom thing is a killer. Yeah, you definitely are not sleeping well that night. Because you're right. I mean, your brain needs some time to process the information that it's taking in. And without that processing time, it all probably happens at night and your brain goes crazy. And then you wake up at three in the morning and then should you try to get back to sleep? If you're waking up at three in the morning but you still feel fully rested and your brain's on fire, what should be the next step?
- [51:07]
B
You should. I think that people might misjudge a little bit. So people will say that I feel wide awake, but I want people to be open to the fact that they can fall asleep. And I even tell patients with insomnia this. Let's say they get up at 5:30 and they wake up at 5. Be open to the fact that you could fall back to sleep for 15 minutes. If you sleep 15 more minutes seven days a week, that's, you know, a couple hours. But you need to be open to the possibility or even just be open to the idea that the rest is helpful as well.
- [51:37]
A
Yeah, yeah, it's so true. Is there a number of hours that you believe people should sleep? And I'm asking you this because, you know, I look at a lot of sleep data on people and there's some people that sleep six hours, but they get a good number of sleep cycles in. Their deep sleep is really a big percentage of their sleep. And you know, I'm looking at wearable data, so it's not super accurate. I totally get that.
- [51:59]
B
Yeah.
- [52:00]
A
But they feel fine, you know, and I'm just wondering how you think about this, is that like if you're not sleeping seven hours, that's a huge problem and you need to keep, you need to keep aiming towards that or is there some lower number that makes sense to you?
- [52:15]
B
We have really good epidemiological data about that and I do feel pretty strongly about seven hours. And I would really want to interrogate those folks a little bit more. We're not always the best judge. And some people are taking in a lot of caffeine and they're just hyper stimulated so they're not going to be aware of sleepiness. And I'd be really wanting to ask those questions, ask those people questions like, well, when you go on, you know, if you're a passenger in a car, would you doze off? If you were watching a show, would you doze off? Are there these sort of other signs? I mean, I see people. I kind of got into a little mini argument with actually a physician on Instagram because she was saying that she's such a great sleeper. She fell asleep at the Taylor Swift concert. And I was like, that's not normal. You know, I think I read that
- [53:02]
A
back and forth, by the way.
- [53:04]
B
Did you?
- [53:04]
A
Yeah.
- [53:05]
B
And you know, it's really just more letting people know like that's not what a good sleeper is.
- [53:11]
A
No.
- [53:11]
B
And so if you fall asleep when your head hits the pillow and you're sleeping six hours and you feel fine, I'm still going to wonder. Well, and that's the sneaky thing about sleep disorders is you can be very successful and very high achieving, but guess what? You could feel even better and be even healthier if you slept a little bit more and be more productive. Right?
- [53:31]
A
Yeah. And I also think the way you feel, our bodies are so incredibly resilient. Right. Especially our brains. And the way you feel, it takes those symptoms decades to catch up to what's really happening in your biology. And so I'm so glad I pinned you down on this number because this is a big debate. Right. I have this debate with so many patients. You know, some people swear to God that they're genetically blessed, they can sleep four hours and they're completely fine. I'm like, you're not?
- [54:00]
B
No, it's very rare. That's a very rare genetic trait.
- [54:03]
A
Yeah. And even those people with that genetic trait, like, I'm suspect if they're still building up damage over time. Right. Like, what do you think about that? Like, as the. Have the people with that. I can't remember the gene. What is the gene?
- [54:14]
B
I don't know off the top of my head, but they. Yeah, they're short sleepers. It's called short sleepers.
- [54:19]
A
Short sleepers. Yeah.
- [54:20]
B
I mean, I think the people who, like, it's genetically proven and they have like a family history of it, I believe it. And those people have been rigorously tested, but most people, if you test them at six hours of sleep, you'll see drops in their cognitive performance. So. And they might not be aware of it, but it's there.
- [54:39]
A
Yeah. Yeah. Okay. So I want to tell you something that I've been doing just lately. I'm a big believer of n. Of one experimentation. And there's some really great cognitive tests available online now that are just 10 minutes long. Right. And you could take these tests, they test your reaction speed, they test your memory, they test your attention in 15 minutes. And when I'm talking to people about their sleep, I'm trying to convince them to sleep more hours. I'll have them do it, you know, a couple of nights in a row and take these tests and see what their computerized testing actually shows. And the few times I've done that, they've seen improvement by like 30% just getting an extra hour of sleep. Yeah. And so that kind of tells them, like, oh, even though I'm feeling fine at five hours or six hours, that last extra hour I added worked, you know?
- [55:27]
B
Yeah. I mean, it goes back to what you said earlier. People don't realize they could feel better.
- [55:31]
A
Right, Right. Yeah, absolutely true. I wanted to talk a little bit more about the different sleep medications out there because this is a huge topic now, especially with the introduction of new classes of medications that are non addictive. And so can you kind of run through the different classes and how you think about them?
- [55:50]
B
So I put them in different buckets. I think about the over the counters. So antihistamines are very common for people to use. So Benadryl, Unisom, and then there's Trazodone, which is a huge one and not FDA approved for insomnia, but probably the most commonly prescribed medication in the U.S. and then there's the Z drugs, which are huge because in my career they were considered a huge advancement from the benzodiazepines. But over time we've seen maybe they weren't as safe as we thought. And then could you name some of
- [56:20]
A
the Z drugs real quick? Sure.
- [56:21]
B
So there's Zolpidem, which is Ambien, and then there's a Zopiclone, which is Lunesta, probably used more in Europe than in the US and then Sonata or Zalplan.
- [56:31]
A
Right, okay, good. Thank you. I just want people to know you're talking about Ambien in the United States when you say Z drugs. So. And then the next category, and then
- [56:39]
B
there's, excuse me, the Dora drugs. So these are Orexin. They work through the orexin mechanism. And those are kind of newer and they're kind of interesting because, you know, they're being perceived as being safer. But because people have such an expectation of being sedated from a sleep drug, I found that people don't find that they work. I don't know if you're finding that. And so they just kind of haven't taken off the way that some of some of the other medications do, that their mechanism is more sedating. And there's some interesting data about them that they may have some other benefits for sleep or for brain health, I should say. But I think the jury is still out. And for whatever reason, I just don't feel like they've taken off that well in terms of people prescribing them. I mean, part of it could be there's a whole prior authorization process and there's that whole headache too.
- [57:33]
A
Yeah. So my experience with the Dora's has been this, and I fully agree with you. I think if you've been on one of the Z drugs and then you try Adora, you don't get that same feeling where you're like conked out, right?
- [57:43]
B
Yes.
- [57:43]
A
Like, I think when you take an Ambien, you conk out and you almost feel like drunk, you know, and that kind of a feeling, you don't get that with the Doras. But if you have never really taken an Ambien before or a Z drug before and you tried the Dora, you kind of come into this, like, with a virgin mindset and you have no idea what to expect. And those people actually I think do okay on them. It's better than, I think it's better in my opinion than starting a Z drug. But I do think that all these should be thought of as temporary aids. Right. And so the other thing I will say you mentioned the prior authorizations because they are all under patent. So they're thousands of dollars a month to take one of these. Like no one's going to be able to pay that unless they have an insurance authorization. And we all know about insurance companies. I will say that one of the Doras, you can go online and the company can give you like a coupon code. And I've had a few patients do that and they can get it for like a really low price, like 10 bucks for a month supply. And I think that's really, financially.
- [58:40]
B
They can just try it.
- [58:41]
A
Yeah, so they can try it. And so that's been great. So a few of my patients have done that. They actually told me about it and they're like I said, that's amazing that you can get them for so cheap.
- [58:50]
B
Yeah.
- [58:51]
A
But I do think that in the hierarchy of sleep medications, it's another option now. But I do wonder about the long term effects of all of these. And the main kind of problematic thing I think about is I think there was a study that was published that showed that Ambien does prevent glymphatic clearance at nighttime. Like it does kind of shut off the glymphatic system. Do you believe that? And do you think the Doras also do that?
- [59:17]
B
So I don't think there's any studies showing that Doras have done it. So that study in particular was published in Cell and the way we think the glymphatic fluid is propelled through the cerebral, the cerebrospinal fluid is propelled, is from the pulsations of the large arteries. So it's kind of a pump, they're pumping. And so that's why having healthy vascular health or having good blood vessels is very important. And it's mediated by norepinephrine and so the zolpanum. And this was, I think in mice or rats it blocked that, that pump like mechanism. And so there was decreased glymphatic flow. So I do believe it. I mean you always have to wonder. You can't jump from mice or rats to humans, but you do have to wonder about that. And with Dora's, I think maybe it's, it hasn't been shown or maybe there's research showing that it's not the case. But we're not, I think we're not sure. But it's certainly interesting and it certainly corresponds with what patients say, that they have memory problems from zolpidem, they feel foggy. I mean, I don't know if you see this, but I get patients where they're thinking they have early dementia and you take them off the Z drug safely and they're fine.
- [60:29]
A
Yeah.
- [60:29]
B
Even if you have them do neuropsych testing.
- [60:33]
A
Yeah. The way a lot of patients describe it to me is they feel like they're an alcoholic, you know, and it's, it's, that's not a good feeling for people to have. And so I, I, I'm, yeah, I'm, I'm on the camp of like, if you're an Ambien user, you gotta do something to try to get off of it. And maybe switching over to one of these other ones temporarily and then seeing a practitioner like you to eventually get off all of it could be the, the right way to go.
- [60:55]
B
Right. And so going back to cbti.
- [60:57]
A
Yeah.
- [60:58]
B
A really important part of that is the mindset change. Because when you take something like Ambien for this first time and you get that conked out feeling, I tell people it's kind of like hitting a slot machine. And so if, if you're constantly seeking that, if that's what you're seeking, you're always gonna be thinking, I need to take something. And we need to change your mindset about that. That's not actually what we're looking for. So we need to move away from that. And that's where even I think sleep supplements can be shaky. Because what you're doing is you're training the person that the thought pattern is the solution to this is to take a pill. And we just wanna move away from that because that's not a good long term solution.
- [61:35]
A
Absolutely. Can we talk about Benadryl a little bit and the antihistamines? And I've read a lot about how dangerous those are also to take long term. Can you talk about that?
- [61:44]
B
Yes. I see a lot of pregnant women get put on em because they're safe or they're so accessible. Right. But they do cause so much sedation the next day. I mean, people will actually say, I feel horrible when I wake up. And then as you get older, then we start to worry about falls and motor vehicle accidents. And so it just becomes a really bad combination. And you know, I think they're perceived as safe. So they're used very, you Know, I think billions and billions of dollars per year, right?
- [62:19]
A
Yeah. Yeah. And I think also going back to, like, what you said earlier about Ambien is people think they have to take it to sleep now, and so they're just looking forward to that feeling where they just fall asleep immediately. And long term, that's not a good thing.
- [62:34]
B
Yeah. So another big problem with sleep, sleeping pills, is something we call rebound insomnia. So you are. You are physically dependent upon it in some way. Psychologically too. So if you try to go cold turkey, which is what a lot of people try to do, they have rebound insomnia. This happens with cannabis is like the worst. And so then it just reinforces, I can't sleep without it. Something in my brain is broken. I just need it. And it sort of reinforces that pattern. And so having, like you said, the plan to get off of it and it needs to be not a cold turkey plan is really important.
- [63:11]
A
Yeah, fully agreed. You know, there was a huge movement for a while about people taking cannabis to sleep, and I was against it from the very beginning. Was that your experience as well?
- [63:23]
B
You know, I was very against it too. And I think Washington was one of the first states to legalize it. And I had this friend that we used to go on these long recreational trips together, and she was actually a pot farmer, and she maybe opened my eyes to it a little bit, but, you know, it's so much stronger now than like when I was in college. And you just don't know how much you're taking. And, you know, smoking is horrible. And so. And the rebound insomnia is really bad. I mean, you can have psychosis when you go off of it.
- [63:56]
A
Yeah, I agree. And so I think whenever. And I've seen many, not many. I've seen a few people get psychosis both on and trying to get off of it. And just seeing that even one time you're like, I'm never going to prescribe this for sleep. It's is detrimental. And I've also seen people, their sleep architecture is actually really messed up at night. They're not really sleeping. They're just completely. Just passed down like they're under anesthesia almost when they do cbt.
- [64:23]
B
Yeah, it's when they.
- [64:25]
A
Sorry, cbd, not cbt.
- [64:27]
B
Yeah, I think of it almost exactly like alcohol, where there's this perception of better sleep, but it's really messing up the sleep architecture, like you said. So objectively, you're not. Your sleep isn't better. You're just sort of, you know, putting A band aid on it.
- [64:41]
A
Right, right. You're just under anesthesia, basically, you're like alcohol. Like you're passed out from alcohol. And people, anyone who knows is passed out from alcohol, they wake up the next morning feeling horrible, like they hadn't slept at all. Right, so.
- [64:52]
B
Exactly. Yes.
- [64:53]
A
Yeah. Can you talk a little bit about Trazodone as well?
- [64:55]
B
Yes. Trazodone is actually FDA approved for depression. That was originally when it came on the market. But it is the most prescribed sleep aid or sleeping pill in the US and at lower doses it works through more of an antihistaminergic mechanism. And, you know, people, I think because of the sedating effect, feel that it works and it's pretty low risk, which is why I think people prescribe it a lot. But it's interesting, I was in this Facebook group of physicians and there were, er, physicians saying they've actually seen cases of priapism and really scary stuff. And then at higher doses it's, you know, acts as more of an antidepressant, I think. And so maybe I have that reversed, but either way. But yeah, so. But it's the same thing. It's almost the way you think about it. It's going back to that. It doesn't matter how safe it is, it doesn't really work long term. And then now you've got a second problem. I need this and I have side effects.
- [65:53]
A
Yeah, yeah, that's so true. On the sleep supplement, you know, there's a million of them. Are there any ones that stand out to you as potentially being things that people should be trying and things that people should even be taking every night? Because it universally provides better sleep.
- [66:09]
B
So a sleep medicine physician's favorite supplement is Melatonin, but we have a couple problems with that in the US because it's not regulated by the fda. There's highly variable dosing even in like a labeled product, whereas in other countries, like Europe, it's used and been studied much more. So for instance, in an older population, 55 and older in chronic insomnia, in Europe, they have a drug called Circadian that's been studied very extensively. It's a long acting form of melatonin. And the rationale is that we have an age related decline. And so I really like thinking about that in my folks that have trouble staying asleep. I also think that the dosing, whether using it for jet lag or for someone who has delayed circadian rhythm, you really have to think about when and how much. And that's where a sleep doctor can really help or a physician. And so even though I love melatonin, I just don't think everyone should go out and take it. Because what a lot of people think is they think I'm gonna get sedated. And so if I don't, it doesn't work. And more is better. And with melatonin, that's not the case.
- [67:13]
A
Yeah. So what's a good dose for someone to try if they have like an age related decline in melatonin? I, you know, I always try to get people to do less than 2 milligrams, even like 1 milligram. Um, if, if that's the case. What are your thoughts around that?
- [67:26]
B
Well, for this drug Circadian, that we, you know, there's a lot of data, like safety data, and I believe it's three milligrams.
- [67:33]
A
Okay, good.
- [67:33]
B
Yeah.
- [67:34]
A
So, you know, I think what's important there too is that, you know, like you said, like, if you take it as a supplement, it's largely unregulated, so you don't know what is the quality of this. And there's all these, like, melatonin gummies now, which, you know, a lot of them been tested and they have nothing in them. And with a drug like Circadian, however, you know you're getting 3 milligrams of melatonin in there. Right. They're held to a different manufacturing quality. Is there any melatonin, like in the United States that you think that is like, super high quality and very readily available, but also like, more consistent?
- [68:05]
B
I think there are supplement companies that do independently test their products, so that's something I would look for. And a lot of those are. Is it the usp?
- [68:12]
A
Yeah.
- [68:13]
B
Okay. Usp, usp. And then compounding pharmacies are also an option. So those are a couple.
- [68:21]
A
Is that what you use in your practice, compounding melatonin?
- [68:23]
B
No, I usually have people get a high quality supplement. But the compounding pharmacy, you know, can be an option if you're looking at maybe a unique dose for that person.
- [68:34]
A
Got it.
- [68:35]
B
But usually it's more expensive, I think.
- [68:37]
A
Yeah, yeah. And for jet lag, is it the same dose or do you go up a little bit higher on the dose for that?
- [68:42]
B
You can do either. And it really depends on the timing. So if you use 8.5, like a lower dose, you're gonna give it earlier, whereas if using more of like a 2 to 3, it's gonna be closer.
- [68:53]
A
Got it.
- [68:53]
B
And that's if you're trying to, you know, shift the person back, you're Trying to shift them back to their earlier. Yeah. If they're going eastward.
- [69:01]
A
Got it, got it, got it. And then what about some of these other supplements? Like there's a lot of talk about taking magnesium specific forms like magnesium glycinate at night.
- [69:09]
B
Yeah.
- [69:10]
A
Inositol is another one. Can you talk about some of the other ones?
- [69:13]
B
Yeah, those are so interesting to me because there just isn't a lot of strong evidence, especially magnesium. And what interests me about magnesium is people will say it helps. I can tell a difference and I've even experienced that myself. But again, if it's chronic insomnia, it's probably not going to help that much. But if it's, you know, I have some leg cramps or maybe I don't have the healthiest diet and I am magnesium deficient, then yeah, maybe it's, maybe it will help. But yeah, there just isn't a lot of great research around that.
- [69:46]
A
Got it. So the data is not there. So once again, it's very end of one.
- [69:49]
B
Yeah.
- [69:49]
A
I mean most people need magnesium anyway, so it's not going to hurt you to take. It's probably help you in some way and then, you know, placebo effects are real effects. So if you feel like you're taking this and it's getting you better sleep, keep doing it.
- [70:01]
B
Right, Yeah. I mean that's how I think about it is it can't hurt. So go ahead.
- [70:05]
A
Yeah. It is also a good, I think long term, like if it is helping you and you getting additional magnesium anyway, which your body needs, it's probably a good long term thing to take too. Which is very different than any of these prescription sleep drugs. Right. Which could have a long term consequence of you getting addicted to it. Side effects and also the cost of it is quite extensive.
- [70:27]
B
Yeah. I haven't had any patients with magnesium glycinate or some of these sort of newer formulations. I haven't had anybody tell me they had a side effect. It's like either it works or it doesn't.
- [70:37]
A
Right, Exactly. So exactly, exactly. Are there any other things that you try to get your patients to think about just in general to get better sleep? If you're not suffering from sleep apnea, you're not suffering from chronic insomnia. What are some of the top two or three things that you love for sleep hygiene?
- [70:55]
B
Yeah. So the sleep environment is very important, especially in this modern world we're living in, especially for people who live in urban environments where there's sound pollution, light pollution, air pollution. So I love a Cool, quiet, dark bedroom. So anything, it can be a sleep mask, it can be blackout shades, it can be an air filtration system. And we just want that to become a very relaxing, quiet space for people to. To just immediately feel when they go into that space that, you know, it's a cue for sleep.
- [71:30]
A
Yeah, the. All those little things help. Even, like I talked to people about, when was the last time you changed your mattress, your pillows? Right. Temperature is critical, especially if you're sleeping with someone in the bed with you. You know, those kind of things can be game changer to get. You know, we. At our home, we have a mattress pad that changes our temperature, you know, and so those are the kind of things that can. That can be really helpful also. You know, I think a lot of times the one thing that I've noticed a lot of my patients do is they use their phone as an alarm clock, right?
- [72:01]
B
Oh, yes.
- [72:02]
A
And even just putting their phone in a different room and not using it as their alarm clock and just getting some physical separation away from their phone can be a game changer.
- [72:11]
B
It's shocking how much of a difference it makes.
- [72:13]
A
Yeah, it really is. Yeah. I have personal experience with that myself. Now my charger is in the kitchen where it's like the farthest point from my house.
- [72:22]
B
Good for you.
- [72:23]
A
From my phone. Because it just gives you that little bit of space, even away from your phone at nighttime where you've put it away, you can spend some time away, like you said, with your own thoughts. Right. Because when you have your phone, you're not with your own thoughts. You're with everyone else's thoughts on that phone. And it gives you that little bit of room to get your default network working.
- [72:43]
B
Yeah. And there's no urge to grab it because it's not there.
- [72:46]
A
Right.
- [72:46]
B
You're not thinking about it. Oh, let me just check it real quick. It's not there. So you can't.
- [72:51]
A
Yes, exactly. And you're kind of lazy to get up and go get it from the kitchen just to check for text messages. Just so you're not going to go
- [72:57]
B
out of sight, out of mind.
- [72:58]
A
Exactly. Wow. Well, this was an incredible masterclass on sleep, especially from a doctor that treats this from. From a medical perspective with all the different tools that you have in your belt, from cognitive behavioral therapy to sleep apnea treatments and surgery, all the way to all the medications that we talked about. And I really love it that people now have kind of the full tool belt that they can think about as they look to their sleep and to improve it, especially if you're suffering from insomnia or apnea. I think those are two things that, like you said, such a huge percentage of our population have and they really need to consider all the tools in their tool belt. So thank you so much for doing this with me.
- [73:37]
B
Oh, it's my pleasure. Thank you for inviting me.
- [73:39]
A
How can people find out more from you or hear more from you?
- [73:41]
B
Sure. My website is soundsleepguru.com that's my practice in Bellevue, Washington. And I also do telehealth to California. And then I'm very active on Instagram. My handle is leapdoctormare.
- [73:54]
A
Yeah, leapdoctormare. That's where I found you. Yes.
- [73:57]
B
Yeah.
- [73:57]
A
Thank you so much for joining me.
- [73:59]
B
Oh, thank you for having me.
- [74:02]
A
Thank you so much for listening to the podcast today. Please remember to subscribe if you like this episode and give us a good review and share a link with your friends. It really helps us support all of our efforts. I also want to remind you that the information information shared on this podcast is for educational purposes only and is not intended to replace professional medical advice, diagnosis, or treatment. Please consult with your healthcare provider or physician before making any decisions or taking any action based on what you hear today, especially if you have any underlying health conditions or on any medications. Your doctor knows your personal health situation the best and it's always important to seek their guidance.